Sunday, 10 May 2009

Nurse Interruptions/Staffing Numbers: The number 1 cause of patient neglect

Reading through some comments on Nellie's Shift .

Do people really think that if the workload triples on a shift that I/we get extra nurses? Do they think that if we go from having 3 patients who need to be fed to 15 patients that need to be fed that we get extra staff? Nope. But we may end up with less staff.

If we have all stable patients we have two staff nurses. Those patients go home and we take unstable admits....and we still have 2 staff nurses. One staff nurse pulls her back out during this shift and can't move....she goes home. Now we are down to one. Finding another nurse in the middle of a shift is impossible.

If we did get another nurse in the middle of a hectic shift how the hell would I escape from the mayhem to spend an hour telling her all the information she needs to know about the patients. If she hasn't had report then she cannot function. Who would carry on with all the late medications etc while I stopped to give report to this nurse?

Now we have sicker patients than we did in the morning and only one staff nurse and a few care assistants.

That same staff nurse is automatically in charge during a situation like that, even if she is newly qualified. She is the RN. It's not like years ago where every shift had a sister in charge, a handful of RN's as well as EN's and care assistants. My hospital recently left a brand new grad as the only RN on a large med-surg ward with only 3 useless care assistants. So the new grad was in charge, and she had to do all the patient care that can only be done by a nurse. The care assistants went about their merry way toileting, bathing, and making beds. What else can they do?

So in addition to being the only one who can administer medications, assess, do dressings, nasogastric tubes, trach care, monitor patients, trouble shoot, admit, discharge, do ward rounds, hang iv's and deal with emergencies the lone nurse for a group of patients also has to:

1. Field every phone call. The care assistants don't usually answer the phone, and if they do they just have to go and get the nurse anyway. It's not like the care assistants can take handovers. answer relatives questions, take critical lab results from the lab, talk to pharmacy, talk to social services etc etc.

2. She has to field the visitors questions. I may be the only one to do the drug round for my 14 patients but I am also the only person that the care assistants can direct relatives with questions to. So between phone calls and visitors I am interrupted ever 2-10 minutes on average, all day long.

I am often stopped 30 or 40 times during drug rounds to answer relative queries either in person or by phone. It's not like we have a nurse in charge without an assignment who can deal with all this. All these constant interruptions lead to a whole lot of patient neglect and errors. Nurse Anne is not kidding. I am dead serious.

But every single person who walks onto that ward thinks that it is their god given right to stop a nurse with no consideration for what she is in the middle of....and expect her to drop what she is doing to deal with their problem. Ever wonder why your dad always gets his insulin so late? No, it's not because "the nurse is too stupid to know that insulin must be given on time". It's because she was stopped 9 times between grabbing his drug chart and going to the med room to get his insulin and a further 7 times between drawing up and checking his insulin before she gets to his bedside.

3. She has to make phone calls to try and cover the next shift if that shift is short. If she leaves it and does nothing, things will be no better for the patients on the next shift, possibly worse. The patients will suffer.

4.Supervise the care assistants. How? The nurse is literally legging it to the phone every 5-10 minutes and getting stopped by visitors in between. As a matter of fact I never get down the ward for more than 5 -10 minutes without having the leg it back to the phone. The nurse's station is a long walk from the bays.

On the rare occasion that they allow us to have a "ward clerk" she answers the phone. She finds out who the caller is and goes to get the nurse. The ward clerk cannot tell callers about the patients because she doesn't know. She drags the nurse off of her drug rounds to take the call and then goes back to facebook. I cannot even get one pill out of a pack, or one IV med bolused without Fiona the ward clerk shouting "Anne,so and so's daughter is on the phone and wants to ask about 10 questions". WTF? I haven't even laid eyes on the caller's father due to the constant phone calls and interruptions. Constant. When do these relatives think that we are going to get some uninterrupted time to take care of patients if they call all day long? Why do they think that there is someone with all the up to date information about the patients somewhere near the phone at all times? Not on a large general medical ward baby. Places like CCU and ITU are better equipped to deal with it all because they are smaller units with a better lay out.

IT'S FUCKING ILLEGAL FOR nurses to be giving information on the phone anyway. I can get away with it if I know for sure that I am talking to the patient's designated next of kin. Genetics doesn't matter. The name under "next of kin" listed on their hospital admission form matters. Really it is a big no no and we will be fired if caught. Immediately. This has nothing to do with the trust wanting to "hide things" from the relatives and everything to do with patient confidentiality laws. NHS bosses did not invent patient confidentiality laws and neither did nurses and doctors. But man oh man, do we get BUSTED if we break them. Many hospitals have had million dollar lawsuits because Nurse Susie gave information to the caller who passed herself off as Mrs. Doe's sister.

These interruptions are constant. This goes on all day long. I am telling you this as someone who panics and wants to run to the phone when one of my loved ones goes into hospital. I want to but I call the next of kin instead. If my dad, as the next of kin for my gran, wants me to talk to the hospital then I make an appointment. My dad, has to give permission for the hospital to talk to me about gran or it doesn't happen.

All I want is some uninterrupted time to see to the patients. I walk down to my first patient and get halfway through her meds and assessing her, and the phone rings. Back up the ward. Answer the call. Before I get back to her the phone rings again. I finally finish with the first patient and go to the second patient. The phone rings again. This goes on and on and 2 hours later I still haven't got to my third patient out of fifteen. And it never stops. In between walking up and down to the phone patients are shouting for commodes and visitors are stopping me with questions. This leads to a whole lot of patient neglect. Actually, in my 13 years experience as a nurse I would say that interruptions and staffing is the number one reason for patient neglect rather than uncaring nurses. I am not kidding about the sheer number of phone calls that are coming through either.

I am trying to do everything that I need to do in the minutes I have between interruptions. We cannot escape them. I will not have a 10 minute block of time uninterrupted in a n 8-14 hour shift. Ever. Every single thing I do is done as a rush job because I don't know if the next uinterruption is coming in 30 seconds or 4 minutes. The care assistants, the physios, the ward clerk, they dump every query back onto the nurse and go on their merry way. What else can they do? They don't have the information that the relatives, social services, and pharmacy want. Only the RN does, but just barely. How can I look at the patients, and look at the doctors treatment plans in the notes with all this going on?

We complained to management about this. They know that if the nurses are constantly interrupted that it will lead to patient neglect and missed assessments that blow up into massive lawsuits. So they worked with us on solving the problem.

They haven't staffed the wards well enough yet to allow for one nurse to be in charge, fielding the queries etc while the other 2 nurses carry on with the patients. They tell me they are trying and I have seen evidence to back that up this month. Even then, I would have to be constantly stopping to update the charge nurse as to what was happening with my patients so that she could answer the questions. Lots of information gets thrown your way very fast. It all moves very quickly and is constant. Keeping up with it all is like chasing a race car. We need lots more nurses each with small groups of patients.

But management did do something. They have visitor cards with information about the ward etc and on the card they printed a nice reminder that goes something like this:

We understand that this is a difficult and uncertain time and that you are concerned for you loved one. If you can, please ring once a day. Only the patient's designated next of kin should ring. The next of kin should then disseminate all information about the patient to concerned loved ones.

Nurse Anne would have added "if your fucked up family dynamics do not allow for this because you all fell out and you aren't on speaking terms that is not the hospital's problem. Grow up. One caller once a day. Full stop. Nurses cannot answer 12 queries an hour from 12 different members of the same family who are not on speaking terms. Duh. This is especially true if the patient is stable and never ever has any change in condition.

If people actually followed this request nicely spelled out by management it would cut down on the vast majority of interruptions and promote patient safety.

But the public is as resistant (and paranoid) as all hell. I'll give you some examples in the next post.


Sean said...

How many plastic-suited management twats took how many meetings to come up with the wording on that card, I wonder? I'd say at least 5 or 6, with at least 3 or 4 meetings. It beggars belief.

It sounds like you're on a Nightingale ward. I worked on one last year. It also doubled as a short-stay acute medical unit, with a maximum bed stay of 3 days. 26 beds. Occasionally, we'd get two RNs on each side. Very occasionally, we'd get two RNs on each side and a separate co-ordinator. Most often, we'd have one RN for 13 patients, and one handling the constant movement of patients, covering breaks and helping out where she could.

It was completely mental. Completely mental.

When I moved round to surgery, our main surgical ward was 4x 6-bedded bays and 4 side rooms. Some of the time, we'd have 1 RN for each bay with a side room each, and a separate co-ordinator. Far too often though, you'd have one nurse covering two bays. Again - terrifying. It got to the point when our HDU wouldn't transfer patients back to the ward, because they knew they'd see them again in twelve hours' time. Scary as hell.

Did the nurses complain? No. They just stuck their heads down and got on with it. There are times as the doctor on-call when I've gone a bit mental at nurses for repeatedly bleeping me about the same jobs - one of me, 450 medical patients. A diabetic with a blood sugar of 12 because their cannula has gone on their sliding scale is not going to kill them, and I will be there when I can.

Thankfully, I've become more sympathetic of late. Part of that is experience. A lot of that is down to reading your blog, and I've got to thank you for that, Anne. This should be on medical school recommended reading lists.

Thank the heavens I'm going into paeds... We occasionally hire the odd nurse!

Nurse Anne said...

Hi Sean,

Once I worked in a 14 bed short stay surgery unit. We had two 6 bedded bays and two side rooms. It was bliss. Bliss. We had the phone and the station in a central location. Total bliss. The patients thought that we were saints. We moved from one side of the UK to another due to my husband's job so I had to leave.

We have bays, sometimes I have 3-4 BAYS and no such things as a coordinator. Sometimes nurses fuck up because of stupidity and they shouldn't get away with that but most of the time it's down to the kind of crap I describe on this blog.

SSS said...

"if your fucked up family dynamics do not allow for this because you all fell out and you aren't on speaking terms that is not the hospital's problem. Grow up. One caller once a day. Full stop. Nurses cannot answer 12 queries an hour from 12 different members of the same family who are not on speaking terms."

Oh I do like that.

I'm still sending out vibes for a transfer to the urology ward for you, Anne. Either that or falling over a large pile of cash on the way to work one day.

Happy1 said...

"I would say that interruptions and staffing is the number one reason for patient neglect rather than uncaring nurses."

The day I decided to get out of ward nursing (and almost nursing altogether...) was the day that I was accused by a relative of being uncaring...because I couldn't get to her Dad - due to staffing and interruptions.

2 RN's to 28 patients.
Other RN giving report to late staff.
= ME for 28 patients.
No ward constantly ringing...
20 urgent priority treatments in my mind..
IV's to complete...
Doctors queuing to give me more jobs..
Call bells going..
Queue's of relatives at the desk..
etc etc etc.....

A relative screamed at me as I hurried by..that I clearly didn't care cos I hadn't been into her Dad for hours.

Hmmm. She wasn't to know.
But that was my (final) que to get out of it.

Nurse Anne said...

Their (visitors) assumptions are disgusting aren't they?

Even when I run my tail off for 14 hours straight I am barely able to see people for more than a few minutes at a time and because of so many interruptions. Constant interruptions.

It takes me hours and hours before I get to some people and it isn't because I am not trying.

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