Monday, 11 January 2010
Glossary of Terms and Mythbusting: The Nurse Image
I always find it very difficult to get my points about nursing, staffing, and patient acuity across to your average Joe. This is the case no matter how I present my point of view.
Why is this? Let's look at what Joe thinks he knows about hospitals, nursing, and doctors. If Joe has never worked as a real nurse or spent an huge amount of time in an out of hospital just where the heck has he learned about nurses, doctors and hospital structures?
He has learned what he knows from the media. Most likely from the entertainment industry. This is absolutely tragic. No medical TV show, film or novel has ever even come close to depicting nurses in an accurate light. Shows like ER, House, and Casualty stay stuck on ancient and ridiculous stereotypes when they portray nurses and their professional relationships with doctors. Children's books that introduce pre-schoolers to the concept of who is who at the hospital depict nurses as angels who hold your hand and doctors as the boss who is in charge and delivering every aspect of your hospital care. Again, this has no basis whatsoever in reality. It merely promotes stereotypes. Journalists and hospital administrators are a victim to this way of thinking. They just really don't know any better. Nurses themselves have never been able to verbalise just what it is we are responsible for or what we do. Probably one of the most important things that we could as a profession is let go of the angel stuff and focus on explaining that compassion is important but not anywhere near enough of what it takes to be an RN. An RN needs knowledge, high level skills, analytical and critical thinking skills and further education all the time. We know that a lack of these characteristics in an RN kills patients regardless of how caring he may be..
So why do we never get these aspects of our jobs across to the public? Why do we merely focus on the angels with wings stuff when that describes such a small part of who we are and what we do. I am going to throw together some ideas for educational posters and adverts that promote nursing in a realistic light later on. Until people understand what an RN does we have no chance of getting them to understand why a person who has been an HCA for 20 years is nothing like a nurse, and why short staffing kills.
But for now I am going to add a glossery of terms for average Joes who are conditioned to have a poor view of nursing secondary to woefully inaccurate media portrayls of nurses and doctors. No wonder they think the hospital nurses are mean and uncaring? Casualty has taught them that nurses work for doctors, hold hands, and if they are not doing as they are told it is because they cannot be bothered! Joe has a poor image of nursing and then he comes into hospital and the nurses are not doing what he expects. Then Joe thinks that nurses are crap. TV either depicts nurses as evil murderers, poorly educated empty headed waitresses who give injections, or they go in a whole other direction and try to make out that nurses are smarter than doctors. All of these things are extremely destructive to nurses image. We are not stupid. We are not smarter than doctors. Further education in nursing does not equal "closer to becoming a doctor". We are educated in nursing, not medicine no matter how far we go with our education. We are not angels with 19th century notions of virtue to uphold who are above being held accountable. We are highly educated and skilled professionals who also need to be caring. So are doctors and social workers. We all just do different things in healthcare. And if we screw up just this much they'll haul our behinds infront of the nursing boards and possibly a judge in a courtroom. So we are most definitely not angels with halos who exist in a realm of lovelyness way above censure and the law.
Back to the avertising ideas later. I want to have a militant medical nurse glossary of terms.
A highly educated professional who has completed three years of practical and theoretical training. Research has shown repeately that the more education a bedside nurse holds the better equipped she is to save the lives of her patients as a bedside nurse. Look up degree nurses at the bedside doing nursing care and patient mortality rates. But nurses require vocational training as well. Completing your training as a nurse at a well respected school of nursing is not enough to call yourself a registered nurse. You have to cough up some serious money and become registered with your country's (or state/province) board of nursing. You must do this at regular intervals (annually in the UK and cough up some cash) or you are no longer a registered nurse and cannot work as one in any healthcare setting. IF your registration lapses it doesn't matter how many degrees or certifications you have, you will completely be unable to do things such as administer medications etc in a healthcare setting.
You have to do copious amounts of continuing education and prove it to the board to renew your registration. Your board of nursing can strike you off the register if you harm a patient or take an unsafe assignment and don't blow the whislte on staffing. This is regardless of the fact that your employer is utterly hell bent on not staffing and resourcing wards, forcing their RN's to take too many patients, and forcing other kinds of unsafe assignments on them. Non Clinical managers cannot be struck off of any kind of register. They are merely put on leave and paid large amounts of cash or they are put into another highly paid bullshit job.
Registered nurses take on a group pf patients when they arrive to work and are legally mandated not to abandon those patients until another RN relieves them of duty and receives a handover. They are responsible for understanding enough about disease process and pharmacology to monitor for deterioration in condition. They need to understand enough about disease and human anatomy to ensure that the ill patient does not get worse as a result of things like immobility and poor nutrition. They need to ensure that the physicians plan of treament to diagnose and treat a disease process is implemented correctly and they need to be able to implement these things without killing patients. That on it's own requires a lot of education.They need to know what drugs can do what damage and what to look out for in the unwell patient. What happens if you push to much fluid into a congestive cardiac failure patient? If your patient with an infection suddently crashes out his blood pressure and becomes tachycardic what needs to be done? The RN is with the patient 8-12 hours a day. The doctor is with the patient 5 minutes a day. I can learn a 100 things about your and your nursing needs by walking you to the toilet or asking you about the weather or how you liked your dinner. This has a huge effect on what I will need to do with your plan of care and what I need to communicate to the doctors.
Many patients have anywhere from 2 to 6 different doctors involved in their care and it is the responsibility of the nurse to coordinate and communicate between these doctors to ensure that the patient is getting the right care and that everyone knows the plan. Many times (especially out of hours) we are communicating the patient situation to an on call doctor who has never before seen the patient and does not know that particular patient. IF you are not able to grasp what is going on and cannot communicate this to the doctor your patient is screwed. If you are worred about dehydration, cannot get the patient to drink and are calling the doctor for orders for fluids you must make sure that you mention that the patient has a history of CCF otherwise you could overload him with fluid and kill him. If your patient is more hypoxic and short of breath than usual and your are calling the on call doctor your must be sure to tell him if the patient is a COPDer etc etc etc. Otherwise you could make things worse by blowing 02 at the patient. A nurse needs to know how drugs interact because she has multiple doctors prescribing things for one patient without looking at what the other guy is doing. If a mistake happens with that, the RN gets nailed. Keeping on top of this stuff is not medicine it is nursing.
You need to know when to withold prescribed drugs due to an unexpected change in condition that causes the prescribed drug that was at one time necessary, to now be dangerous. The RN is with the patient, not the doctor. It is her job to catch this stuff and her ass if it all goes wrong. I could go on forever. I am not doctor, a mini me doctor, a wannabe doctor, etc etc. Nurses are hired and fired and discipline by the nursing directorate and NOT doctors. Doctors are not ward based and although they are brilliant at what they do, they do not know enough about nursing to have a say about nursing. We are not a subspecialty of medicine. We are a different profession entirely. We cannot function without doctors and they cannot function without us.
I am probably about as ignorant about doctors as they are about nurses (and believe me, they don't understand nursing at all). But here we go. A doctor is an extremely highly educated individual who has at minimum something like 5-6 years of training at school and than years of training after that. They are 100% in charge of officially diagnosising a disease process and prescribing treatment. The amount of stuff that they have to know to recognise and treat illness is insane,. They are scientists of the human body. They spend very little time with the patients, especially on general wards. They do not know what goes into implementing the orders that they give or how a nurse stops a patient from getting worse or dying as a result of their illness and treatmentsjust by using basic nursing care. They do not know that nurses have responisbilies other than assisting them. They think that the nurse is only caring for their patients and ignore the fact that she is handling 10 patients and 16 different physicians who are AWOL. They are brilliant at medicine. But diagnosing and prescribing is only one (large) peice of the puzzle that keeps you alive in hospital. You can have a brilliant, perfect doctor but if your nurse is stupid you could die. The nurse is at your bedside, monitoring you for change in condition, ensuring that your diagnostic tests are performed and that the doctor is made aware of any results or changes. If I ditch these things to spend my time mopping floors and holding hands I could get someone hurt or killed. This is the reality of how hospitals are set up. I bet you thought that doctors were always with the patient managing all aspects of care with nurse there to assist him and that the doctors hired and fired nurses! You saw that on the TV show Scrubs didn't you?
Doctors have, for years, pushed the stereotypical view of bedside nurses as being nothing but useless waitresses in order to inflate their own egos. They have aided and encouraged the poor and misleading media portayals of nursing. They were the first people to do this. The situation has deterioted so badly, that even our own nurse leaders, who left the bedside years ago, are denying that bedside nurses are important. Even our leaders are focusing on the angel crap and not educating the public about how important bedside nursing is and how knowledgable you need to be to do bedside nursing. Everyone has been conditioned to have disdain and disrespect for bedside nursing. Even nurses. Even nurse academics are pushing the idea of bedside nurses being "losers" and refusing the admit that it is indeed a difficult and challenging occupation that requires skill and knowledge Nurse academia only seems to know how to "promote" nursing by portraying nurses as mini doctors. Now people hate nurses even more. Doctors have contributed heavily to this situation and now they are moaning and whining about nurses leaving the bedside to become noctors and penpushers. Hey Doc, thanks to you leaving the bedside to practice a science that I am not qualified to practice is the only way to get a raise or a shred of respect from anyone. Why can't we all just admit that bedside nursing is crucial to patient safety, and that bedside nurses needed to be highly skilled and educated? We, as a society, won't admit this and it has led to cost cutting hospitals denying the importance of real nurses at the bedside and replacing them with unskilled and uneducated care givers. Make no mistake about it, this is lethal and it is not cost effective. They savings they are making on labour costs go out the window when patients are experiencing expensive after expensive complication as a result of lack of RN input. It ruins the bedside nurses who are left with so many patients and information to work through that they cannot function and it harms and kills patients. And that brings me to my next group of people who work in the hospital.
Healthcare assistants/ unlicensed assistive personnel/ care givers:
Hospital administration is no different than your average Joe.. They don't understand or value professional bedside nursing so they felt that there was really no need to keep paying all these nurses. They lost nurses via natural wastage and replaced them with carers. Now a nurse has 15 patients to keep track of and nurse rather than 5. Health care assistants or nice, often hardworking, they do basic care and many of them are bright. Some hold degrees in history or English lit etc and were never able to get a job in that field. Others are pre-med or pre-nursing students trying to earn some money. Others can barely read or write and have no interest whatsoever in becoming a nurse. They are simply there for the paycheck. If you walk onto a general ward these days and see 6 members of staff in Nurses uniforms, at least 4 of them will probably be care assistants. They won't have had any nurse training. They are not licensed and cannot be "struck off". The RN takes the fall for anything that one of these carers does wrong.
Healthcare assistants may now be staffing the wards instead of real nurses but they cannot take over for nurses. They can only do small aspects of basic care. This isn't even close to being a snapshot of the whole picture of what a nurse does. Sometimes they bathe all the patients because their RN has critical patients. They do some blood pressures and maybe change a dressing. Then they declare "hey I am just like a nurse, I do most of what she does". Not so kiddo. Not so. About 90% of what is going on in that ward is way over the heads of the care assistants, even if they have been a care assistant for 20 years. Most of the things that I, as the nurse, are responsible for or am troubleshooting are things they have never even heard of nor do they understand what I am doing and why. They don't get why I can help them with baths some days but not others. They think it is because the nurses don't want to be bothered. They see their jobs as 90% of what nurses do, even though it is really only 10% barely. I don't think some of them could even pronounce the word acuity. They are doing basic care without the additional assessing and planning that goes with all that and not pulling the information together. I do work with smart care assistants however and I do listen to them.
Lets look at the 30 bed ward I worked on years and years ago. We might have 6 registered nurses and 2 auxillaries on duty for a day shift. Yeah really. The most senior nurse took charge. The other five of us staff nurses each took on 6 patients each. I had 6 patients, to assess, monitor, medicate, care for, and keep track of. The auxillaries helped out rather than taking charge of hygeine and basic care. I was there also doing the bedbathing and basic care too. I needed to in order to get a handle on my patients conditions.
Fast forward to a 30 bed medical ward in 2010. Now if we are lucky we get 3 RN's. 99% of the time we have 2 RN's. Sometimes (and this is getting worse) we have one RN. Over the last decade hospital administrators have decided that nursing is so retarded that untrained people can do it.
Let's go with the typical staffing these days of 2 RN's and 3 care assistants for a large general ward. If there are two RN's we split the ward in half and take 15 patients each. Now I have 15 patients to monitor, assesse, medicate, and keep track of with no charge nurse back up. And patients are sicker these days and they are in and out of hospitals quicker so we have to do more with less time. I am so over my head with all the drugs, information, monitoring, family member questions, multiple doctors for each patient etc etc that I am left completely unable to deal with the basics. That side of things are getting left almost 100% to untrained and unregulated care assistants. They can do a bedbath but they cannot extract the knowledge about the patient condition and act on it like a nurse can. Things get missed. Some carers don't take things like pressure ulcer prevention and nutrition seriously because they don't understand the consequences nor can they be held accountable. And they have too many patients to feed anyway. We have more care assistants but they are still always going to be outnumbered by patients who need help. I can't get on top of those basics eitherwhen I am the sole RN for so many patients.
This has been a fucking disaster. It is a mess. You walk onto a large general ward nowadays and you will not be able to find anyone who has a clue about what the hell is going on. The care assistants are not really able to explain rationale for treatments, or drugs, nor do they read notes. Most of what is said in shift handover goes completely over their heads. They are merely concerned with who is allowed to eat and who is incontinant and telling anyone who will listen that they are the "real" nurses doing all the "real" work. And still there are more patients to feed and clean than there are nurses and care assistants.
It is a mess and until people start understanding the importance of knowledgable bedside nurses and why staffing is important it is a situation that is going to deteriorate even further.
Mark my words. If something isn't done the level of basic nursing care on the wards is going to get worse. And no amount of magic red trays to "help nurses understand" that some people need help with meals or dignity lectures is going to help.
If by sheer luck anyone reading this is a member of the media or involved in the entertainment industry please realise that every time you depict nurses as nothing but compassionate brainless angels, handmaidens, servants, or mini doctors you are contributing heavily to this problem and you are hurting patients.
If you want to learn more about this from a real writer/journalist who has been studying issues in nursing since the early 80's I suggest you check out any book ever written by Suzanne Gordon especially nursing against the odds. She is the only non nurse I know who really gets it. All I have done is this post is rehash a lot of what she is saying based on my personal experience.