Monday, 29 March 2010

Even More Fun at Mealtimes and Productive Ward

At 6 PM they send a food trolley up to the ward.  At 6:30 they take it away.

On this particular shift we had 2 RN's and 2 care assistants for the shift.  That was the entirety of the ward staff. No ward clerk to answer the phone.

There were 15 patients that needed to be fed.  The entire ward consisted of 30 patients.

Between 6 PM and 6:30 PM thirteen people rang for commodes.  This takes at least 20 minutes for each patient as you have  to find a commode, get two staff to transfer the patient onto it, transfer the patient back to bed and then wash the commode for 11 minutes between patients as specified by the infection control bitches.  They should do it themselves.  It might help them lose some weight.

Between 6 and 6:30 five people needed analgesia.

Between 6  and 6:30 two new admissions were sent up.

Between 6 and 6:30 four IV pumps beeped and alarmed because of empty bags, pulled out lines, occlusions, and air in the lines. Time consuming to fix.

Between 6 and 6:30 one confused patient fell.  She thought she was late for her bus.

Between 6 and 6:30 seven phone calls came in from family members who tried to talk my ear off and refused to get off the fucking line so I could get all the way back down the ward to my patients.

Between 6 and 6:30 one hundred and seventy drugs were due to be given.  170.  Most were not on the ward.  Many needed careful and time consuming preparation.

Between 6 and 6:30 one man had chest pain.  It looked pretty classic.  I had to page a medic (when I could actually manage to get a line out between relatives phoning).  Get observations, GTN spray, an ECG, bloods and 02.  I had to ignore the food trolley, and the call bells to do this and run past frail patients who were left with a tray of food that they couldn't manage to feed themselves.  When the medic came I had to give a load of other stuff to the patient, and organise a transfer to CCU as well as hand him over to CCU and ring his family and answer all of their questions.  I was quickly losing the ability to feed any patients.  I found myself wishing that these poor bastards would let me get off the phone as it was mealtime.

Between 6 and 6:30 recovery demanded that either myself or the other RN working with me escort a patient back to the ward from theatre.

Between 6 and 6:30 a consultant showed up to do rounds and his junior doctor snapped his fingers at me to let me know they wanted me to follow them around as they reviewed each of their 11 patients.

By 6:25 one care assistant managed to get all the trays handed out.  Then she started on the first feed. And it was then that kitchen started demanding all the trays etc back so that they could get them washed, sorted and get home on time.

I am not exaggerating.  If anything, I am being conservative with all this.

The productive ward fuckos have given us some new ideas to try in order to help is avoid malnutrition in our patients.  I wish I could scan the letter onto this blog.  They gave us 5 orders suggestions to facilitate meal delivery.

1. They will be buying red trays and red tops for water jugs to help the nurses identifty who needs to be fed.

2.  We are getting this giant laminated flow chart/ map of the ward that we have to fill in every mealtime identifying who needs to be fed in red marker.  If someone doesn't get fed we have to colour in their block with a green marker and if they are able then we colour in that block with blue pen. If they are NBM for whatever reason we use a purple marker.

3. All staff have to drop what they are doing and participate in meal delivery.  This is a dig at RN's who often leave meal delivery to the assistants because we have unavoidable ill patients, orders, and drugs due at mealtime.  The assistants cannot help us with orders, drugs, and ill patients.  ( I really don't think that they ladies crying for commodes and the man with chest pain would have appreciated being ditched at mealtime.)

4. We are to complete a nutritional care plan and audit.  A "nutrition score" must be calculated for every patient over the age of 60.

5.  Doctors will be told NOT to do rounds at mealtime.  (They have never complied with this rule on any other occasion so why the hell would they start now?).

Management thinks that they have covered their assess with these 5 objectives.  They can turn around and say "we have done this and that to help our nurses stay on top of malnutrition and be more efficient at mealtimes."

How completely dumbass is all of this?


Dino-nurse said...

Ah, the red trays! Productive ward is a waste of time. So far, the ICU has managed to avoid it but I have had to sit through/go through the motions for MAU and SAU. Our alphabetised drug system was thought too complex (its based on the ALPHABET) we were ordered to rearrange it into body systems and use little laminated pictures rather than, say, the NAME of the drug...also had a load of arrows painted on the floor to indicate where equipment was supposed to live. Hmmmm. First arrest situation, one of the F1s ran to the drugs cupboard and couldn't find any dobutamine....silly boy expected to find it under "D" and labelled "Dobutamine"...just as I had predicted would happen. Patient survived and I lovingly filled out the IR1. Now I have been told that I am being obstructive as I have allowed the staff to undo most of the productive ward suggestions, as they Do NOT WORK! As for protected meal times, if they are a joke on an acute medical ward, imagine the chaos on an admissions unit. We have also been informed that we need to do a nutritional assessment within 4 hours of admission. At the original meeting, it had been suggested that ED should also do this...thankfully the consultants backed me up on this one...can you imagine? One advantage to the red takes the hostess twice as long to dish out the meals, so we get an extra 20 minutes to feed people. Unfortunately catering are kicking up a stink about how late they are running because of this, so we wait to see what happens. As for doctors rounds during meal times...try this one- put a screen across the door with a big notice on it signed by the unit director. Laminate it and put his big grinning face next to it. Inform medical staff that you will be personally handing IR1s about ward rounds to him. Worked for me. After a few weeks of IR1s, said unit director actually left his office and met with the consultants. Finally, doctors who snap their fingers should have said fingers cut off. Or some other appendage. We are not their bitches (but I can certainly behave like a bitch if needs be).

the a&e charge nurse said...

There is undoubtedly a deep cynicism that pervades such initiatives - so how did such a miserable state of affairs arise?

I suspect it's because few staff on the shop floor believe that policies like this one are being implemented to improve standards, but rather as a device to persecute staff when an an entirely predictable catastrophe finally take place?

Look, the investigating managers will say, this standard in the policy, or that standard in the policy was not adhered to you - therefore, it's all your fault you naughty ward nurse, you!!

Ask yourself this - how many hospital policies include either anticipated demand on time (such as specifying how long it will normally take to feed 30 patients with a ratio of 1-10 say) or the cost implications, including, training, equipment, manpower etc.

And if this data is NEVER factored into the calculation, bearing in mind there are literally hundreds if not thousands of 'policies', how is anybody ever meant to determine how realistic or otherwise each set of objectives are when they are all placed side by side?

TonyF said...

Call me a cynic, but what if your 'managers' came and gave you a hand? They obviously have plenty of free time to come up with this nonsense. I know that were I in power, there would be a major cull of administrators.

the a&e charge nurse said...

"but what if your 'managers' came and gave you a hand?"
Hang on TonyF - I'll just have to check and see if the policy permits such an unusual set of circumstances?

Now then, page 94, sub-section xiii - managers assisting staff on the ward - no, sorry Tony, it says here that managers helping would conflict with Health & Safety (see page 201 - sub-section iii, paras 4-8)

Nurse Anne said...

Well Tony first of all the managers all go home for the day at 4PM.

Feeding patients isn't always simple. It's not just a matter of spooning food into someone's mouth. You have to understand things like dysphagia, renal diets, high or low K+ diets, diabetic diets...which patients are NBM for procedures, fluid restrictions etc etc ad nauseum. The assistants we have fuck a lot of this up and I don't think that managers and or volunteers are competent or capable of helping out at mealtime without a disaster occuring.
And with everything that goes on it would be impossible to hand over all dietary information to oncoming managers/volunteers at mealtime.

Anonymous said...

Al sounds very familiar. You sound burnt out. At some point you'll have to stop. There is a name for all this - structural violence. I stopped because after 2 years, 3 months and 1 night shift in an a&e department I'd received

Anonymous said...

Anonymous said...

zero input or interest in my job from clinical educators or managers - except to ask why a patient was almost breaching. Most of the charge nurses were burnt out or imbecilic or both. Not much to inspire you. Bored of apologizing to patients and watching disaster unfold.

toby said...

Anne, its quite simple. apart from serious medical issues, drop everything to do this stupid stuff and direct all complaints to the fucktards that come up with this crap.

soon they will be swamped with complaints and at which point you could turn around and ask sweetly 'poo or food' do you want OUR patients (cos managers seem to forget they're ultimately responsable for this too) to lay in their doings and be fed, or the other way around, pray tell.

TonyF said...

Ah well, plan 'B'. Give them mops and brooms...

Anonymous said...

Don't forget the food charts and fluid balance charts MMN!

Anonymous said...

"Well Tony first of all the managers all go home for the day at 4PM."

Where on earth do you get that bollocks from Anne? Since I've been in a senior nurse post in January, I've not been home before 6.30 pm one single evening, last night it was gone 8pm and this is after starting 7.30am most mornings. No time owing, no overtime, no time back and no lunch or breaks. Yes, most of my day is spent on the wards and the reason I have to work so late is because after I've been working on the wards, I still have to get my own work done as well.

My ward staff all know who I am, but may not tell you they see me all the time as I am responsible for 6 wards across 3 hospitals as well as a large community nursing team covering a whole county, I can't be everywhere at once sadly. If I'm working on one ward, the other wards may wonder what the hell I'm doing with my time and why I'm not supporting them. Today one of my wards rang me for help when I was in another hospital 40 miles away interviewing for Band 5 posts. I'm sure they thought I was letting them down because I couldn't help.

This weekend I am on call for one of the hospitals in my Trust, and yet I don't get paid for being on call. I'll be in for most of the weekend and called throughout the night and I'll still have to do my usual 50 hours plus during the week as well on top of it.

Its really crap on the wards right now, that can't be denied at all. I hate it when I go to the wards and see how much pressure they are all under, and how different it is to when I started nursing, but please don't think that all managers have it easy, there are still pressures, just different ones.

As for staff shortages, yes, we have those as well, but mine are all due to vacancies, not due to cutbacks. I've advertised 3 times for Band 5s on two of my wards and not managed to fill them at all except for a few hours here and there. One of our hospitals has 50 WTE vacancies that just can't be filled. No wonder its tough on the wards.

Productive Ward? I must admit I was extremely sceptical, still am, but its been well recieved on all of our wards much to my surprise. Maybe its been implemented differently, I don't know. I was talkiing to a good friend of mine who is a Ward Sister (not on one of my wards so she has no reason to lie) saying it has been the making of her ward.

Great blog BTW.

Nurse Anne said...

Hi there,

It's not bollocks. Many of the upper managment are out of there between 4 and 5. I know the matrons are for certain. The ward sisters on the other hand, work 70 hour weeks. They have lost their management days and have to work full time shifts as the only staff nurses for a large number of patients when they are on duty and then do all of the management stuff in their own time.

I think that management thinks that as long as there is a ward full of auxilliaries that the work can get done. Idiots.

But I am glad you are a good manager. I think the "leaving at 4" thing depends on what level of management we are talking about.

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