Thursday, 9 July 2009

Let's get something straight: The Chicken or the Egg.

All over the Internet I see posts that try and blame nurse education and nurse "snobbery" for the state of things on the wards. It's true that the wards are violently short staffed. It's true that many registered nurses are no longer ward based. The fact that many nurses are no longer ward based has nothing to do with the situation on the actual wards. Short staffed wards are that way as a result of business managers.

Let me tell you what I know after over 13 years of nursing in multiple countries and an obsession with issues surrounding nursing care.

We'll be real simplistic in case any daily mail readers are looking at this blog (doubt it but I'll endeavour to keep things on a year two reading level anyway, just in case).

The wards did not suddenly become short staffed overnight when health care delivery became more complex and the role of a ward nurse changed. Having a caring heart and a strong stomach are not enough to make a good staff nurse anymore. I often hear comments from people on seem to think that degree educated nurses do not want to be at the bedside. Complete rubbish.

They are educated to work at the bedside, they need years of bedside experience before they can change jobs into specialist roles. The abusive conditions at the bedside drive them away time and time again. These working conditions drove the 1972 grads with certificates away and it is driving degree/diploma grads from the class of 2009 away too. People who like to look down on nurses just cannot STAND the fact that nurses of the class of 2009 have more escape routes from this hell than the class of 1972 ever did. They want to keep it hellish for nurses and ensure that nurses have no escape routes. It allows them to put money towards things that give the illusion of decent patient care without ever really providing it.

The wards have always been pitifully staffed by greedy managers. This has always resulted in an abusive work environment for nurses. Their experiences were so harsh that they will never return. For these people, working a 40 hour work week with lunch breaks minus life and death responsibility is like a permanent vacation with a paycheck. Most escaping nurses do not go into practitioner jobs within health care. They go into everything from teaching to theology to working at GAP. And you wouldn't get them back into health care as a nurse if you offered them double the pay, so atrocious were their experiences.

Many people seem to think that if specialist and managerial nurses were forced back to the wards then we would magically have enough nurses to do the job. This is bullshit. Ward staffing by registered nurses does not follow the rules of normal supply and demand. "Supply and demand" of RN's is very tightly controlled by twats with a financial agenda which does not benefit nurses or patients. Do you know how many new grads are still looking for jobs, and feel that they have very little in the way of options?

Most of the time we only ever have 2 RN's per shift. This number seems to remain constant no matter how many new staff we hire, no matter how many leave, no matter how many are off sick, no matter how many want to work over time. If we have 3 + nurses for the shift, one gets sent away for the shift to staff another unit. If we only have 1 for a shift either she attempts to cope alone or they take from another unit to ensure that we have 2 RN's. 2 RN's for the whole ward seems to be the minimum number that management can get away with, without they themselves looking like the bad guys. The number 2 is the magic number and usually constant no matter what. We have 20 something beds. The medical ward downstairs has over 35. Neither ward ever really seems to have more than 2 RN's per shift even when they hire new people and have staff begging for overtime.

The ward budgets as designed by business managers do not allow for the wards to be staffed well with much needed RN's. They just don't allow for it. The specialist nurses and the managerial nurses will never be brought back to the ward for this reason. Ask any one of them, they would come back if they knew for certain that they would not get shafted i.e. have a manageable number of patients rather than ratios from hell. But even if they all came back, we would still be heaving with only 2 RN's per shift.

If we ever, god forbid, get 4 RN's for a shift, one gets sent to staff another ward and the other gets sent on a study day that she should have gone on two years ago (legal requirement) but could never go because the ward would be left too short. No matter what happens we always end up with 2 RN's per shift.

If all the nurse practitioners, nurse specialists, and practitioners came back and begged to be ward based we would still only have 2 RN's per shift.

IF every nurse who left health care came back, re-qualified, and begged for a job as a staff nurse on the wards as well...we would still only have 2 nurses per shift.

If every British nurse who left the UK for pastures anew came back to Blighty and begged and begged to be put to work in an NHS hospital as a staff nurse....we still would only have 2 RN's per shift.

And, if in addition to all that, every single dead nurse arose from their graves like something out of Thriller, and came along dancing with Michael Jackson towards the wards looking for jobs....we still would only have 2 RN's per shift most days.

Being only one of 2 RN's for a whole ward is hell on earth. This blog does not even begin to touch on how much a nurse in the position is crucified and made to suffer. When I was a kid I shoveled horse shit and worked as a sales assistant. When I was at Uni I worked in a bank and a museum. I know I take on more work and abuse in 5 minutes as a staff than I ever did in all of those jobs combined.

If you think that the normal rules of supply and demand apply to nursing then you are batshit fucking crazy.

The nurses who have long ago left the bedside know this. See, they know a lot more about the situation than the likes of NHS blog doctor. Doctors may be highly intelligent and brilliant at diagnosing an illness and prescribing a course of treatment. But they don't know shit about nursing. My 5 year old understands nursing and nursing issues better than any doctor ever could.

The AWOL nurses who left the bedside know that even if they come back, and all their friends who left came back and they all got jobs on the ward......the business managers would find ways of shedding other RN's through what they call "natural wastage".

All nurse managers and nurse practitioners know that if they come back, and everyone else comes back to the ward, that they will end up getting overloaded with too many patients. They know that they will be in the exact same position that Nurse Anne is in right now. They see us working 12 hour shifts without being able to eat drink and pee, getting crucified and screamed over things out of our control, slamming our heads into the wall with stress etc etc. If they all come back, the staffing numbers STILL would not change one fucking iota...and these returning nurses will be straight into our shoes.

It's a classic chicken and egg scenario with a bit of catch 22 thrown in for good measure to deflect blame from the real culprits who are responsible for shit nursing care. Did the wards become horrific and short staffed because of nurses being too snotty to work at the bedside, or did the nurses leave because the wards were horrific and short staffed? Make no mistake about the fact that the latter statement is correct while the former is complete and utter bullshit.

Never forget the golden rule of nursing. There is no shortage of RN's. There is merely a shortage of RN's willing to put up with appalling conditions. Appalling working conditions for nurses saves money....well that's how the business managers see it anyway. The reason that people cannot stand a well educated nurse is the fact that she has more options to escape than older nurses ever did. People resent that.


nurse with screwed up teenagers said said...

we must love those are nearest to us, in our own family, From there, love spreads toward whomever may need us.
i worked once in a hospital in zimbabwe; there wasnt even a bucket to wash the operating room floor with and we were handed out one pair of gloves FOR THE WHOLE SHIFT. we used to wash our gloves and hang them on a tree outside to dry. anyhow one day i decided: Why is god letting all these people die of AIDs? the i thought, why am i thinking like this? TIME TO GET OUT. surely your priority is your 5 year old and not the old people on the medical ward. just walk away and be a good mother instead of a harriden. your husband might otherwise run away to america WITHOUT YOU and you will end up working full time and next thing you know you will be a modern matron and be sucked up into becomming a clipboard.........and YES THERE WILL STILL ONLY BE 2 TRAINED NURSES PER SHIFT!!!!!

GrumpyRN said...

Sadly, nurses know this and doctors like Crippen will always blame nurses for daring to improve their lot. I don't actually blame the doctors, it is their training and their experience that makes them behave like this. Hopefully as the present junior doctors move up and on they will have a different outlook on nursing, but I am not holding my breath. Actually I am lucky, the doctors I work with are supportive and understanding and the Lancelot Spratts are dying out.

Nurse Anne said...

I agree Grumpy. Our Junior docs are fab. Just wonderful. They are overwhelmed too. They have a much clearer understanding of the situation than old GP's and consultants who are so far removed from reality that it is ridiculous.

Nurse Anne said...

Of course none of this means that bad nurses and nurses with attitude should get let off the hook.

It means that good nurses are consistantly failing and that something needs to be done.

Anonymous said...

Nurses with 'tude?

I started to develop a bad 'tude at Shitford General. This was a mad busy surgical ward, horribly understaffed and with some very acutely ill patients.

Because of the pressure in ITU we were taking HDU patients all the time. These patients were not really stable enough to be nursed on a surgical ward having had major ops like gastrectomy and oesphegectomy.

These patients needed at least half-hourly monitoring. Some had trachys. All had multiple drains, feeding tubes, catheters, stomas and multiple IVI's and IVABx. You might have two of these HDU patients to your twelve-bedded bay.

In your bay you might also have recovering colosomy, appendectomy, amputation patients with the usual complement of diabetics and complicated medical problems.

I got an attitude all right. One day a patient newly back from theatre after having extensive bowel surgery developed obvious cardiac signs (low BP, tachycardia) and was going down the tubes fast. I bleeped the team and we swung into action.

In the midst of the emergency another patient stuck his head round the curtains and demanded I do his toe dressing RIGHT NOW. The Registrar yelled at him to get out.

We saved the post-op patient. He went to CCU and all was well. I left that shift four hours late then had two days off.

On my return the ward sister pulled me up for not doing the toe dressing, the patient had complained and had said I had a "bad attitude"

Fuck him and the selfish horse he rode in on.

Nurse Anne said...

Oh I love your post.

When I said attitude I meant nurses who intentionally harm patients or act rude for no reason. Very very rare are these nurses but they exist.

The problem is that patients don't understand when a nurse is in a situation like the one you described vs when they are just being grumpy. The most likely explanation for attitude from a nurse is the fact that you are in a bad situation (as you described).

I snapped at a patient the other day. I am not proud of it but I had been 10 hours without food and drink and she nearly caused me to make a fatal mistake with her constant demands for one to one care when I was trying to treat another patient who was going down the tubes. Every time I would try and get to this dying man she was on my back screaming and demanding customer service.

I like the kind of attitude that you have and would love for you to be my nurse. You obviously no how to prioritize. If I was crashing and someone demanded a toe dressing I would hope you would tell him to fuck off!! If I demanded a toe dressing whilst you were dealing with an emergency I would hope that you would tell me to fuck off!!

I don't want a loved one to have a nurse who stops to kiss butt in the middle of an emergency. What if my grandma is the one having the emergency? But the public doesn't seem to think like me.

They don't think about the fact that a nurse may very well have to leave a crashing patient to change their toe dressing. They must think this way, otherwise they would learn to shut the fuck up and behave.

Anonymous said...

What is WITH these people? Patients and relatives that think they are the only folk in the universe to suffer that problem?

To be honest and to talk about my new Oncology ward. The vast majority of the patients are lovely. They don't moan. They just get on with it.

Granted I was lucky enough to snag a job at a world-famous Cancer Centre.

This is proper nursing. You have time to talk to your patients. Get to know them.
The ward has SIX trained nurses per shift and three of those need to have done the Chemo course.

Go for a speciality Nurse Anne. Oncology is a good one.

I originally worked in the rare speciality of Plastics and loved it. I switched to Oncology only after learning the full horror of Shitford General

Let me tell you a tale. A patient who had a ileostomy came back to Shitford with deranged U&E's and what was very obviously excessive output

He was pyrexial. Something was amiss. I called the surgeons. They stuck a ryles tube down. The output was huge. He was leaking.

I called and called again for the surgeons to assess the patient. Too late they did. The ileostomy was leaking causing peritonitis

Nurse Anne said...

Something tells me that most of the horrors of shitford haven't come to light yet. For that too happen, they need to speak to the bedside RN's.

Instead they'll talk to doctors/ consultants who so far removed from reality that they are not on this planet, matrons and managers who will give scripted responses, and patients who know it was horrific but don't understand where the blame lies.

They should talk to the bedside nurses.

Nurse Anne said...

Sorry typing one handed because my kid is sick.

Anonymous said...

Hi Anne - wonder if ol' Beasley and gang ever look in ? To great fanfare our hosp is rolling out 'the productive ward' nurses working smarter adapted from business. A 'lean and mean' nursing work force conveniently overlooking it's skeletal already.
If they could get away with it - the administrators would have computer surveillance of patients in preference to nurses.
a bit depressed as RNs seem to be on the road to obsolence.

Oncology would be a good move - as a result of the Cancer Networks the RN ratio to patients is better.

I am depressed as I see c/o the dying as fundamental to nursing yet being being parcelled off to HCAs. See Marie Curie website. By stealth replacing RNs with HCAs.

As for salaries: AfC ha ha ha. We have CNS 90% employed as part time. The public think they have a wacking salary but THEY offer only part time /knowing they will work over and above hours paid for their patients.

Nurse Anne said...

I know what you mean by the stealth hca thing.

The other day the ward had 1 RN and 4 HCA's. "But you have five nurses" says the managers. The fuckers. The fucking fucking fuckers. Anyone who says that 1 nurse and 4 hca is like 5 nurses needs to be shot to death.

No, there is only one nurse who will be carrying (by herself) the medications, IV's,central lines, troubleshooting, emergencies, assessments, labs, information, chart checking, rounds, admits, discharges, answering questions from relatives all by herself for 25 patients. If a relative approaches an HCA with a question or request the hca just dumps it on the nurse and goes to lunch. The nurse meanwhile, is in the middle of trying to sort out multiple problems.

Meanwhile the hca's (who cannot get involved in any of that stuff) wash a few patients and do a few temperatures and go to lunch. The skip the patients that they don't want to do observations on. Then they come back and do a few (not all) fluid balance charts and then say "oops no time to get the weights" as they are going out the door to leave work on time. They are not licensed. If they leave something undone the nurse pays the price.

Meanwhile the nurse stays over an hour (or 4) unpaid at the end of her shift and listens to the consultant scream at her saying "are you too stupid to know that patients need to be weighed".

I want the HCA's to wear big letters on the uniform that says "I AM NOT A FUCKING NURSE OR ANYTHING LIKE A FUCKING NURSE"

Glamorganist said...

Superb post ! Really superb ! Angry, honest, accurate...

Another Medic said...

Hi Anne

I'm a Med Reg in Care of the Elderly. Our wards are like yours.

Our nurses are fab, but they are just hanging on, just in there. They do their best, they work hard, but they are struggling.

I feel so sorry for them when I see the amount of paperwork the have to do, to 'cover their back' when they admit a patient.

A score for pressure sores, a score for falls, a score for this. No one seems to trust their judgement on how is safest to nurse a patient. Or give them time to nurse a patient.

None of the nurses seem to have the engery to stand up to all this rubbish. None of them have the energy to say

'This is impossible, I can do this, this and this, but not this, maybe on a quite shift but not today'

We need you nurses, experienced ward nurses to stay on the ward.

I love you guys. I love the ones of you that stay in a shitty job to care for people.

You only see a ward when there is an exeperienced nurse on it - as you are an experienced nurse. I have seen wards when very junior nurses are left on their own. And it's hell on earth. At least you manage, at least you get things done.

Thank you for staying. I wish more value was given to ward nurses.

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