Saturday, 14 February 2009

Nurses should not take report on all patients on the ward...PART ONE

I got a massive shock to the system when I stupidly returned to the UK following my training and working for a short time in the USA.

Over there I was working on a 36 bed general medical surgical unit. It was considered violently unsafe for a nurse to take any more than 6 patients...12 in an absolute staffing emergency. You could increase the ratios at night due to less interruptions.

We had "pods". Each 6 bed pod had its own nursing station, it's own phone and it's own nurse, it's own supply cupboard and it's own hand washing station. This staff nurse only had handover on those 6 patients. All the info she needed for those 6 patients was right there, not mixed up with the other 30 patients. The idea was that it is extremely dangerous to have handover and irresponsibility for more than your pod on busy day shifts. on nights there was one nurse to 12 so she had 2 pods.

Every single day we had a charge nurse (sister) who was in charge of the whole ward. She was there 5 days a week and knew about all 36 patients on the ward. That was good. She was our leader. It is stupid to expect a staff nurse to come in after days off and take report on 36 patients anyway. It takes forever to get handover on that many patients and it is way too much information to keep track of for any amount of time.

Things change so violently and quickly during the day that if you were trying to care for a group of patients and keep track of all the issues for the whole ward you would fail. This was understood by our managers and anyone else with a fucking braincell. That is why each staff nurse stayed in her own pod, only had handover on those patients. The charge nurse was the only one who had report on all 36 patients from the night charge nurse. She did not have a specific patient assignment. She went from pod to pod checking that the nurse and the patients there were doing okay.

Picture the shock to the system I had when I came to the UK to find that on a 35 bed ward there were only 2 staff nurses, no charge nurse and that we were supposed to listen to report on 35 patients we never saw before. How fucking stupid. On a 35 bed ward there would be 2 or 4 nurses listening to report on all the patients. Report at the beginning of the shift took hours. Now we don't even have four nurses, just two. All the notes for all 35 people are jumbled together at the nurses station and there is only one nurses station and one phone. It's fucktarded.

Let's back up a minute. Decades ago an NHS hospital ward had 35 beds and it worked out that you always had one nurse on duty to know about all of the patients. Matron or charge nurse was there every day without a specific patient assignment. First of all, the patients were no where near as complex as they are today on a general ward. General wards today are full of chronic people with complex problems who would not have lived very long back then.

Decades ago patients stayed in the hospital for a lot longer allowing the staff to get to know them. Things didn't move as fast or happen as fast. There were not as many targets, paperwork and changes throughout the day as there are now. I may do 11discharges in one day now. Things were at a slower pace back then. There were more nurses and everyday there was a charge nurse/sister/matron on the ward in charge. She was there every day and knew that ward like the back of her hand. She had staff nurses to care for the patients while she supervised and kept up with the information.

We don't have any of this going for us now. And it's not our fault.

They certainly won't pay for a charge nurse to be there everyday on top of two staff nurses. Most you get now is a charge nurse and a staff nurse or two staff nurses. Each will take a side of patients. If the charge nurse is the primary nurse for her 12-14 people than it becomes impossible for her to follow what is going on at the other side. We did try and have both nurses listen to both sides and get handover for the whole ward. We failed miserably. There was so much information to know for all those people that report was taking nearly 2 hours. There were so many changes during the day that we couldn't find time to catch each other up. Every time we tried we failed due to interruptions.

The other problem we have is this: Nurses are often working 14 hour shifts 3 days a week rather than being there 5 days a week. Saves the hospital some cash. To come in after 2 or 3 days off and listen to handover on 25 or 35 patients you don't know and then try and keep track of all the information is crazy. It's like begging for errors and mistakes. As a matter of fact we know for a fact that it will cause vital info to get missed out lead to mistakes. American nurses would be shocked at the idea of having all ward nurses know about all the patients on a 25-35+ bed ward. Actually anyone with a fucking brain would be shocked that people think that this could work nowadays.

I need to go now and will finish part 2 of this later.

Then I will have a holy motherfucking shit fit angry rant at the people who deem the ward nurses thick and lazy for not having up to date info on all the patients on their ward at all times.

If there are any nurses (especially outside of Britain) who are reading this I would like to know how many patients you get report on at the beginning of a shift. What would you think of sitting and listening to handover on 35 patients at the beginning of a day shift in acute med-surg? Maybe you'll decide for the only 2 staff nurses on duty to listen to report for both sides and work together. Do you think it would work? If you split it and each took 17 or 18 patients each how would you keep track of your 18 patients and your colleagues 17 patients as well? How can you keep track of all the minute details of 36 people with rapidly changing conditions and orders?

Please answer if you have time. British blog land is full of doctors and members of the public having a shit fit and calling the ward nurses stupid and lazy for not having up to date info or assessments of all 35 patients on a ward at all times.


Anonymous said...

Hi Anne, As a nurse of the 80's who left the ward situation in 1987 because you could never finish a task for one patient without having to do 25 other things at the same time, I can barely believe the extent to which things have become so dire! (sorry about the long sentence).

Why do we think it is ok to treat nurses in this way? Why do we think that nurses should take the flack from patients and relatives for all of this while managers take cover?

We are generally obsessed with copying US practices - LEO leadership, community matrons etc. But don't think copying staffing ratios and practices would be a good idea.

People wonder why I wouldn't return to the ward with a barge pole??


DundeeMedStudent said...

When I was working as an NA we would have one nurse and 6NAs for 30 patients during the day and 1 Nurse and 2 NAs for night shift on a long term geriatric ward- Deeply dangerous. Why is it acceptable to treat elderly people so badly- this would never be allowed on a surgical unit.

Nurse Anne said...

The thing about medical wards is this: Not only do they have geriatric patients but they are also taking people who are extremely acutely ill, and would have been in ITU years ago.

Nurse Anne said...

The thing about medical wards is this: Not only do they have geriatric patients but they are also taking people who are extremely acutely ill, and would have been in ITU years ago.

Saad Amir said...

This has been very sorrowful for the hospital management.It destroy the management of the hospital.
regards, saad from

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