Tuesday, 27 October 2009

Productive ward. Again. Kill me please.

Productive ward: releasing time to care is back in full swing on my unit.

Apparently the ward would run as smooth as silk if only nurses understood how to tidy cupboards and work more efficiently.

The physical ward layout (appalling), the chaos, the constant interruptions and the massive lack of qualified staff make the idea of working efficiently a joke. The closest we can come to being efficient is taking dangerous short cuts just to ensure that we can actually assess everyone and get all the drugs out and administered without a fatality. All registered nurses are forced to do this on a daily basis because of the working conditions that they cannot control. Anyone who says that this isn't true is a liar.

Even if we could tidy and reorganise the cupboards we would still be up and down that ward constantly, wasting precious minutes. The thing needs to be redesigned and rebuilt to be truly workable. Half our supplies are always missing and require the ward staff to abandon patient care to obtain things constantly throughout the shift. Productive ward isn't going to fix this mess, it just puts more culpability onto the nurses. Pharmacy, and equipment /central supply are 9-5 Monday to Friday. And even during 9-5 they are fucking useless. They cause is more work than any patient ever did. Their worldview is that the lone RN on a ward with 20 something patients is there to make their job easier. God how I hate them.

Let me give you an example of something that happens about 100 times during an 8 hour shift. The lab calls me at 4PM and tells me that my patient's most recent blood results are barely compatible with life. My job is to inform the doctor who is covering. He orders a medicine. Of course pharmacy won't allow us to keep it in stock. To get the medicine I have to ring pharmacy, leave a message, wait for them to call back and then argue with them for about 15 minutes. They are pissy because they are supposed to finish work for the day at 5PM. They stomp their feet and say that they will not bring said drug to the ward. I have to walk the written doctor's order for the drug to pharmacy.

I get there and they ignore me for another 15 minutes while I bang on the glass. I. am. Serious.

They say that they will ring me as soon as the drug is ready. I reiterate the fact that I need this drug NOW. I cannot sit there however. I have many other things going on with my other patients that are almost as high a priority.. 30 minutes sat in pharmacy could seriously harm my patients who are now nurseless. Pharmacy promises me that they will bring the drug to me asap. If I send a care assistant rather than go down there myself it is bound to get all fucked up. 99% of the time we cannot get through to them via phone as they have it permanently on voicemail.

Back to the ward now. I need a special pump to deliver this med that we also are not allowed to keep on the ward as per central supply's dumbassness. I call central supply. A grumpy man who is obviously eating something chewy answers the phone. I tell him what I need. Very slowly he responds with "Well you will just have to come down here and get it".

But I cannot. I am hoping to get this drug administered ASAP as soon as that slut from pharmacy gets her ass here (and she had better hurry I swear to god).

I tell Dick from Central Supply that I am in no position to leave the ward (yet again) and my care assistant is trying to stop my alcohol detoxer from attacking the other patients (so am I while I am on the phone).

He chews whatever the fuck he is eating and slowly responds with "sigh sigh siiiigghhh. I will bring it up if I must. You had better go around your ward and find every piece of equipment that belongs to central supply. Clean it and label it before I get there and put it on a trolley so I can bring it back with me. I don't wanna make two trips. I'll be there in 15 minutes so have it ready for then."

Yeah right Dick. I am chasing pharmacy right now. There is now only myself and a care assistant on the ward. The other RN is now in recovery picking up her post op patient and the other care assistant had to escort a dementia patient to the CT scanner because the staff down there don't want to deal with it. I have a patient who has blood results that show that she needs this drug infusing via this particular pump NOW. I have an alcohol detoxer who is beating the care assistant, trying to beat other patients and myself and we cannot get her doctor to come up here and prescribe sedation. I have 20 other patients as well. I had over 15 IV antibiotics due in the last hour that I haven't even begun to mix. I have a que of angry relatives that want to know exactly what it is we are doing for their loved one. I will certainly be ignoring Dick from Central Supply's request.

And pharmacy still is not here. I ring them. I get voicemail. I can't go down there and neither can my care assistant.
You leave one person on the ward and a crash occurs you are fired.

Now the doctor who prescribed the drug for the patient with scary blood results is on the ward. He looks at his patient. His face turns the colour of a tomato. He glares at me. "Why the hell hasn't the drug I ordered been started yet? What the hell are you doing? Do you not understand that it is priority?" he screams.

Yes I do doc. But I cannot give what I don't have or pull syringe pumps out of my ass. I have already been ignoring many sick people over the last hour trying to pull this together. By the way...do you see that patient over there beating the healthcare assistant? See the scratches on my arm? Her doctor is tied up somewhere...will you prescribe her some sedation? Benzos not appropriate I know...how about haldol...anything?

"No. Not my patient. Get the anti -scary- blood- results- drug up now and call security for your combative patient."

The he left. We did call security actually. Those are the porters. They informed us that they are too busy.

OMG where the fuck is that slut from pharmacy. Their phone is still engaged. I cannot leave the ward. Dick from central supply showed up with the pump, took one look at the alcohol detoxer who was licking the floor and trying to hit anyone who came near and left quickly.

Now I have my pump. But where oh were is that slut from pharmacy.

I run to the end of the ward and peer down the hallway. There is the slut from pharmacy. She is holding what looks like the box containing the drug I need. She is stood talking with her friend from medical records that she has obviously run into on her way here. I walk over to her. I grab the box out of her hands. "Is this for ward R" I say. "Yes" she says whilst looking shocked that I just grabbed something out of her hands roughly. And off I go back to my ward whilst shouting "I needed this an hour ago".

"Those nurses really have an attitude don't they" she says to her friend.

Now I move at the speed o0f light getting the drug out mixed, ,measured, drawn up and doing my maths calculations. My other RN is back from theatre and quickly she checks my arithmetic. I get the drug up and grab a set of obs on my patient. Finally after over an hour of bullshit she is getting the treatment that the doctor ordered. What if I had dropped the ball on this an hour ago? What if I hadn't notified her doctor of her blood results or stayed on pharmacy's ass, multitasked, moved quickly and ignored my other patients calls for help to get this patient her treatment? The brilliant doctor and his brilliant treatment orders go nowhere if they are not implemented. And implementation of treatments is totally the domain of the registered nurses. It takes knowledge and you have to fight! Diagnosing and prescribing (the doctors domain) is only the first step of a very complex process of caring for hospital patients.

Now I brace myself to settle down this detoxer (she has already taken a chunk out of my upper arm) so we can get back to caring for all the patients...but in 10 minutes it will all start again and we will be looking for things.

This is how bad things are during 9-5 hours. You should see what it is like trying to get what you need out of hours.

But they want us to understand that if we tidy cupboards on the ward all will be well. Productive ward will not in any way shape or form deal with the bullshit from central supply and pharmacy. It will not address the fact that we are running these wards with so little staff that we can barely address 1% of what we should be doing. But this is their "solution" to problems that they do not understand.

Now that productive ward is back in full swing our ward sister has been forced to put a cork board up at the nurse's station. On it she has been forced to put little motivational messages. We are supposed to add to these messages by writing our feelings onto the board. The messages say things like:

Releasing time to care: I will understand that I am here for the patients

Working more efficiently so every shift will be a joy!.

Helping the ward to be more organised so that we can spend time with the patients.

Every single member of ward staff is supposed to grab a colourful marker, some nice paper and add their happy visions about the productive ward to this board. I haven't added mine yet. Do you guys have any suggestions for me?

I was thinking about stealing this from mental nurse and posting it on the happy happy joy joy board.


Eliza said...

I've seen the literature sitting on our "leaders" desk, I had a quick look, that was enough, I was looking for the nearest shredder! Just more timewasting crap. Our supplies only come every 2 weeks now, and they always seem to miss half of the order. Our pharmacy - the same.

Prisoner of Hope said...

Can you suggest requisitioning a dammit doll for all staff might do more good?

I'm sure you've seen the rag dolls that are accompanied with the words:

Whenever things don’t go so well…
And you want to hit the wall and yell…

Here’s a little dammit doll
That you can’t do without.

Just grasp it firmly by the legs
And find a place to slam it

And as you whack the stuffing out

I came across one on the desk of a good friend who was chief nurse at a hospital in Saudi Arabia and thought it very therapeutic.

Anonymous said...

Couldn't agree more with everything you say. 1 RN to 22 patients last Monday afternoon on my ward (I'm a consultant) - how many of the possible 8 discharges could she help organise then (chase pharmacy for TTOs, organise transport, ring relatives)? I had to go to clinic so told her not to worry if none of them went home, just keep everyone alive and we'll sort it out tomorrow. Every consultant in my department has been telling management for at least 8 years that their nursing establishment is wrong and only works if there are no bank nurses and no sick patients! Now I am being forced to a workshop to discuss how to speed up discharge without spending any money or staffing the ward properly with nurses. Your blog keeps me going when I despair

Murse said...

Dear fucking Christ God. And the royal mail strike over fuck all? They should make them come and do our job, that'd sort it.

Anonymous said...

I'm an A&E nurse. I took a poorly patient to the ward today, and found 1 RN there, looking after 30 patients. The Other RN was away grabbing food mid-way through her 14 hr shift. The sole RN was having to stay by the bedside of a confused patient thhrowing herself over the cotsides on to the floor. I felt like shit having to dump 'another' patient on her, especially as he was poorly. Its riduculous, cos if the shit hits the fan an someone dies, that poor, lone RN will get the blame. Disgusting NHS. Disgusting.

Anonymous said...

Productive ward is a sticking plaster, that would not be needed if there were enough nurses to do the job that we are meant to do.

Nurse Anne said...

...and it all costs like 50 million. It would be more cost effective and have a higher success rate to increase the ratio of RN's but noooooo.

Soon I will be the sole rn for twenty something patients. I will have 4 untrained brand new care assistants who are mostly teenagers. Therefore I will be carrying everything myself. Just doing all the drugs etc on all those people will be all encompassing. The first morning drug round will take 3.5 hours and in that time I won't be able to focus on anything else.

The untrained little care assistants will be completely taking over the actual care side (which they will screw up because they have no idea). They won't remember to document fluid balance, won't notice changes in condition, they will "forget" to do blood sugars and think it funny. I am responsible for any fuck ups they make.

Yet I am over such a large area I cannot supervise, I will be up to my eye balls in meds, assessments, interruptions, rounds, relative enquiries. I won't ever go more than a minute without interruption and getting pulled in another direction.

But management will say something stupid like "but there are 5 of you, what are you complaining about?". And the fucking visitors will waltz in there and say "there are 5 nurses here, why are patients waiting an hour for pain meds"

It makes me sick. Productive ward will be a fail. It will always be a fail until they realise that the wards need to be staffed primarily with RN's who have a small group of patients each as well as a charge nurse coordinating. Until then every scheme will be a waste of money and it will be fail fail fail.

Legislate safe ratios and they (RN's) will come. When California mandated ratios ordering the hospitals to have no more than 5 patients to every bedside RN on a ward like mine the hospitals cried out "but there aren't enough nurses to do this! we will have to shut wards!"

The ratios were forced on them despite their stupid worries. Thousands upon thousands of registered nurses (like 80,000 in the first year) came back to bedside nursing once the ratios went into law. And even though they are paying many more nurses they are saving more money than they are spending because of the reduction in complications, errors, deaths, and quicker discharges.

This has been the result everywhere that has ratio laws. Hospitals with a higher proportion of highly educated RN's at the bedside actually have lower costs than hospitals who staff their wards with mostly untrained kiddies.

Nikita said...

Hospitals to replace nursing posts with lower paid assistants.


Old news I think to you perhaps, but apparently... 'increased use of electronic monitoring of paients meant it was now possible to replace registered nurses with health care assistants.

I am so pleased I don't work for the NHS - I feel so safe!

Hang on in there!

Anonymous said...

I'm so glad to be retired(only just) and was comtemplating doing some bank work, but have had a taste of that in the past - the only RN for 12 heavily dependent patients - No thanks.
The Productive Ward deserves an award for the top useless idea.

Nurse Anne said...

Hi Nikita,

I am in the process of blogging about that article that you posted!

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I think those places should be careful because it's suposed to be a serious institution and I think no one wants to get that experience.

generic cialis said...

You are right the health is very important, so nurses should find a quickly solution for these problems, they have to improve the health cares because a simply mistake will be an awful result. So organize the important things first.

Metro Ethernet said...

The closest we can come to being efficient is taking dangerous short cuts just to ensure that we can actually assess everyone and get all the drugs out and administered without a fatality.

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Anonymous said...

This blog is a joke and I sure as hell hope that neither myself or my family end up in your care.
You can change the way you work, it just involves some determination. Or if you prefer to stick your head in the sand, then I hope you get sacked soon...if you have not been to a disciplinary already.
Thank god there are staff out there who strive to make every day better for our patients, instead of just moaning about anything.
Less moaning, more 'doing'!!!!!!
Create a positive, proactive ward, not one waiting for accidents to happen.

Anonymous said...

Re Anonymous 3 sept.

If you are a nurse then you are the one with their head in the sand. Guessing ward manager level or wannabe ward manager level.

If you aren't a nurse, you really have no idea just how shit the job of being a nurse is, and kindly jog on.

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