Monday, 16 February 2009

Taking report on too many patients PART 2

I am having a really tough time articulating this for people who are not nurses. I will try anyway because it is so important. If have ever wandered onto a ward expecting the first person you see in uniform to have the information you want, and then threw a tantrum about the "stupid nurses" you should read this. If you have ever become upset because a nurse responded with "that's not my patient" you should read this. You need a reality check.

I have had a few emails off of nurses about report and handovers. The American nurses are telling me that they arrive to work and take report on 4-12 patients on their 30 bed acute wards. That report alone takes 45 minutes due to the sheer volume of information one needs to know to be a primary nurse for those patients. Then there are the constant interruptions throughout handover. The idea of taking report on the whole ward and staying on top of everything for all of those people is generally understood (by those of us who do this everyday) to be "ludicrous". First of all it would take hours. You cannot be away from those patients for hours receiving handover.

However, the idea of getting involved with the patients that you haven't had handover on is understood to be dangerous. It is impossible to keep up with your own assignment let alone get involved with the other one. What if my patient gets labs drawn late, IV med late, or I miss a change in condition because I went to research a patient on my colleagues assignment so that I could answer a relative's question? I have harmed my patient if I do that. I want to help the family but it may take ages to hunt down that patients nurse and it will take ages to make my way to the notes and research and investigate the answers to their questions. it's doubtful that anyone has had the time to document everything anyway. I am constantly interrupted during the day, constantly with these queries.

It is a nice idea to think that all nurses on the ward during a shift have up to date knowledge about all the patients. But in practice it doesn't work at all. Yet having report only on one side of patients and not being aware of the situation with the other nurses patients is also a massive problem. This is what I am trying to reconcile.

If nurses decide to constantly try and update eachother about their patients so that everyone knows what is happening we end up with nothing but big fuck ups. First of all, any time spent away from patients trying to handover is dangerous. Who the heck is doing the work and watching the patient with a trained eye if we are constantly updating eachother? The teenage cadets? You would not believe the sheer volumes of information we are trying to keep track of and you would not believe how quickly things change and how unorganised it all is these days in acute care. You also wouldn't believe how easily a patient could be killed either because the nurses are constantly trying to handover to eachother, or because they weren't.

Nurses are of course encouraged to help out their colleagues and their colleagues patients when the need arises. But taking something on with a patient outside of your assignment when you do not have up to date info on them is a minefield. If another nurse's patients asks for something so simple like a glass of water or a pain med and you supply it without being updated you could seriously harm someone. It's more complex than this, but I am trying to keep it simple for the sake of clarity.

Our acute medical wards started moving from 4 nurses to 2. This what at a time when the patients were becoming more complicated, the work loads were tripling, and everything just started moving faster. Things will continue in this upwards spiral due to modern changes in healthcare.

We realised at this point that 2 nurses taking handover at the beginning of their shift on 35 patients was taking too long. We started work at 7:30 AM. The night nurse comes off the ward at 7:30 AM and starts giving us report on each patient: Name age, doctor, diagnosis, history, tests, assesments, treatments, social , physio, meds, problems, old issues, new issues etc etc. It was 9:00 before report ended and we hadn't even set eyes on the patient yet. You need a heads up on so much information your brain hurts when it is all over and you can barely process what you heard. It's likely that I haven't met any of these patients before.

Not only that but the care assistants would constantly be in and out during handover to tell us that someone had fallen, someone couldn't breathe, this patient needed morphine, another has just vomited a litre of blood. You can't leave that until the end of report. You also cannot touch a patient until you have had report. The phone rings constantly during report. No ward clerk present thanks to cutbacks.

The first thing all the relatives do when they wake up in the morning is ring to ward to find out what kind of night mother had and ask what time the docs are coming. Be damned if we nurses know when the consultants are going to grace us with their presence. If the night nurse is on the phone constantly answering questions we are not getting handover. We are sat there getting pissed off because we haven't started our shift yet. We (the day nurses) can't head out onto the ward and start anything if we don't actually know anything about the patients.

We do not learn what we need to know about them by osmosis or psychic ability. We are not there everyday and when you come back in after a day off everything has changed. We need time to learn about the patients' issues. That's why we have handover. This is not an issue in nursing homes and subacute units. They have the same patients there day after day and only need a quick handover to update.

I have often come in after 3 days off to find that I am the primary nurse for 15 + patients I have never laid eyes on before. And we can't even get through report or have a quick look at the notes before we start our shifts due to constant interruptions primarily in the form of phone calls from relatives. Jesus try keeping all the names straight in that situation let alone everything else. Just try it or shut the fuck up.

We know that you can't have the day nurses sat in a room for 2 hours at the beginning of their shift trying to get handover. The night nurses stopped being paid from 0800 onwards so they were there unpaid until 0900 or even 1000 trying to give us report. What is the solution to this? We no longer have a charge nurse/sister/matron there 5 days a week who knows the patients like the back of her hand. If we do have sister on duty, she is there instead of a staff nurse. That means she has to be a primary nurse doing care and cannot fart about with the doctors all day staying updated on patients. We tried taping report. That failed due to constant interruptions.

So our solution was this: There are 2 nurses for a 35 bed ward. Instead of both of us trying to listen to report on all those patients we will EACH TAKE A SIDE. Night Nurse Kate can handover patients in bed 1-18 to me. Night Nurse Beth can take the other day nurse aside and handover beds 19-35 to her. Then we are usually out of handover at 8:15. Then I can go and actually set eyes on my patients a lot earlier and get started. All 35 of them are due meds that have to be given on time before 0900. Otherwise they are written up as errors. We need to get started.

This is why nurses each have a "side" rather than updated info on all patients.

Are you guys following me so far? I hope so. This is really important even if you are bored.

I'm not done with this subject yet. The ranting and swearing is going to come in part 3.


Prisoner of Hope said...

Thank you so much for trying to get to the heart of the matter. As a frequent in patient with multiple co-morbidities you can imagine that I too have some insight into the pressures that you refer to. I am often on the receiving end of clinical decisions not being communicated effectively.

In my experience this does not just happen on the ward (acute or otherwise) but also between wards (e.g. High dependancy or Post Op Surgical Units) and the acute ward the patient is later transferred to. It also - damn it - happens between one clinic and another and between all clinics and the general practice whenever any change is made to polypharmacy - with potential for systemic failure if not criminal negligence.

This is my reality - as a patient! I do not blame "nurses" or "doctors" or "paramedics" or "GPs". I realise that most are well meaning even if some are a little confused. I understand also that there will be a (hopefully normal) distribution of skills and "competencies". From time to time however I do experience the plain stupid as well. Generally though the clinicians do as well as can be expected with current staffing levels and the need to demonstrate adherance to protocols.

Throughout the health care system in the Northern city that I inhabit we do seem to have excellent clinicians albeit they work under resource and managerial inadequacies.

If they were to compete in the Olympics however the relay teams that they would form would forever be dropping the baton!

The misinformed management (of both patients and the service as a whole)might start on the ward during the handover but it is by no means limited to that situation. It pervades the current NHS which, while it may be able to demonstrate eficiencies, struggles to demonstrate - let alone achieve - effectiveness.

Too many of the reforms over the past 20 years have pandered to an excess of faith in the mechanisms of the market place in a vain attempt to depoliticise the setting of local priorities based on bottlenecks in local systems.

I expect it will take a few more years before the shake out in financial markets sees altruism replacing fear and greed as motivators of behaviour in public services. The managerial bully boys will hang on a little longer in the UK public sector I'm afraid - but a fall from grace will also come to them in time.

In the meantime with an ageing population requiring more complex yet safe care for multiple co-morbidities the importance of collaborative clinical records and handover reporting will be more important not less.

The ward handover stupidity you are describing is symptomatic of more general problems caused by understaffing, exacerbated by current vogue for a storm trooper style of local management, and sadly soothed by the apparant indifference of patients and carers. However "this too will pass".

In the meantime please do not think all "patients" are incapable of empathy and of understanding the plight you are describing. Some feel as strongly as you do and I for one wish all power to your literary elbow in - describing the situation from your viewpoint - and look forward to part 3.

GrumpyRN said...

When working on the wards I knew every patient there, if I told a relative "that is not my patient" sister would have been on me like a ton of bricks. On night duty I had to give an accurate ward report to the night sister and to the night nursing officer - no excuses, I could make it up but I had to be confident. I knew what each patients preferences were, I knew what drugs they were on and what tests they were going to be getting. BUT, and it is a huge but, I worked a 5 day week, there were a few more staff available and patients were in hospital longer. I could go on annual leave and know that half the patients would still be there when I came back with nothing changed. As an example, in the acute medical ward I worked on patients who were post MI were in bed for a minimum of 3 days (this was after their time in CCU) then they were only allowed up once a day then crossing to toilet. they were in the ward for at least 10 days. A much more calm and civilised way of working - also wrong and as has been proven extremely bad practice. So continue to complain and don't let old farts like me tell you "it was better in the old days". It was, but for much more complex reasons than that we were better nurses than those of today (we were not).

Nurse Anne said...

I agree with you Grumpy. Who was looking after your patients while you were giving these handovers and who was fielding questions from families, doctors, and requests from the patients during the handover? Were there other nurses on the ward?

Nurse Anne said...

I also think that this is all another negative outcome resulting from management getting rid of nurses and having care assistants instead.

Whether or not I have 2 care assistants or 100 I still have to deal with all the information, changes, meds, familiesm, doctors and interruptions single-handedly.

If I am off handing over or dealing with families there is no nurse to see to my patients. No one.

GrumpyRN said...

I know I shouldn't say this but sister ruled the roost, The nurse in charge gave the handover to everyone - 20 minutes tops - there were always nurses on the ward, HCA's , other trained staff, students. Ward round were very regimented and done at the same time every week, different consultants did their round on different days. Busy 24 bedded acute medical ward would have only 2 HCA's, but would have 1 sister, 4-5 staff nurses 3-4 enrolled nurses, 3-5 student nurses and 2-3 pupil nurses. Students and pupils would be at different levels. Each shift would be minimum of 2 staff nurses, 1 enrolled nurse 2 students 1 pupil and 1 HCA, that's a minimum. That is why the old days were good, we had the resources - I should point out that I am talking about Scotland which has historically been better staffed than England. I put the blame squarely at the internal market which tries to do things as cheaply as possible and as Prisoner of Hope said it can be efficient but it is not effective.

Nurse Anne said...

My gosh I knew they were staffed better in the old days but not that well. CHRIST. How dare they come down on today's nurses!!!!

Our consultants never show up at the same time twice. We do not know when they are coming. But when they do come they snap their finger at the staff nurse and expect her to drop that syringe of pain meds she is about to give, and follow them around for an hour. This leaves no one to care for the patients. This happens 3 or 4 times between 8AM and 1PM.

Nurse Anne said...

...and then if I tell them to hang on a minute because I am just about to give a patient pain meds, or another doctor's patient is bleeding out..they start screaming and saying that we are holding them up and don't understand how to prioritize!! Fuckers.

Anonymous said...

I trained 50 years ago and I think the problems you have now started with the "market forces" brigade.
Maybe they need to start the apprentice style training again, which gives a steady supply of student nurses actually on the wards. The student nurses were all grades from 1st year to third year, which gave us experience and assured that there were nurses (with a permanent sister and staff nurses in charge) at all times. The rapid turnover of patients does not help and leads to cases like the one reported recently where an elderly man was sent home alone and died the next day.
Care assistants with little training maybe a false economy if the hospitals are then paying out for mistakes and poor hygiene.

Nurse Anne said...

Granny Anne,

Apprentice training will not give us extra staff. We often get student nurses on the wards doing placements. When we do, management sends our care assistants away "because we have a student". They got rid of bank and the float pool and use wards to staff eachother.

You can't just train nurses as apprentices anymore. Nursing school needs to be hands on as well as academic. Things of changed. The ward nurses have to do a lot of critical thinking. I had to take a lot of science and math and university and it helps me everyday on the ward.

If a student was simply trained as an apprentice without the academic side as well they would not be able to handle being the primary nurse for a group of patients in acute care upon graduation. They need knowledge behind there actions. It's not like we ever have doctors on the ward anyway. They need to be able to think and think fast.

Not understanding the science behind what you are doing is a good way to get your license pulled.

Nurse Anne said...

"their" not there.

I haven't had my coffee yet.

Anonymous said...

Apprentice style nursing was not all practical nursing! We too had to do study blocks and also had to "make critical decisions". I left school with the necessary qualifications for university, as did many of the girls I trained with, we just chose to train as nurses. There were two grades of nursing qualifications State Registered nurses (3years) and State Enrolled nurses (2 years). The latter concentrated on the practical aspects. I realise that many things have changed and there is far more technology used now, but I can assure you that we were not glorified care assistants.
Many of my colleagues have had very responsible positions around the world.

Nurse Anne said...

Hello again,

The university educated nurses also do clinical placements and study blocks that alternate.

Their clinical placements aren't very good as the nurses are too overwhelmed to mentor them properly. The care assistants get floated elsewhere when students are on the ward.

Anonymous said...

Thank you. I work as an Administrator in a busy Nursing home,& it's important to me to protect the RNs from interruption during Handover & drug rounds. If a relative goes to hospital I shall ask when handover is and when is a good time to phone & will ascertain whether I am speaking to the correct nurse rather than just waylaying any nurse who is writing at the nurses' station, as I must confess I have in the past when my daughter has been on a ward. i have never minded waiting at all, because I know that although my query is important to me, it isn't urgent, but I know that I haven't always picked the right time.

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