Sunday, 28 February 2010

What actually happens when we are shortstaffed?

You should know what it means, since we are like this all the time.
First of all it means that during my shift I am responsible for so many patients that I can not keep all of the pertinent information about them that I need to know straight.  And I'm pretty good.

If I have 4 patients I can get through their notes and information pretty quickly.  I can catch onto new orders from the doctors quickly and plan nursing care around this. I can see the whole picture regarding the patient and communicate effectively with the family. I can do this and still have time for nursing care.  I can do my initial assessements of the patient and make sure that they are clean, dry, have a drink pretty quickly at the beginning of my shift. Then I have 10 minutes to get through those charts and answer phone calls before I go back to those patients.

If I have 20 patients I will never get through more than three charts at a time, without being interrupted.  By the end of my 12 hour shift it is very unlikely that I have been able to read any notes.  Every attempt I make to read those notes means that I am leaving people who need a nurse at their side.  It would take me hours and hours to do my initial checks on my patients.  Having the phone calls of 21 relatives to take means that I am being interrupted constantly.  It means that during my shift I am having to leave the patients and run to the phone every 5 minutes.  Once I finish one phone call and start to head back towards the patients, another call comes in.

If I have 4 patients, and all their relatives are phoning the ward all day I can handle those phone calls without neglecting my patients too badly.   With 20 patients the phone calls are never ending.  They never stop.  I am constantly having to leave the patients to answer the phone.  I am getting asked questions that I cannot answer because I do not know what is happening with my patients.  There is too much information for me to wade through and too many people wailing for help to allow me to do it.

If I have 20 patients it takes me from 8 AM until 11:30 to get everyone their first lot of medications that are due at 8AM. Unacceptable that half of those meds are hours late but it is the best I can do.  And  I will only do that well if I ignore the phone calls, abandon the idea of looking through the notes to get that information about you that I so desperately need, ignore everyone requesting a commode and ignore the wet beds throughout that drug round.  I must also abandon the idea of staying with patients and helping them to take their tablets.  I must move fast and keep my eyes down and remain focused.   I have to mentally block out everything else that is going on around me and focus. If I didn't do it that way, it would take until 3 PM before your mother got that pain killer that she was due at  8AM.    I really have to be strong and limit the amount of time I spend with each patient to ensure that I get to all of them fast enough.  If I am not firm about this and drag myself away from people who need me then patients will wait 7 hours rather than 3.

Shortstaffing means that if I take all the time that Mrs. Smith needs to get washed and go to the toilet, take her meds and eat and drink that it is done to the exclusion of all the other patient care for all other patients.  I could hand pick 4 of them and take care of them really well by ignoring the others.  Or I can do little bits and pieces very quickly to ensure that I can get around to all of them.

 In those 30 minutes that it takes to help a confused and reluctant Mrs. Smith take her tablets your mother is at the other end of the ward, falling out of bed.  If I rush and push Mrs. Smith and do it in 20 minutes than it is 20 minutes before I get to your father who has been ringing his bell,  waiting for his bedpan.  He gets out of bed and pees on the floor, slips and falls.  If I really push Mrs. Smith to the point of causing her great distress than I can get her tablets into her in 10 minutes.  That allows me to appear caring to your loved ones but I will appear uncaring to Mrs. Smith's loved ones.  If your Uncle Peter has stopped breathing at this time I will get to him too late because I spent 10 minutes in that attempt to get Mrs. Smith to take her tablets. I have 20 Mrs. Smith's to medicate at 8AM.  If I am going to do this right it is done to the exclusion of multiple other things that are happening on the ward for hours and hours.

I cannot do one thing right by one patient without causing harm to all the others.

Mrs. Jones is immobile and unable to use a call bell. She has had a bowel movement and it is smeared from her head to her toes.  I immediately stop what I am doing and clean her up, taking the time to reassure her and coax her into taking a drink while I am there.  Doing all that efficiently takes about 40 minutes.  Sounds good but there is one problem.  Your mother has cancer pain and she is in agony.  Two minutes after I commenced cleaning up Mrs. Jones your mother cried out, begging and sobbing for her pain killers. 

It will take me 10 minutes to hunt down her pain killers and 10 minutes to track down another staff nurse to check them out.  If I finish cleaning up Mrs. Jones first your mother is left in agony for an hour rather than 20 minutes.  If I immediately abandon Mrs. Jones to help your mother then I am leaving Mrs Jones in a bed smeared with shit for an additional 20 minutes.  And it is only 20 minutes if I ignore the other requests for drugs and commodes that are being shouted out to me as I run past beds.  If I stop for them, it takes longer to get back to Mrs. Jones.   Visitors will jump in front of me during this, angry and demanding that I speak to them about their Aunt Joan's care. They won't take "No I can't stop right now" for an answer so I get real stern and push past them.  As I am running back to Mrs. Jones'  bed I avert my eyes to ensure that I don't make eye contact with the other patients or that I don't get dragged into any other jobs, as they will only delay my attendence to Mrs. Jones even further.

Your son has just arrived back on the ward from surgery and post operative patients can deteriorate very quickly.  Patients with his issues are known to crash more quickly and dramatically than the usual post surgery patient. If that redivac starts to fill up and his blood pressure starts dropping and I don't see it your had better start planning your son's funeral.  Get the baby pictures and your black suit out.

Post operative patients like him get sent back to the ward too quickly from recovery, so that more people can get operated on.  If you have a post op patient like your son arriving back onto the ward you must immediately do a series of checks and jobs to ensure that he is okay and does not need to be rushed back into surgery.  If you do not document every single action that you do for this patient as you are doing it then you DIDN'T DO IT.  If you didn't document his observations, respiratory rate or document that you checked his morphine drip and redivac bottle then YOU DIDN'T DO IT.  And it doesn't matter if you have a thousand witnesses declaring to a court of law that you did do it but were too busy to document it on the paperwork.  Write it down as it is happening or they will say that you didn't bother to check that redivac and that is why this man bled to death.

I did good by your son.  I went to him as soon as he arrived back onto the ward.  I know how patients like him can crash.  I did all of the necessary checks and stayed with him to do look for an emerging pattern with his observations.  And there was a pattern.  His blood pressure was going down, his pulse was going up.  His redivac which looked good at first check 15 minutes ago is filling with blood. He is less alert than he was when he arrived back on the ward 20 minutes ago. I look at what I wrote and saw 20 minutes ago and compared it to what I am seeing now.  Oh shit. But we caught it and the doctors swung into action when I phoned them and implemented the necessary steps to sort him out.  He went home.  Had I delayed my checks on him I would have found a corpse in that bed.

Sounds like I did real good with your son but there is a problem.  At the time that the theatre staff were dumping your son back onto the ward I was at the bedside of  Mary.......  a lovely 50 something woman who is full of cancer.  She is going to die anytime and she knows it.  There is nothing that the medics can do and she has requested a DNAR.  Her pain is under control and up to this hour in time she has been smiling, strong and stoic.  She is completely aware. But in the last hour she has been scared, trembling and clingy.  All nurses know that patients know when they are going to go.  Mary has an inkling that today is it, and now she is terrified.  I was at her bedside when your son was dumped back onto the ward by theatre action that they could not delay to allow me to stay with Mary.  Her fingers were clamped around my arm "please don't leave me, please don't leave me".  I had to pry those fingers off of my arm and run out of the room to check on your son and nurse him properly.  Had I not, your would be dealing with the funeral home now.   As they were taking your son back to theatre the first thing I did was run back to Mary.  I ignored call bells, patients shouting for commodes, family member phone enquiries and averted my eyes to the visitors and patients in order to get back to Mary.  She had died while I was with your son.  I can't even feel good about the fact that we helped him because I feel so bad that Mary died alone and scared.

Do you see how the nurse can be at the bedside of one person, oblivious to her surroundings and focused on filling in documentation whilst another dies alone?  There will always be an observer (a visitor) watching this situation with an untrained eye.  And he will say "look at that nurse messing about with the notes of that young lad whilst other patients shout out for help".

What if I had stayed with Mary?  What if I delayed my checks on your son to go to the nurse's station and call Mary's family? There are visitors at the nurses station and once they saw me that would be it...I would never have got to your son on time. What if I cleaned every bed that was wet at that time and picked up every confused and elderly patient off of the floor or coaxed them into eating rather than doing that series of observations on your son?  It's all happening once and this is during mealtime. What if I hadn't bothered to document his initial assessment and change in condition so that I could sit with Mary instead?  Well, I can tell you now that he would not have received the help he needed.

It's mealtime and if I take all the time I need to feed one person it means that I will not see any others until long after the domestics have collected the trays in.  So I try to do a spoonful each.

If I go around with a cup of tea for everyone it would take so long that it would be to the complete and utter exclusion of all drugs and treatments that were also do at that time, and all day long.

If I go to the nursing station to answer your phone call about your loved one I am having to leave people who need help to do it.

If I am ringing your about a change in your grandmother's condition I am having to leave a confused patient who is climbing over the siderails to do it. I can spend an hour with her, repeatedly stopping her from falling out of bed.  The minute I leave to finally ring you about your mum's condition she will be on the floor.

If I am helping one patient with toileting and hygeine properly, than I am leaving 19 other patients without for as long as it take to help that one.  If I do a half ass sloppy job for each person and limit myself to 3 minutes each I might get to see all of my patients and catch and deteriorations in condition.

I am responsible for an elderly lady with dementia called Jane.  Jane cannot walk but forgets this.  She frequently tries to stand up and falls.  Even if I am there, kneeling in front of her and talking to her she still screams "Help me" and stands up and nearly falls.  I show her how to use the call light and she tries to eat it.  I give her food and she spits it out.  I could spend hours with her, reassuring her and making sure that she has all she needs to the exclusion of all other patients on the ward. I could spend those hours toileting her and cleaning her and stopping her from falling.  I could sit with her for 6 hours and do that.  Five minutes after I walk away she will be lying on the floor with a broken hip, lying in a puddle of piss.

And I cannot pick her up off of the floor  and clean her up without ignoring your father's cries for help, or delaying the treatment he needs for that massive allergic reaction he is having to those IV antibiotics he was just given.  His face is swelling up and his lips are blistering right in front of our eyes and his breathing is sounding wheezy.  Do I leave Jane on the floor to help your dad?  What do I do about the other patients who are making requests for care while this is going on?

Let me tell you.  The situation on the wards is crisis management. Everything is happening at once.  As a nurse you must look at what is highest priority and what can be left undone without killing someone (i.e. toileting). 1.  Life threatening problems and related paperwork, 2. pain control, 3. doctors orders, 4.monitoring for changes in condtion,5. medications, 6. treatments, 7.basic care (care assistants can help you with number 7), 8.discharge planning, 9.stupid  paperwork.

And when we are short staffed we are never getting past number 5.  Sometimes we cannot get past number 2.  Unless you want to cause harm you can never tackle number 7, not even for a moment, if numbers 1-6 for all 20 patients are not sorted out first.  You may not like the idea of leaving basic care undone while you do a never ending drug round.  But the facts are this: if you tackle basic care before ensuring that the higher priority stuff is dealt with you will almost certainly cause great harm to someone.

If I had only 4 patients I would get from numbers 1-7 and get it all done well before half past 10 in the morning.  With 20 patients It takes the first 5 hours of my shift to get to number  5 (if I take shortcuts that cause observers to view me as callous and uncaring, otherwise it takes longer) and after that I will only hit on various fragmented parts of numbers 6,7,8, and 9.

So this is what happens when we are short staffed.


Anonymous said...

I know the feeling of trying to go about doing your necessary work without meeting anyone's gaze (patient, relative, even nurse) - on my ward I work (standing up naturally) at the nurses station (there is no doctors office) in the centre of the room, I am constantly available to every single relative or patient who wants to harrass me as I desparately try to get my work done. That isn't so bad because I don't mind (so much) hanging about for an hour or so at the end of the day.

But when I'm on call covering wards everytime I enter a new ward to check out the patient who I'm told has just read a blood pressure of 60/30 enroute to see the patient vomiting litres of blood, having just come from the patient in status epilepticus, before getting the crash call, I inwardly scream as they scurry over with the 3 warfarins that need prescribing, the requests for fluids, the night sedation, the paracetamol for a headache, and the 4 venflons.

And when I say that I'll only do the one venflon for the septic guy and no one else, and refuse to asssess the patient with mild nausea or the one with known fast AF who has tachycardia, or say that I'll try and come back later to do the warfarin, they get annoyed. And if a patient wants to know something about their relatives care 'from the doctors' at 7pm and they are not peri-arrest then they are just not getting anything from me I'm afraid.

Dino-nurse said...

This highlights exactly why admissions to ICU are on the increase- simple things are being missed because nurses are having to rely on HCAs and APs to monitor post-operative patients. When I first qualified, post-op patients stayed in recovery until the staff nurse from the ward was happy to take them back. Now they are dumped back without any real warning. I was horrified to see this happen recently whilst transferring a patient from the ICU back to a ward after 6pm. Recovery staff brought a young patient back with a resp rate of around 6, tolerating an airway (whilst still snoring becuase his head was practically on his chest) and looking pretty pale and clammy. A PCA syringe was included but without a pump and not clamped off. There were 2 RNs on the ward and a handful of HCAs. Wishing that I had hung onto my patient for a bit longer, I finished handing over ( we needed the bed for an ED admission and if you transfer out after 8pm an IR1 is involved). The recovery staff were trying to fob off their patient to one of the HCAs- I intervened, patient was obviously not stable enough to leave recovery and gave them two choices- take him back or stay and recover him properly. They took him back saying that they would write me up and tell the surgeon. Go ahead. Pretty sure that the surgeon would thank me for not getting him out of bed at 3am when this patient crashes horribly or ends up as an ICU emergency admission and spoils his stats.

Nurse Anne said...

" And if a patient wants to know something about their relatives care 'from the doctors' at 7pm and they are not peri-arrest then they are just not getting anything from me I'm afraid"

I think doctors can get away with that attitude but as a nurse one cannot.

If I am not sympathetic and able to make myself immediately available to everyone's needs at all times I am deemed "uncaring, mean, cruel, ignorant".

Once I did have a man who was periarrest and as I was sorting him out by implementing the registrars orders I was accousted by a family member who wanted me to bring their mum a commode. I told her (apologetically) that I could not.

"well nurse this isn't how you would want someone to treat you when you are old" she spat.


Nurse Anne said...

Dino Nurse I just read your comment.

You saved that patient's life. Had they fobbed him off onto the HCA's while the RN's were busy he would have died no doubt. The RN, probably completely unaware that he was even on the ward, would have been blamed for his death.

What the hell was going on with that PCA? Did he need narcan?

Imagine if that man had been dumped on the ward...that you were not there to intervene. Imagine that the nurse went around helping everyone with hydration on her way to his bedside.

The poor lad would have been a corpse.

Anonymous said...

I've seen a post-arrest patient come back to the ward from recovery. "Doctor, could you see this patient even though he's not one of yours, he seems quite unresponsive". Too fucking right he was!

As I went over to assess the patient the nurse from recovery just handed me the op-note, said his BP and sats were low (yeah, 50/20 and 40% - practically ready for discharge), told me what he'd had done (this wasn't actually right) and then cleared off before I or the ward nurses could say anything.

Fortunately this was endoscopy recovery and the patient was the usual DNAR bleeder otherwise some people would be losing their registration.

Dino-nurse said...

PCA syringe had been removed from the pump prior to transfer as recovery like to hang onto their pumps (even though they officially belong to the equipment library not individual units). The numpties forgot that without a clamp these lines often syphon if held above the patient for long enough. Yes he needed narcan which the nice F2 on the ward gave him before we made the recovery staff (Nurse plus ODA) take him back. The IR1 was completed by me at a later date and dumped on the desk of the theatre services manager (plus when I mentioned it to the consultant invensivist on my return he bent the ear of same said manager). We often get unstable patients transferred to us from theatre as most ICU patients bypass recovery and are dealt with by us. ICU has the luxury of 1:1 ratios and gasmen on hand. General wards do not. Its something that is being brought up at the next surgical services meeting- surgeons are getting huffy about delays to elective lists (and hence loss of cash for the Trust-not to mention fines) whilst ICU is getting huffy over the increase in elective emergency admissions (surely a cost issue as this is the only issue that service managers seem to understand). I wonder who will be listened to?

Nurse Anne said...

"PCA syringe had been removed from the pump prior to transfer as recovery like to hang onto their pumps (even though they officially belong to the equipment library not individual units). The numpties forgot that without a clamp these lines often syphon if held above the patient for long enough"

We have the exact same problems. Thank god a surgical patient is a rarity on my ward.

The porters and the mau health care assistant will bring admits from mau. There is saline with 40 mmol of potassium in the bag. The pump is gone. The clamp is open, the bag of fluid is on the bed, there is blood going half way up the tubing. They dump the patient in the bed, whether I am ready for him or not.

The venflon is now fucked, unusuable and he needs another inserted and I have to chase around the hospital looking for a graseby pump.

And about 10 hours later we'll get those fluids restarted.

Nurse Anne said...

And I am sick and tired of these little fuckers with no registration like porters and health care assistants causing the nurses these kinds of problems. They just do what they like and dump it back onto the nurse. Who can I dump on when I am overwhelmed?

NHS Nursing Student said...

On my first day as a Student Nurse I nearly jumped down the throat of a HCA who was being very willy nilly with several patients during bed washes when it came to IV lines. At one point the prick bashed open a pump because it was being a bit naughty and beeping on/off all morning (there was nothing actually wrong with the meds or pump besides it being a shitty old piece of equipment) he said "I hate the effin beeping" right infront of the patient. He has no idea how important that pump is, he had no idea what he just did, he was thinking of himself. Luckily for the patient and him I did. My time being a HCA and spending 2 fucking seconds listening to what was going on in hope I would gain knowledge, along with my BioMedSci degree and the little theory I had in Nursing school before I went to placement set the alarm bells off in my head. I very calmly went around to his side of the bed and but everything back in it's place and put the pump back on, I know my way around one of these things thankfully during my time in A&E/CDU but never actually had to fix the kind damage this HCA had done. By the time I had straightened the pump up the line in the patients hand had been pulled out (for reasons unknown, probably from being a little rowdy with the pump) and there was blood pissing everywhere. I would have informed any nurse in charge since this pump needed to be reset and a new line put in asap, but since sister was on that day and this patient was hers I thought it was going to be a very unlucky day for this HCA. What does a ward sister do when one of her most loyal HCA's of 10+ years sticks their nose in dangerous territory? Absoloutly fucking nothing it seems, the enemy fucking lies within.

The Shrink said...

Is there anywhere in the UK where there's an NHS acute hospital that's got it right, or at least better?

Being optimisitically hopefully that it's at least possible to have better support, is there anywhere that has made positive change?

It'd be great if there was a unit with better staffing and better outcomes, so it'd be possible to look at a poorly staffed unit (e.g. Staffordshire) and the outcomes, but contrast that to a better resourced unit.

Is there such a place?

NHS Nursing Student said...

Where I work are getting there, my trust have good staff ratios all together, but we could always do with more. With 20-something patients a good shift is three RN's and one NA to each of these RN's, and the RN is assigned to one of 3 teams of patients. As well as students, and we know what we are doing more and more everyday. A bad shift is 1 RN and 1 ward sister, who is spending half of her shift in her office doing stuff she should have done in her "management" day. And 3 BANK NA's. Bank NA's are the worst.

It just all depends. The NHS don't want to invest shitloads of money into acute elderly medicine. End of story.

Nurse Anne said...

It's not bad everywhere Shrink. I did a post awhile ago about a day where he had 5 staff nurses for some reason.

But it varies and when it is bad it is really really bad.

Nurse Anne said...

Nursing Student,

Bank NA's are just scary. I ended up on a shift where it was myself and 2 bank NA's for 12 hours. I nearly walked out.

NHS Nursing Student said...

They send alot of Bank NA's to our ward to do their supernumery shift, I suppose my ward is a good start for them. Ward Sister and one of our senior nurses prefer us Nursing Students to teach them whats what, I'm not sure why. I like the Bank NA's who are in it for the right reasons, ask lots of questions and use their initiative. You can usually get them up to speed on what needs to be done. In my experience these kids are either med students or pre-nursing students desperate to make a buck and like helping people. I don't like the bank NA's who are in it for the money, use no fucking initiative and end up being nothing but a burden. These are usually full-time domestics or foreigners that come to the country desperate to get into work, any work. They don't care what they are doing. I helped get one girl from eastern europe up to speed on her first 2 supernumery shifts, she had booked a good 2 weeks worth of paid shifts and then came back to us yesterday, she was still just as clueless, and unaware, and uncaring. The amount of times I told her to pull her finger out... She went to some really, REALLY heavy and understaffed wards to, much worse than mine.

The Shrink said...

Nurse Anne, it could be worse. You could be given mroe staff. Like Nurse Practitioners.

Dino-nurse said...

Admissions units have their own problems. It won't be long before they also have a time target (like ED and thats worked sooo well). Burn-out rate is high and ours are really little more than glorified dumping grounds. Doctors change every day and continuity sucks. I have had patients admitted to the ICU that are dehydrated and now in acute renal failure- check the charts/notes and no one has reviewed them in days...even worse if its over a weekend or bank holiday. One of my very good friends is part of CCOT and is always begging me to jack in the sisters post and join them. If I tear my hair out at the moment, I doubt that I have the tempramant for Outreach.

devry columbus said...

It's really hard when you're shortstaffed. I admire nurses who are so dedicated with work and service that they still continue even with limited staff available.

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