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.