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 relatives.......so 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 it....to 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 staff......an 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.