Saturday, 5 December 2009

Feeling Sorry for the Kids.

I have done a lot of complaining about the kids. You remember the kids right? They are the untrained youngsters hired off the street, given nothing in the way of useful training and placed on the ward in pseudo nursing uniforms. They are told that they are on the ward to learn and can earn credits to go to university (either 3 year degree or diploma-the only way to earn the title Nurse). What really happens is they are used as cheap labour, they are hired instead of real nurses and no one has time to show them or teach them a goddamn thing. I am a nurse. If I am on a 25 bed ward with 4 other nurses then I have 5 patients. If I am on a 25 bed ward and those 4 other staff are kids rather than nurses, I then have 25 patients to keep track of, troubleshoot and medicate. The latter is how the wards are now run.

The kids work under the direction of a nurse who is "caring" for 20 patients. I put the word caring in quotes because you cannot care for anywhere from 10- 20 patients. That is such a high number of patients that the nurse can barely keep their names straight let alone nurse them properly. The nurse is so over her head with drugs, assessments, IV's, critical troubleshooting, labs, interventions, relatives, admits and discharges, j-tubes, chest drains, NG tubes, unstable patients, coordinating care between physio, OT, pharmacy, social workers and the medics that she cannot even see straight. I am not exaggerating when I say that I cannot go five minutes without having to answer a phone call. This is never ending, unrelenting, never stops for a moment. It's like getting hit on the head with a baseball bat over and over again. No we don't go for more than a couple of minutes without incoming calls from relatives- sometimes 10 separate calls from the same family because they won't talk to each other. They each want to hear it from the nurse- who probably has been on duty for 3 hours and not yet seen her patients.

The kid can not help the nurse with any of this. The nurse is on her own. That means the kid is on his own as well. He is the person most visible to the patients and also the person least likely to be able to help them. They want pain meds-the kid cannot even access the drugs cupboard as he is not an RN. Patients want information and questions answered-the kid has no training-he listens to the handover with the nurses but it all sounds like Greek to him. They want their dressings changed etc etc. He can't do that either. He is constantly getting orders barked at him by an overwhelmed nurse who is doing her best to triage her workload, do all the things that only a nurse can do and delegate anything else to James.

From the almost the very first day that a kid is at work he will find himself trying to deal with basic nursing care by himself for a large number of patients with no theory, no training. Nothing. The nurse he is working with cannot get away from the chaos for 2 minutes to even see her patients let alone supervise the kid. We hate this situation because even though it is 100% impossible for me to spend 30 seconds uninterrupted with a patient or watching and teaching the kid; I, as the nurse ,am still responsible for everything, especially any kid screw ups.

When I came on duty for the afternoon once I found 17 year old James crying in the utility room. This was awkward for two reasons. First of all the small, filthy utility room is the only place for staff to change on that particular ward and James was in there. Second of all, it's rare (for me as an older middle aged woman and a nurse) to have ever seen a young strapping lad reduced to tears at work. Of course I reduced tons of lads to tears in my young heart breaker days, and reduced many doctors to tears with my stupidity but that was a long time ago ; ) Yeah right.

James was pretty upset. He had been on the job a month-was thinking about attending nursing school or looking at some other area of health care at some point and needed a job. When the hospital advertised for paid cadets/apprenticeship he jumped at it.

He was dead keen and seemed like a real nice lad. We liked him from the get go but of course no one ever told him that because we are all so bogged down with negativity.

It's like this all the time: Oh no bed 1 -can't breathe, bed 2- has chest pain bed 3- has maleena bed 13's daughter is on the phone spitting mad and demands that I get my ass to the phone right now and speak to her or she is going to sue and bed 4 needs the commode.

James can only help me with the last thing on that list so it's constantly "James!!! so and so wants a commode".

No one talks to James or teaches him anything because they can't. It's just "James can you do this" or " James I am coming to help you clean up bed 8-oh wait bed 16 has just pulled her central line out of her neck and is spurting blood sorry have to deal with that you'll have to clean up bed 8 on your own or wait for me to stop the bleeding". or "James we really need to turn all 11 patients that need to be turned every two hours" and just as I get my gloves on the phone rings and it is the 3rd family member calling about bed 26 in the last half an hour. The caller is irate over hospital food and keeps me on the line for 20 minutes. "Sorry James-I will try and get down there and help you I swear..oh and bed 10 is crying for a commode".

How about "James, we have 10 feeds I will do these 5 and you do those 5, oh shit bed 11's surgeon is here and is snapping his fingers at me because he wants me to stand there while he sees his patient, and bed 17 is on the floor and bed 19 wants pain killers. Just feed as many as you can and I will try and get there after I sort all that out". Before I even get to sort the first thing out (that asshole surgeon who is actually standing there snapping his fingers to beckon me) one of bed 20's relatives are on the fucking phone again. The 3rd one in less than an hour. That goddamn fucking phone.

Why was 17 year old James crying and banging his head against a wall in the supply cupboard? Was it all this? Nah, he handled all of the abuse pretty well up until today. He did something today and a patient died from it. But let's back up a minute and take a look at James's short career in the NHS first.

From James's first week he found himself looking after 10-30 patients with only an RN to help. He didn't even know where to begin as far as location of supplies, how to bath an immobile but combative patient, the need to moniter intake and output, what hypoglycemia looks like etc etc but he was the one down there with the patients (and visitors)...and he was constantly getting orders barked at him by the stressed out nurse.

Patients would ask James for pain killers. James can't get them or give them and doesn't know clopidogral from zomorph. So he would tell the nurse that the man in bed 10 needs pain killers. She can't get to bed 10 with them because her other patient with cardiac problems has chest pain and shortness of breath and either there is no other nurse or the other nurse is even more tied up. No, you cannot leave a possible heart attack patient for 15 minutes to do everything you need to do to obtain and administer morphine for a stable patient.

James assures the patient that the nurse will bring the pain drug as soon as she can. Two minutes later the patient gets a visitor and they call James over "This is that lazy fucker nurse who hasn't brought me any painkillers even though I asked him over 10 minutes ago" says the patient to his visitor as he jabs his finger in James's stomach.

Patients and visitors are angry that dressings haven't been changed, IV fluids haven't been recommenced, that CT scan hasn't happened yet but they assume James is some kind of nurse and lay into him. He can't do anything but pass on their concerns to the nurse, and she probably can't do anything. It's a nightmare for him. The public sees him as a nurse who is passing the buck. But he is not a nurse. Well, his uniform is identical to mine.

Patients scream at him and blame him for their wet beds when he was singlehandely trying to toilet 5 heavy patients at once, they go mad when their food goes cold but don't realise that James is trying to get 5 people fed while answering call bells and dealing with the alzheimers patient on the floor. The nurse at this point still cannot get away from the chest pain patient or the constant incoming phone calls. She gets it in the neck even more from patients and relatives. Constantly.

They throw water at him, slam tables into him, pinch, bite, kick, (and these are the ones without dementia). The only rock and support he has is the registered nurse who runs past him at the speed of light shouting " Hey you James that your name....will you bring a commode to bed 4 -my epileptic patient is having a seizure and needs drugs to stop it so that is where I will be. After that I will come and help you". But she rarely does come. She rarely can. She is fighting her own battles.

This describes most shifts from week one onwards for untrained but lovely and keen to nurse teenager James.

James held onto his stiff upper lip and did real well until today when I found him crying. A new patient came to the ward that lunchtime. He seemed very alert. The porters dumped him there without letting the nurse know he arrived onto her ward. The nurse was in sideroom 4 and didn't see her patient arrive. The nurse knew that the patient she was expecting anytime could not swallow but she didn't know when he was coming.

She had only received the notice that he was coming and the information about him five minutes before the patient was dumped on the ward. Once you get told you are getting a patient they will show up either in 5 minutes or 5 hours or anywhere in between. Relatives with questions and patient problems were interrupting her every move as she tried to find James to tell him that the new patient coming any time could not swallow and could not stand. This patient would, however, tell anyone that he could do these things and then demand food he could not safely swallow. It was mealtime, and James gave the patient dinner. He didn't cough and splutter right away but instead appeared like he was swallowing. James realised something was wrong after a few minutes and got the nurse. Bad outcome.

Rule number 1: Never ever trust a patient when they assure you that they can safely swallow and eat, even if they walked onto the ward and look healthier than the staff.

Rule number 2: Never ever ever give a patient diet or fluids until you have spoken to the nurse. If the nurse cannot speak to you because she is tied up elsewhere, then you have to deny the patient food and fluids until she can and shoulder all their nasty comments accusing you have being too lazy to get them a glass of water.

I have known these rules for well over 10 years but James of course, did not..or he was under pressure and he forgot. Most kids his age cannot handle running the grill at Burger King very well.

Who is in trouble here? The nurse is in trouble because she is the one responsible for everything everyone does. The fact that the phone was ringing off the hook and nothing is done to protect us from these constant never ending interruptions, drugs were due, and patients were unwell at the other side of the ward, that the porters dunped the new patient without telling her, and that she well and truly meant to tell James that the patient could not swallow as soon as she could mean nothing. The fact that management put staff in these situations and then won't communicate with them mean nothing. The fact that management allow these stressed out and heartbroken visitors to come in and stop these nurses mid step and demand instant service in the time frame they want means nothing. There should be a system in place to communicate with the relatives effectively. The fact that we have to field constant phone calls by ourselves and that patient area is away from the phone mean nothing. And believe me when I tell you that the nurse cannot walk down that ward when visitors are around. You cannot move ahead two feet without "Nurse can I have a word". Tell them you can't (and you really can't stop even for one minute because you are on your way to bed 6 with a drug that is overdue and takes ages to bolus) and many of them go fucking ballistic. They are stressed and scared too.

It's not good for James either. The poor boy is a goddman wreck. He feels totally responsible and ended up leaving his notice via phone message, never coming back. I have seen him in town. Being the cheeky bitch I am I asked him if he was still thinking about nursing school. "Hell no, I am going back to college to study restaurant and hotel management". It's a shame because when he first started he was dead keen and was thinking very seriously about becoming a nurse. I think he could have been good and told him so.

Another new recruit getting a taste of reality, realising it ain't all Holby city, and running like hell.

99% of the time we do a great job when you take into consideration our working conditions. We actually do quite well on my ward. But when the ball gets dropped, holy shit it really drops.

* So much information has been changed in this post to protect the people involved that this post in no way resembles what actually happened that day and confidentiality has not been breached. It is an utter figmant of my imagination but you all get the gist. Lots of people choke on medical wards all the time, including rushed staff nurses (oh yes I did). The situation described in this post did not happen to anyone you know.


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yellowbug60 said...

This is all too familiar. The "shit hit the fan" like this when I was working in Scotland a few years ago. I had been working in ICU for 2 weeks on a 3 month contract from Australia. My patient in ICU passed away early in the shift so they deployed me to a "medical ward" being opened to cater for demand from 2100hrs. A Health care worker and myself were to admit 15 patients from other areas most awaiting nursing home placement. I was handed a clump of keys and sure enough nurses came and "turfed" their poor patients. There were no sphygmos, meds were locked in an ajoining ward, no water jugs...Patients were crying and disorientated. A daughter who was visiting her mother said she was taking her home. I said I would too if it was my mother. I rang the Nurse Manager who curtly said she would be sending another patient since we had a discharge! I let her know how negligent she was and how pissed off I was too. I refused the patient but she had this poor 16 year old girl transferred from ED half an hour later. The patient was doubled over in pain in a wheelchair. I asked what analgesia had been given. The nurse transferring said she was only doing the transfer and did not know. She said the patient was going to Operating Theatre that night. It was a fucking nightmare.We raced all night. Trying to handover to the morning staff was dreadful. I stayed hours extra....couldn't see straight either!

Nurse Anne said...

Yes that is often how it is.

Even when we are swamped and have no staff we still have to take admits, the additinal hallway of beds that is supposed to belong to the adjoining surgical ward is opened and filled. They cancel surgical patients to fill those beds with medical patients.

They have no place for all these elderly medical people and it takes social services a week to come and assess them once they are medically fit. Then we wait weeks for a nursing hom with a bed to be found. Then it takes 2 weeks for the nursing home to come and assess them. Then it take another week for them to get the room ready. And by that time the patient has developed a hospital acquired chest infection and then we have to start all over again.

Meanwhile there are no beds for the acute patients.

Anonymous said...

I've been saying for a while now, we should strike. I really mean it. We all have concerns about how our patients will fare if we walk out but I hope that with enough warning just the threat of a strike would be enough. But we would have to be willing to follow it through so how about this. We could walk out, but be willing to return to work whilst still officialy striking but as agency staff. Or maybe offer our services at overtime rates? It's the only way I can think of covering the shifts while still making out point.

Toby said...

no, don't even think about it. The 'public' wouldnt stand for it and the press are too stupid to report properly.

Your only hope relies on good communication and bending the ear of the possible incoming government (they all mean well in the beginning)

People need to pass information to their MPs, as its only MPs who can change or influence management in PCTs.

this stuff shouldn't even happen in a 1st world country (and maybe Nurse Anne is just unlucky) but it sounds like a heavy dose of reality and common sense is badly needed, WHAT do these managers DO ffs (are they human ..?).

I'd love to win the lottery and build and open a hospital and run the staffing on the type of contracts explained in one of your posts. I would also make sure there proper facilities and that the staff wore uniforms that match ID their jobs (ffs, you'd think this would be basic entry level stuff) I'd also keep the 'kids' but have 2 supervisors per ward running shifts with a remit to introduce, train and oversee the basics that the kids could actually help with and make a difference.

Nurse Anne said...

I also think striking would be a bad idea.

I can just hear them now:

"Those lazy slags who leave people lying in their waste abandoning their posts to demand more money".

If we did strike, I think we would have to make it very clear that the reason for the strike was primarily patient safety and ratios. Don't think it would get across though.

It's a shame about a lot of these kids. We get some nice ones who are really excited about nursing. But we lose many of them. Right now we have a kid who is very young and working at the hospital is her first job. She is a natural. So far she has stuck it out for a year and still planning on nursing school. She's convinced that things will have improved by the time she has graduated from uni.

Anonymous said...

Nurses in other countries have gone on strike and won. There's been no backlash against nurses either. The only thing stopping us is us and to be brutaly honest, people who think we shouldn't even consider it as they are basicaly scared stiff.

Toby said...

a clear communication campaign would be required to get a better-than-vague understanding by the public, before any 'action' be threatened, yet alone taken. This would require time and money and something for the press to bite (another headline story that would inevitably focus on something bad that has happened, no doubt involving lives lost or horror stories of hostpital failures)

It makes me wonder, if its bad for you lot, what the hell is it like for other departments/staff linked to the same patient/service chain you are (like A&E, outsourced cleaning and porters etc.)

Anne, have you had the chance to read Dan Hannan and Douglas Carswell's The Plan: Twelve months to renew britain. Do you think a Singaporean system could work over here.?

Nurse Anne said...

I have had a look at that on google reader really really quickly so I may be way off base with this. It sounds like the singaporean system is quite sensible. The nurses I know who have worked there have left the NHS and gone back. The wards were said to be well staffed. If you did well you got promoted and a raise. If not, you were demoted. The wards functioned like well oiled machines they said.

To institute anything like that here is going to take a long time. People hate change and they obsess about the possibility of being treated unfairly. I see too many people who don't value education and don't want to work .....and then bitch about how unfair it is that the guy who worked hard at school and does 60 hour work weeks in a highly stressful job can pay for bupa. That guy also pays a lot on taxes to fund the NHS (especially compared to themselves) so why do these people complain?

If people could save into a healthcare account and the higher earning can save more into this account then they can shop around for the better provider yeah?

I think thats fine but lots of people would go nuts, even with the government covering the cost of catastrophic illness. People would go nuts.

If the US government covered catastrophic illness and ran medicare and medicaid effectively the current system there would be very fair and work so well. I think their system promotes personal responsibility which is a good thing in pool of bad. That of course does not mean that I think all americans understand the concept of personal responsibility.

The kids there are, in a way told, "screw around at school and don't work hard if that is what your dumbass wants to do but don't come crying to mommy, daddy, or the government when you don't have a good salary and health insurance". That's the stuff many of them are raised on.

Some of my young adult relatives here do not want to go to school for any further education and do not want to work, they are on the playstation all day and then they bitch about how much the local hospital sucks when it took a couple of hours to get their free treatment in a&e. They had to wait around for a couple of hours to get their free prescription meds and they didn't like that. They also didn't like the fact that the hospital put their foot down about paying for a taxi to bring their friends in for a visit. Not a good world view for a healthy able bodied young adult. Sadly there are far to many people behaving like this. An NHS system, even though has so many amazing points, encourages that world view. It is unsustainable.

People will have all sorts of ideas about what should be paid for out of their health accounts and what the government should pick up. With freedom comes personal responsibility. It's the personal responsibility part that is going to piss certain people off. But all in all I think it is a good plan. Small steps though to avoid rioting.

The cleaners and the porters have to do a lot with very little. A&E is hell. Just hellish. I have had a few a&e staff comment on here and their stories made my toes curl. Our a&e with 15 beds and resus rooms at a large hospital was staffed with one nurse and one care assistant one saturday afternoon.

I can't even blog here about what she told me regarding that situation. But the words dead body and waiting room spring to mind.

Nurse Anne said...

and by small steps I mean it needs to be slowly implemented over a period of a few generations lol.

Saad Amir said...

The kids play an important role in the field of the education.The kids are the sunrise of the student.
regards, saad from

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