Monday, 2 November 2009

Happy.




It's not all bad. There is that .1% of the time that my job is great.

We lucked out times two the other day. First of all we had 3 staff nurses on duty. Usually that would not be enough. But something else happened that was lucky.

The same random force that can throw all critically patients at you when you are more short staffed than usual can also throw all stable patients at you when you are well staffed.

Actually there was a third lucky thing that happened. The bed manager will usually float a nurse away to another unit if we have more than 2 on duty. But she didn't on this day.

Only two people were on IV meds. No one was acutely ill.

Since there were three staff nurses we decided to put one staff nurse for each group of 14 patients with yours truly in charge and coordinating.

This allowed the staff nurses to get on with the care uninterrupted while I sorted the doctors rounds, the phone calls and intercepted any interruptions before they got to the primary nurses. I answered call bells, assisted the HCA's and made sure that the primary staff nurses were left alone to concentrate on their drugs and the rest of their job. I got their insulins and IV's out of the way for them to save them time. I helped the HCA's with daily care.

I babysat a confused and wandering patient to keep her from escaping to the motorway on foot and half naked yet again. The previous day when there were only 2 staff nurses on it took them until 11:30 AM to get all the 8 AM meds out. On this day because I was there to intercept interrutpions and deal with problems they were done at 09:15 AM.

When our main consultant showed up for his round I approached him, introduced myself as the nurse in charge and told him that I would be attending the ward round for the whole ward and I knew all the patients very well. I had done two night shifts recently and had time to read all the notes etc. He looked surprised. I explained that I was an extra nurse today so we are coping well, and that there would be two staff nurses on the ward attending the patients while I was on the round (which takes 1.5 hours). He was really pleased.

I like going on the ward rounds. It's easy to trail after the docs and answer questions and take notes. I won't even consider attending if it means I have to abandon my patients for hours without having another RN keeping on top of their care. That is just hasking to get hauled before the NMC. I always learn a lot from ward rounds and it helps me get a better handle of what is going on.

Not only did we get everything done but we got it all done well. The patients were happy and the next day a relative gave us a beautiful thank you later. We even had lunch midway through the shift. That was cool.

Just one extra staff nurse and lower acuity allowed for this!

We have approached management asking if we can always have a senior nurse in charge and coordinating every shift just for this reason. Two words: Shot down.
But I will enjoy these rare days when they occur. On these days I am glad that I am a nurse.

8 comments:

Nikita said...

Hi Anne,

So pleased you had a good day!

Here's hoping your management 'screw up' again and give you decent staffing. Nursing is real good when you are able to nurse!

Prisoner of Hope said...

I too am glad you had this experience to boost your morale. How sad though that it was a "happy" coincidence of low acuity and one extra RN being allocated.

It reminds me of a time when a nurse researcher came to my office with a problem. She had been set the task of introducing the latest nurse acuity model for allocation of ward staff (based on data colected from acute wards) to the authority's geriatric wards. After being briefed by the chief nurse and applying the model she was unhappy with the results and felt that they were impractical and too low.

In my department at the time was an epidemiologist who also had a Maths degree so I asked him to assist with seeing why the research based algorithm made such a nonsense when applied to geriatric wards.

After a couple of attempts he gave up so I spoke to the unhappy researcher and tried to understand the different elements of the equation that she had to apply. I noticed one variable which was termed the "Age adjustment". I asked what this was and was told it was the multiplier to be used to account for the additional problems faced by nurses when having to treat elderly patients with multiple co-morbidities, polypharmacy, and who might present also present social problems and be more confused than younger adults.

At first sight this seemed fair enough. As this was all of 20 years ago I used my then Amstrad PC and a SuperCalc spreadsheet to run a series of "simulations" to test out the how sensitive the formula was to slight changes in any single variable. It not only transpired that the single most sensitive variable was this age adjustment but the uplifted requirements almost always equated to whatever this adjustment was set to be. No other (research based) factor had as much impact on the calculation of acuity.

So I asked about the research evidence behind this age adjustment and was told there was none it was a guess that the Chief Nurse had made - off the top of her head.

The underlying evidence base which gave the appearance of a rational approach to nurse staffing was totally skewed by this subjective assessment.

Your postings suggest that not much advance has been made to provide a satisfactory evidence base with which to be able to model demands on nurses time when faced with similar patients today.

A few months after my attempt to assist the nurse researcher I was a patient in another hospital in a different authority. On the third day there seemed to be plenty of nurses around with time to get to know their patients so I asked why this was. The answer then was that on the previous 2 days they were all so rushed they did not have time to complete the returns to the nurse managers which measured how demanding the patients on the ward were. On this day the patients were easier to nurse so they had time to complete the returns properly. As a result the ward gave the appearance of being under more pressure than before so had been allocated additional nurses (even though they proably required fewer than the days before)

Your posts suggest to me that these 2 errors still apply today and that perverse indicators of pressure are still being applied to best ( should that be worst!) guesses about relative accuity.

Glamorganist said...

Dear Anne,

Your ward seems really weird. Who's in charge? Is there a Ward Sister/ Charge Nurse? If s/he exists, where is she/ he? If s/he doesn't exist, why not?

Your hospital seems to have matrons and clinical nurse specialists and non-clinical managers and 9-5 pharmacists and staff nurses but where are the people who should be leading nursing (not that staff nurses aren't leaders of course).

Nurse Anne said...

We have a sister. Sisters work shifts and when they do so they are the primary nurse for a large group of patients with only one other RN on duty (other RN gets the other large group). It's kind of hard to lead in that situation as she is up to her eyeballs in medications etc.

Sister gets one management day a week to work on things like rotas etc. I tried my hand at doing an effective rota that makes sense. It is impossible with no staff. We only ever get kids etc anymore. Management thinks that if we have lots of young inexperienced kids on duty then that frees up the sole RN to be in charge. Wrong.wrong. wrong.

The rest of us are all band 5's. A few of us were e grades. We are technically senior nurses and in charge of the shift when we are on duty and sister is not there.

They will not promote anyone to officially being a senior nurse or junior sister. They just refuse. So the more experienced band 5's pick it up with no pay.

For example I may find my self on duty with only one other newly qualified RN and a gaggle of care assistants. That means I am in charge as well as trying to handle a drug round, admits, discharges,assesments, fire fighting and constant interruptions by families and the MDT for 14 people.

But whether you are our ward sister or a brand new staff nurse on my ward you are going to be the RN for a large group of patients as well as in charge for most for the shift.

Glamorganist said...

Dear Anne,

Thank you for your very clear answer to my question. I can't think of anything constructive to say in reply except "Well done all of you."

Anonymous said...

Too true Anne. Same situation occured on the wards i used to work on. Sister was just one of the nurses looking after half of the ward. Half a ward was stressful for me...them poor soles had half the ward AND the management side of things.

Nurse Anne said...

That's right. And if your sister gets moved to work on another ward than a band 5 has to take it on because they won't promote anyone.

Being a sister/in charge means that you have to be a staff nurse 40 hours a week since you will probably find yourself as the sole RN for at least 10 patients when you arrive to work....this is all encompassing. But in addition to this you have to do all the management stuff (all encompassing) mostly in your own time. They actually have 60-80 hour work weeks.

But our sister knows very well how bad the situation is for her staff nurses since she is one and does the job. It's just all worse for her.

We are currently trying to get them to allow us to have at least 3 staff nurses on every shift...then the most senior one can be in charge and coordinate the shift as well as knock out all the management bs that gets thrown at the sister. So far...shot down.

It's imperative that we get this.

At the very least we need a nurse in charge every shift to intercept the visitors. From 4PM onwards we cannot get anything done or even get near the patients because of visitors lining up to "find out what's going on with grandpa".

If I have to get down to bed 15 with a bag of blood at that time, I will probably be stopped 10 times by visitors on my way down to the bed. Blood goes off real fast. And if you tell them you can't stop to chat anytime soon they get nasty and assume that you are trying to hide something from them.

It's not like all the care assistants can carry on with the blood, medications, firefighting, handover etc etc while I talk to families....nor can they talk to the families.

When families approach them thinking that they are nurses the care assistants just point them in my direction and continue chatting. I was dressing leg ulcers and swabbing them on a new patient that was septic and I got interrupted no less than 12 times during that procedure.

One family member even came into the room and tried to talk to me while I had this ladies poorly legs all exposed. These visitors have no patience and no shame. But then again, they see the care assistants hanging around and think that we have loads of "nurses" doing "nothing". So they cannot understand why I cannot sit down and speak to them.

And they cannot accept or understand that we really are in no position to stop and talk to them.....look, those little girls you see chatting at the nurses station are care assistants...they are not nurses...they cannot give you information (because they just don't know) nor can they carry on with the critical stuff I am doing whilst I talk to you.

It's just a clusterfuck.

Nurse Ratchet said...

Hi Anne - have you seen this? thought you might be interested!
http://www.timesonline.co.uk/tol/comment/columnists/guest_contributors/article6914832.ece