Wednesday, 16 June 2010

A Nurse with Sense and thoughts on Relatives.


Every once in awhile I see a comment out there in blog land that really hits the nail on the head.  I found this comment over at jobbing doctor.  It was written by Dinonurse who should really have a blog!  I was trying to explain that there needs to be controls over the numbers of relatives ringing the wards.  That maybe we should enforce the one relative rings about the patient and speaks to the other family member rule.  It is the job of the nurse to communicate with family and try and keep the next of kin updated.  But one nurse to 22 patients? Imagine what happens when each of those patients has 10 relatives each ringing throughout the day and demanding a chunk of the nurse's time?  No nurse will be effective if she is on the phone with relatives 40 minutes out of every hour, repeating herself.

Rrecently I was delayed for 10 minutes getting to Mrs. Smith with her blood because Mr. Tate's relatives grabbed me in the treatment room to ask questions.  I wanted to help them but had to get away as fast as I could as blood bags cannot be left sitting around or they go bad and hurt the patient when they are infused.  After talking to Mr. Tate's relatives I went back for Mrs. Smith's blood.  Then the phone rant.  It was another one of Mr. Tate's relatives.  Got off the phone with him and went back for the blood.  The phone rang again.  It was Mr. Tate's neighbour wanting all the same information.  Got rid of him.  Went back for the blood.  Then Mr. Tate's relatives grabbed me again in the treatment room to explain the same thing to another relative who had just arrived. I had to throw a very expensive bag of blood away, order another unit and Mrs. Smith's treatment was delayed.  None of Mr. Tate's relatives felt that I spent enough time with them even though I put another patient's health on the line to give them the time that I did.  When they were nicely asked to try and communicate the information to eachother they responded with a "no, it's not convientant for me to do that".

Now imagine that each nurse has this going on with the relatives of up to 22 people all day long.  The nurse is the only one who can answer phone enquiries, give drugs and treatments, and catch onto changes in condition that require a medical review.  The rest of the staff on the ward are care assistants and cannot get involved with any of this.  Love the care assistants but they don't magically turn into nurses who can carry on with the drugs just because I got tied up with families.

Even the nicest nurses in the world are cursing the relatives under their breath when not one of the IV drugs that were due between 6pm and 9pm have been given because not only are visiting hours occuring around that time frame, but phone calls are still coming in.  You might have to repeat the same chunks of information to 5 members of the same family in 20 minutes. 

One relative (must be the named relative on the admission form) rings or questions the nurses.  And it is his job to let the other relatives know what is going on.  If you are visiting and have a concern to raise with the nurses by all means do it.  But beyond that it gets dangerous.  Relatives are important.  Patient care is more important.  The very last thing that a lone RN on a large ward can do is pull away from patient care to deal with your dysfunctional family dynamics.  Talk to eachother.  You can also make an appointment with the medical team to get a very detailed explanation of your loved one's situation.  I cannot believe that you want me to pull away and abandon my patients yet again today because you, your seven siblings and mum's partner do not want to speak to eachother and each want to call the ward separately.  It is bullshit and I am calling you out on it.   If you mum was my only patient I would happily give you all the time in the world and go through the notes with you.  If I had other nurses to continue with the workload I would leave them to it, make you a drink, and explain the treatment plan to you.  But I don't.

Back to Dino's comment.

Want to know why nursing care is deteriorating?

Want to know why the mean nurses "cannot be bothered" to speak to the relatives?

Want to know why "nurses" today seem so unprofessional and unaware?

Check this out:


A bit late into the fray...heres my tuppence worth (for what its worth). The NHS is in its death throws and nobody is brave enough to tackle the root problems...no one could have envisaged just how far medicine would have advanced in the last 60 years. The original thinking was that everyone would work for a living and pay NI and rarely end up in hospital having to take back some of the money. Nowadays many acute wards are filled with patients who have never really paid any NI (and please, I am not "having a go" just stating a fact) or if they have, a stint on the ICU will quickly cancel out all that they have paid in.


Long ago, staff nurses on acute wards were expected to look after 4-6 patients. They had ENs and auxillaries and students to help them. They had senior nurses and sisters who were clinically active (not stuck in an office) and each "firm" of doctors had their own ward (hence you also had the HO and SHO around on your ward most of the time.) Jump forward 30 or so years and now the acute wards are filled with patients who would have been on an HDU or even an ICU in the 70s. The patients are often older, have more complicated medical histories, people generally are living longer but are not actually that healthy.
 
Add to that that the culture in the UK has always involved drinking and smoking heavily not to mention the ever present problems with crack and other IV drugs. Medical treatments have moved on quickly. Take an MI patient for example...in the 70s if you had a "community arrest" -hell, if you arrested in hospital you had little chance of surviving...now you get thrombolysed and PCI'd and stented and statins etc etc. GI bleeds get scoped and stabilised and ICU admissions if needed, ICU patients get horrifically expensive drugs (APC anyone?). The cost per patient has drastically increased BEFORE you factor in the cost for nursing/medical care. There lies part of the problem...more acutely ill patients with expensive therapies...the NHS managers know that in order to pay for the meds and the rehab etc they have to save money and the easiest way is to replace nurses with HCAs.
 
Afterall they can do most of the "nursey" stuff right? Wrong, they can do very little of the stuff that an RN has been trained to do...jump forward another 20 years and you wll not find a qualified nurse outside of the ICU. Many of the acute wards where I am are already full of APs and HCAs...these are not nurses. The one poor staff nurse that is on for the shift has TOTAL responsibility for the lives of 28 patients.
 
Now I understand that this has been said before but really think about this. Imagine that you are responsible for 28 people. One of them suddenly deteriorates and requires your input...what happens to the other 27? Next time you visit a relative on an acute ward, count the number of RNs and then compare the number of HCAs. Count the number of patients with IV infusions and then work out in your head if it takes 20 minutes to sort out an IV infusion just how much time is left for EVERYTHING ELSE? Nurses do not run for their own health so if you see one running past you, they are heading for the crash trolley or a bag of noradrenaline not tea and biscuits! Sorry if this sounds unfeeling but at the end of the day, nurses are supposed to be there for the patients...if your relative was having a heart attack and the patient in the bed next to them was having an acute asthma attack ( both potetially fatal) would you be happy if the RN was stuck on the phone?

19 comments:

Maria said...

Hello Anne.

I am anonymous from Jobbing Doctors site whose dad died. Please be assured that I do no think the nurse 'killed' my dad as I know the stroke did. I made the complaint because if she had checked dad over at least I could have been there when he died and not at home thinking everything was alright. As I said she was not directly in the middle of things but just making entries on the computer which I realised was part of her job. There was not countless other relatives demanding of her attention and in fact there was none.

I do agree with you regarding Dinonurse and I also think that A&E nurse should write a blog too as they are both very rational and do not seem to over-exagerate in the sense that they do not become venomous.

I am returning to Uni next Monday and using my spare time off - compassionate leave so to speak - in looking at blogs.I have spent a lot of time on yours and have read back for months of your posts. I can understand your frustration and anger Anne and I do really feel for you, but I get the impression that you over-exagerate to prove a point. Perhaps you don't and if that is so I am sorry.

It seems that you hate relatives and I would ask you to see things from my point of view. I had a right to ask about dad but it seems to me that you think relatives have no right to ask questions at all. How are we supposed to know what you deem as
important? The average 'Joe public' is not aware of staffing levels on a ward and there is no reason why they should be unless they read blogs like yours. How are we supposed to differentiate between nurses and HCA's when we do not know (and why should we) until our relative goes into hospital? And even then we don't know. We see people in uniform and consider that they are nurses. Unless someone is unwell, I think that no-one (and why would they) would consider nurse/HCA ratio's in hospitals. I certainly didn't. I was just there visiting my dad.

As said I have read back onyour posts for months. It seems that you hate everyone! Relatives especially and I do realise that there are some arseholes out there! But most of us are not. We just need to know! Do you really think it is realistic to expect relatives not to ask about the well-being of their loved one? I really do think you have exagerated in this latest post about every Tom, Dick and Harry phoning up about Joe Bloggs! You must exist in a different world from me Anne as nobody gives a shit anymore about anyone unless they are closely related.

Moving on, you slag HCA's off in one post and in the next they are the best thing since sliced bread.You slag other nurses off if they are not University trained and I would ask how did the NHS survive until you came on board?

I am a psychology student and I wonder and worry about your responses. You react -depending on the circumstances with either initial compassion or disgust. You then make various add-ons as if to rationilise or change your initial statement. I worry about this Anne as it is an an open admisssion that you doubt yourself.
I do realise that you operate under great duress and I feel for you -but I wonder if you are losing it.

I find it sad that Jobbing Doctor as decided to take a break -perhaps for good and wonder whether it was due to the fact that you (for a while)filled his calm posts with your particular brand of venom.

Maria

Nurse Anne said...

Maria,

It was that anonymous guy who always tells JD that doctors are greedy and over paid that sent him over the edge. JD agreed with my posts. The same commentator tortured NHS blog doc and Dr. Rant. If you want poison read Dr. Rant. He got me into blogging.

I am not being venomous I am being blunt. Someone needs to tell the public like it is because at this point there unrealistic expectations are getting out of control.

Relatives are supposed to ask questions. I have said that many times already. It's how they go about it that troubles me. It is how they throw tantrums when the nurse tells them that she can't speak to them right away that bothers me.

Look at some of the comments from nurses on this blog. If I am exagerating so are a lot of us.

I am truly sorry about your dad and cannot defent the actions of his nurse. But just because no one was around that day and the nurse wasn't really busy doesn't mean that we don't have a massive problem with interruptions. We do and it threatens patient safety. NExt post will explain it more clearly.

Dino or UKnurse can you give me a hand here?

Maria, did you read A&E charge nurse's response to you on JD's site.

I am being blunt and refusing to sugar coat a horrific situation. Your percieve this as "venom" and are focusing on that negativity rather than listening to the actual message.

Nurse Anne said...

Some HCA's are the best thing since sliced bread.

And others should be lit on fire.

Nurse Anne said...

Show me where I slagged Nurses off for not being university trained?

Nurse Anne said...

Just found these links for you over at DR. Rant's. He was once a king of GP bloggers. Now this is poisonous. And funny too.

http://www.drrant.net/2008/01/sick-as-mrsa-negative-trout.html

http://www.drrant.net/2007/10/bbc-have-your-say-again-fuckwit.html

http://www.drrant.net/2008/02/reply-to-national-audit-office.html

Nick. said...

Hello Anne.

I'm dual-qualified as a doctor and a psychologist (medical degree + graduate conversion diploma in psychology), and thought it worth saying that I neither "wonder [nor] worry about your responses"; they are pretty much spot on.

Personally, I worry much more about (a) passive-aggression and (b) unqualified pontification than either of the above.

Carry on the good work...!

Nurse Anne said...

Thanks Nick.

I worry about my responses and posts. My grammar and typing are appalling. There are many of us fighting over the computer in this house. I need to make haste. And haste makes waste.

I am starting to understand why management isn't more direct with the public. They simply do not understand the situation and cannot handle the truth.

uknurse said...

Maria,

What happened to your Dad in hospital that day is truly saddening, and I am sorry that you have had to experience this. As said before by one of the commenter’s on JDs site, the outcome may not have been any different had his named nurse listened to your concerns, but your anguish, sense of helplessness and hurt maybe have been a little less intense.

As Nurse Anne has stated, a young man showing signs of a stroke should be a priority for any nurse, regardless to what else they are in the middle of - whether this be legally required documentation/computer work, feeding an elderly patient, fetching a commode, mixing IVs or even giving complex medications.

(Although please also be aware, that unless all hell breaks loose making the situation evident to all, the patient who’s commode was abandoned to enable the nurse to attend to this emergency, would no doubt have relatives left believing that the nurse did not care about toileting needs).

Nobody here, least of all Anne, has defended the actions of your Dads named nurse. This nurse made an error of judgement, for whatever reason, and she will have to answer to that, professionally, morally and emotionally. She was not on the ball that day, and has created additional grief for you at this difficult time. As a relative of a hospitalised family member myself, I would feel exactly the same anger and hurt as you do. I would feel let down, and I would feel bitter, and I would fight for full investigation and consequence.

Unfortunately, none of this changes the observations that Nurse Anne makes here on this blog, about relatives. A&E Charge Nurse mentioned something about nurses becoming defensive with relatives, and sadly it is true. Relatives on the whole can often be extremely challenging and demanding. I believe that it is the fault of the media, such as the Daily Mail etc. Headlines scream about lazy, uncaring nurses all of the time, and relatives (amid their fears and concerns) seemingly hold this in mind the minute they are thrown into the stressful experience of having a relative in hospital.

Nurse Anne verbalises on her blog what many nurses experience in day to day life on the wards. A blog is a place to vent frustrations, which is what Anne does, and although not all relatives behave this way, high proportions do. I have always been astounded at how challenging and aggressive some relatives can be, the minute they walk through the door. As I said before, this is likely based on fear, as I’m sure these normally respectable people wouldn’t speak to Tesco staff in this manner.

Anne very clearly has her patients’ best interests at heart and I suspect that, had Nurse Anne been your Dads named nurse that day; she would have been there, on the ball, assessing the situation and dealing with it, despite the concerns of other abandoned patients and relatives. The anger and frustration that she blogs about is not directed towards relatives like you, with genuine need who behave in a reasonable manner, but rather those that behave aggressively, thoughtlessly and selfishly. This is all too common, and cannot be denied, sugar coated or excused.

I wish you comfort in your grief Maria, and I hope your investigation into this sad event brings you answers, closure and some peace.

uknurse

Dino-nurse said...

Thanks for the compliments Anne.I also enjoy reading Dr Rant :0) I also love watching Nurse Jackie. Maybe the general public need to be told that this is closer to the truth than Holby City or Greys Anatomy....Staffing levels on general wards will only get worse during the forthcoming cuts unless we stand up and do something about it. Unfortunately our so-called union will do nothing.
To Maria
I am sorry that your father died. As has already been stated, a stroke in a young patient is unusual and should be taken seriously. I cannot second guess what was going through the RNs mind at the time. Was she tired, overworked, I don't know. I think this highlights what Anne has been trying to say for a long time. Not enough senior nurses, nurses working too many shifts together, not enough senior medical backup, constant interuptions etc... leads to poor judgement. This is happening on a daily basis and on somedays the outcome might be that a patient falls over or is given the wrong medication. On another day a mistake results in a patient dying. The real villains here are the trust managers who will roast this nurse alive rather than admit that if staffing levels were better then less mistakes will happen. Every year when I attend my mandatory risk assesment updates, we are shown the same "swiss cheese" model of how complicated decision making errors occur...as a psyche student I am sure you will have seen it (or something similar) it tries to show that no matter how many ways you try to plug the gaps, as decisons become more complex the harder it is to avoid errors...info overload if you like. At some point human error will always win out...so you have to decide when trying to plug the gaps becomes futile. Unfortunately in the NHS this happened a long time ago as the costs of safely staffing the wards became too high. This is what you need to be getting mad about...vulnerable people are suffering every day in the NHS due to lack of skilled nursing care. Unless something radical happens by the time we are in our 80s it will be safer to stay at home and hope that be admitted to a UK hospital.

Maria said...

Anne and to everyone else who was kind enough to reply.

Thank you for your responses and Anne, I apologise for my own rant at the end of it. Nick you were correct in that it was an unqualified pontification. It is unfortunate that relatives have no where to go when something goes wrong and this has left me pretty frustrated. I am usually level-headed and fair-minded but really feel that I need to talk about it and you have allowed me to do so. So sorry again for the rant.
Nevertheless, I do get the impression that the ranks close and I feel that I have to justify my own thoughts and feelings as if somehow I shouldn't have them.

However, thanks to you I now understand the dangerous conditions you and other nurses work in. I have been doing a bit of investigating and wonder why the NMC allow it as they must be aware of it. I have also been reading about 'gagging restrictions' operated in hospitals with regards to whistle blowing. It seems that you are in a no win situation.

I also know you are right about peoples perceptions of life on a ward are based on what they view on TV. This unfortunately is not the real world where there isn't an abundance of doctors and nurses constantly available.

It is a pity that patients and relatives are not aware of this and I wonder how this can be remedied. It would be helpful if they could be enlisted to help change this and complain about staffing levels - but how?

I did wonder about a blog or a forum where relatives could ask sensible question and be advised to ask about staffing levels and where to complain to. I do not mean a place where people could moan and whinge - but a place where patients, relatives, nurses and doctors could talk to each other and learn from each other. But I suppose this is a pipe dream.

I shall continue to follow your blog and will inform my fellow students of it.

I hope things change for you Anne and thanks for 'listening.'

nurse Jackie uk said...

I love you comments about the bloody relatives and the phone LOVED THEM a whole aqualot of stress has just dissolved. i hate relatives ringing. is she out of theater yet? UGH UGH UGH
THANKYOU ANNE xxxxxxxxxxxxxx

UCL Med Student said...

Anne, I'm not being funny but how about:

If you have have urgent drugs to do, or a procedure or obs ---
Phone rings... screw it?

Relative tries to stop you "Sorry I'm dealing with something urgent, I'll get back to you".
Noone in their right mind would stop a HCP who is trying to deal with something urgent.

Surely?

Am I missing something here? I see drug rounds go on as normal on wards I'm on, and obs done etc etc?

Nurse Anne said...

Do you not think we already thought of that Med Student?

What do you think happens when relatives go screaming to the complaints department about "the nurses not being bothered to answer the phone and tell me what is going on with dad".

We get told off and are asked to write letters of apology.

It doesn't occur to the public or the managers that we cannot answer the phone without harming patients and that frankly we need a lot more help.

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