Friday, 29 October 2010

Dense Doctors

That title may sound a bit harsh.  I know that our doctors are very intelligent when it comes to medicine.

But apart from that they seem to know sweet fuck all.

This is especially true when it comes to what is going on in the wards.  It is true in regards to Nursing.  If  Nursing care goes bad  medical orders do not get carried out  and patients do not get monitored.  In short the doctor's whole plan of care goes out the fucking window. 

You would think that they would be a little more......well.....interested.

But no.  They are delusional.

This is what I have learned about doctors in over a decade of Nursing.

1.  They think all nurses are the same person or clones of the same person with a hive mind.

For example, if the Nurse on the shift before you missed something, it's your ass if you are the one on duty when doc graces your ward with his presence.  If you are forced to float to a specialty you never worked or trained in before the doctors expect you to telepathically mind link with absent Nurses who have experience that area the minute you arrive on the ward  They will not bother to write their orders or give you a heads up about things you need to know and wouldn't know unless you have experience there.  They won't bother with any of that yet they'll go apeshit later when you forgot to remind them to prescribe something. Remember that they think Nurses are all the same drone with a hive mind who know each Doctors' individual ways.
2.  They have no idea how to implement their own orders, or how time consuming and complex it is to implement their own orders.
  Don't even get me started on the bullshit with the IV meds....both getting a hold of them and actually preparing them.  Or fighting with pharmacy, equipment library and path lab.  No Doctor they do not just keep everything on the ward for us.  No they do not keep chest tube kits in a place where we can get them etc etc etc.

3.  They have no idea how to work the system as a result of the Nurses doing it for them.

 They don't understand why things don't happen instantly.  For example, all RN's know it takes 6 weeks to get a patient into a Nursing home and that nothing can be done to speed this process up.    Yet day after day the medical consultant walks in the very afternoon after he wrote that 90 year old Mabel can be discharged that morning and wants to know why she is still on the ward.  Then he goes on a rant about how the Nurses can't be arsed to discharge patients.  I could go on and on about this one, there are thousands of examples.

4.  The saddest thing I learned about doctors and the crux of this post is that doctors are not able to distinguish between Nurses and ward assistants.

There are many times I am running my ass off trying to give a 150 IV meds all due now whilst the HCA's/cadets/auxiliaries are hanging out at the Nurse's station.  The few jobs they can do are complete. They cannot help with the large proportion of the workload that only an RN can handle.  Many doctors will walk onto a ward, take a look at the assistants hanging out at the station and exclaim "The Nurses don't seem to busy today".   Dickhead. I am the only Nurse, and I am on my knees completely overwhelmed.  What the assistants are doing (or not doing) is in no way indicative of how busy the Nurses are!  Assistants are not Nurses. 
Sometimes I will be 3 hours behind getting much needed drugs into patients and managing other patient problems and some young doctor will stroll onto the ward and ask me to hold an arm for him so that he can draw some ABGs.  For god's sake, grab one of the assistants hanging around the Nurse's station for that.  That is something they can actually do.  Don't delay Mrs. Smith's pain relief any longer by causing me to stop and hold an arm!!   It's not like the care assistants can give the meds and handle the Nurse stuff while I am tied up holding an arm for you!

A doctor walked onto my ward and wrote some orders for IV fluids and IV antibiotics for a patient with Pneumonia.  As the only Nurse for all of those patients I was tied up and didn't see him arrive or know he wrote any orders.  He handed the chart with his orders to a care assistant and left the ward.  The care assistant has no idea about orders etc.  She put the chart down on the station where it got immediately buried.  And she said nothing to me.  I had 25 patients that day (a staffing ratio no Nurse can function well with)  and it was taking a hell of a lot of time to see everyone and process their orders.  It was 3 hours before (by luck) I found the chart and the orders.  Patient was in septic shock by that point.  Doctors, you need to tell the actual Nurse about these things, not some underpaid teenage assistant that you have confused with Nursing staff.

Then there was the doctor who started yelling at me for having 4 bays full of patients rather than one!!  "That is too many patients! You should have one bay per Registered Nurse".  Yes Sherlock, no shit.   I appreciate the fact that you have actually noticed that the RN ratios on NHS wards are horrible and dangerous and that this has a dire effect on patient care. But what the hell would possess you to think that they Nurses on the ground have any say in how we are staffed or how many patients we have?  Even the ward Sisters are not allowed to have a say in how their wards are staffed.  Duh.

I could go on and on.  These doctors are clueless about what is going on with Nursing care and RN staffing on the wards.  And frankly, I am getting sick of it.

My cousin in law is a doctor in the USA.  He is not as dense as his colleagues here.  If he finds out that his patients' RN's are being forced to take on more than 4-6 patients at a time he gets on the phone to MANAGEMENT and starts screaming. He tells management that he will have his patients pulled out of there by the end of the day and admitted somewhere else if they do not staff the facility properly.

 He doesn't care how compassionate or knowledgeable or wonderful the Nurses are in that place.  He knows that with poor staffing ratios that they cannot function even if they are wonderful.   The facility would lose a ton of money if he pulled his patients out of there so they wouldn't dare short staff the place.  They did it once, never again.  Managers of hospitals all over the world think that intentional RN short staffing is the way to save cash.   

He is a good doctor, and understands that without decent Nursing care delivered by RN's the patients are screwed.  He understands that there will be nothing in the way of decent Nursing care in a place where Nurses are denied resources and safe staffing ratios.  And he acts on it. 

But it seems it is too much to ask for UK doctors to even understand what a Nurse is, let alone stand up for them.  They haven't even grasped the notion that these Nurses are taking on too many patients to be able to care for anyone properly, and that they are being forced into a position where they cannot spend two minutes demonstrating compassion without risking a disciplinary for not filling in paperwork.  Too bad.


Nursing Student said...

True about some doctors, especially the dinasour consultants, but hats off to the F1's and F2's (for the most part) who are immersing themselves a bit more these days to work more as part of the team. Well at least from what I've seen, and at least till they get past their foundation years... then god knows what happens.

Went out recently with an F1 who I had a bit of a thing with in school (then he went off the radar, and off planet earth, to medical school no less) who had quite obviously had the fear of god put him in on a ward I used to work on by the Nurses and the other Doctors. He was worried about the nurses, saw the nursing issues, saw the staffing issues in general, knew these issues were out of the nurses control and it would affect the patients, knew most of them by their names and realised it was a all one big collaborative effort and not a pecking order.

I suspect alot of the newer doctors who have perhaps seen a bit more sunlight/socialised a bit more in medical school and are not niave (much) that creep up through medical schools year after year will begin to "get it" and what it takes to hold a ward together (in their current state) because they trained and will do medical placements in these conditions and it will be what they are used to in the end. Sad really but one can hope.

If not then the F1, Joe, will anyway. Or at least until he gets a post after his F1 & F2 years, then it's up to him. Regardless my bloody dinner was yummy even we talked a bit too much about work. I think I'll stick to my usual taste in the future though of Bricklayers & Chefs..

Anne, by the way, get to my blog and read my slapheads post, and any other nurse for that matter, I need you!!

Nurse Anne said...

Yeah the younger ones are much better. Dealing with the delusions of the consultants and the GPs(who are mostly older) is hell though.

Anonymous said...

I've been reading your blog with interest, having followed a link to it from somewhere or other. Your hospital, wherever it is, sounds horrendous.

There is no ward at the hospital where I work (I am a HCA, hopefully a good one!) that has less than 3 RNs for 28-30 patients (30 is the maximum ward size). 10 patients is still too many, but better than what you have been describing. Some wards have up to 5 RNs, plus a charge nurse.

Plus 2-4 HCAs, depending on the day. No cadets, and I hope it stays that way.

We also have a discharge person on each ward who organises all the paperwork, liaises with social services etc.. I honestly thought all hospitals were run like ours.

Nurse Anne said...

Anonymous where are you and are you hiring?

The Shrink said...

Huh? Aren't nurses just folk what float about on wards and make stuff happen? :P

My nurse Team Leader says medics are often "clever thick people" with lots of knowledge but little wisdom/common sense.

Anonymous said...

Anonymous 07:56 I work bank at my trust and one of the surgical wards has a Discharge Nurse, band 6 I think.

She is such an asset to the team and chases TTAs for you, books transport, sorts out home care, DN visits, follow up appointments etc etc. All time consuming stuff that takes you away from the patient. She would also pitch in and help the ward staff as needed with drugs, dressings, ward round etc.

I have not worked a shift on this ward for a while, so no doubt she has been demoted to band 5 and is now the sole staff nurse responsible for 30 patients lol!

Sue said...

Anonymous 15.37 (I need an alias; I am the first Anonymous):

Our discharge person is a HCA. They do all the referrals, book the transport, do the walking to and from pharmacy, organise PT/OT, liaise with nursing homes, rehab etc. the RN of course is supervising them all, but ours are good and only need minimal supervision. The only thing the RN does towards the end of the process is to check the TTA medications.

We are very spoilt, I know.

Nurse Anne said...

That sounds really good Sue.

During the course of the day I am usually the lone RN for at least 15 patients. There may be 7 complicated discharges with that group so sorting social services, families, transport, TTA's etc etc falls soley to me.

Usually at the same time I am trying to take care of acutely ill patients. It is horrible. You cannot concentrate on what you are doing. It is also a hell of a lot of paperwork. And you only have a certain window of time to get it all done.

It usually leads to patients staring at you wondering why you are at the station doing paperwork rather than answering their call bell.

UCL Med Student said...

Some fair points MM, and I do know the difference, but I'm quite into knowing about how everything in the hospital works and other "allied health care professionals".

But my question is, how would they most doctors know? We aren't ever taught the differences between HCAs/etc (I only know through personal experience).

Just like a HCA might not know what suture to use for each wound, doctors dont know about HCAs etc...

And I'd like to see what happened to a doctor that dared shout at management about staffing here :S

Nurse Anne said...

But an HCA doesn't start screaming at you and getting abusive and accusing YOU of not doing your job because no one taught her how to suture.

Docs walk onto the wards, get the wrong idea because they "weren't taught about Nursing" and get really really nasty.

Nurse Anne said...

UCL student there have been so many times when I (and other nurses) have been forced to staff wards in specialities we have no idea about. Alone, with no one to go to for assistance.

Do the doctors show any mercy? No. They just start getting abusive and nasty because the Nurse didn't know something that only and experienced Nurse in that particular speciality would know.

Our doctors "forget" to prescribe some pre op things. They "expect" the RN caring for the patient to ring them pre op and remind them to prescribe it. What do you think happens when a Nurse unfamiliar with that speciality and this little game gets floated to that ward and doesn't realise? The docs don't bother to tell her. Then they go apeshit when they weren't "reminded" to prescribe the pre op item.

"I was never taught that. I have no experience with that. That was not communicated to me" is NEVER EVER an excuse that Nurses can use when she has a surgeon or a medic getting his panties in a twist.

So why should the docs get away with saying "but I was never taught to distinguish........"

Anonymous said...

I LOVE how every other bugger in the building wears blue scrubs but carries no ID badge and yet you are expected to instantly recognize who they are and what they want the minute they step on to the ward.

Was doing BM on diabetic patient when man in blue scrubs walks up to me and says "notes." I'm thinking the following:-

1) Who the hell are you?

2) I'm currently with a patient could you not wait 2 minutes for me to finish?

3) Which patient's notes?

4) Would it hurt to say please?

So I ask this person who they are and get the biggest, most unprofessional diva strop of all time for not knowing (was surgeon, as I expected but never assume right?).

Sorry but I didn't realize I was supposed to hand out confidential medical notes to anyone who asks without question!

Anaesthetists and surgeons excel in rudeness!

Anonymous said...

UCL med student,

Much like nurses are not taught during their training the various titles of the medical realm: F1, F2, HO, SHO, SpR and who to contact depending on the circumstances.

In final placement as as student I read an entry in the notes by reg saying to bleep them if there are any complications for post nephrostomy tube insertion patient. I do so concerning nil drainage of urine into bag and get lambasted for not contacting the HO first.

I have had to learn medical hierarchies the hard way!

The Dobbing Doctor said...

I agree with points 1-3, and more than agree with the rudeness anaecdotes as they have all happened to me as a HO/FY1/Tea Bitch/Houseplant from more senior colleagues. And it stinks. I hate how some doctors speak to everyone, patients, nurses, relatives, other doctors. Thankfully this attitude should wean itself out now that the newbie doctors all get taught how not to be a twat at doctor school.

I can't say I agree with point 4. At my hospital at least, the HCAs/Nursing staff have very different uniforms and can normally be told apart by the steam coming from the RNs feet as they run around.

I and all the doctors I know, can demarcate the roles of HCA/RN. Sometimes I hand something over to a HCA after a review as I have run off, it's ALWAYS "The staff nurse needs to know about this". Sometimes my 50 jobs to do and the RNs 50 jobs to do mean we pass like ships in the night. As long as we all communicate it works fine most of the time.

As for doctors standing up for nurses. Doctors don't stand up for doctors, so I wouldn't expect much in the way of advocacy. I once rang a modern matron to complain about horrendous staffing on a ward that I'd requested a special for, and got told "It's nursing problem don't get involved.". I figure when said person falls over and bleeds into their brain it's a medical problem so I will need to get involved.

Dino-nurse said...

Ho hum
Back from holiday and its already a dim and distant memory
Staffing on many wards is a joke. Its a UK wide problem and its going to get worse.
Many docs are in the same boat and their support system is usually pretty poor. No wonder that by the time they get to the top they are megabitches....its not just nurses who eat their young.
As for some medics being rude...I try the following
1) If notes are demanded in a rude way I point to the trolley and politely enquire if they can understand a filing system...stand up for yourself (OK its easier in a sisters uniform)
2) I try to intercept all newbies and introduce myself and give them a tour of the unit...letting them know we are a team etc...if they step out of line later they will know about it.
3) If anyone tries to look big by embarrassing me in front of others I usually smile sweetly and ask them to show me where its written in the notes please...this is especially irksome if the consultant is around as the juniors will panic and its NEVER in the notes...bit cruel but they rarely do it again....
Life in the NHS eh...if only Joe Public knew the half of it....

Nurse Anne said...

Yeah I definitely feel sorry for the doctors, especially the juniors. I know their job is hell times 10. And I know that management sucks and doesn't give a toss.

On the surface it would seem that the consultants are more powerful and would be able to get management to listen. But unfortunately we are ALL nothing but management's bitches.

Anonymous said...

Oh I love the docs really!

I always think it must be hell on earth to be the on-call SHO at night, although the CSMs are generally good.

So true about the management comment. I'm certain if we got more staff nurses and doctors on the floor 24/7 and culled the clipboard brigade completely, the hospital would run like clockwork.

Anonymous said...

Hi Nurse Anne,

You reveal so much about hospitals that most of the general public wouldn't have the first clue about and would never dream that such things go on, let alone that such problems are widespread/systematic. I honestly think you'd be a prime candidate to go undercover with a secret cam for a week for something like Dispatches or Panorama.

I don't think anyone at the top of the management/government food chain gives a toss about how bad it gets for you cos' they can always blame you as a scapegoat for being the person responsible on the ground if anything goes wrong even though these are disasters waiting to happen due to their decisions to ensure there are staffing shortages. In my opinion the only thing that gets their attention or keeps them on their toes is widespread bad publicity. Don't you think so?


Dino-nurse said...

After the last undercover nurse report I doubt anyone would be prepared to follow suit, Neelu. Whistleblowers in the NHS are hung out to matter who you are. What is really needed is a series of suprise visits to an MAU and elderly care ward, all on the same day throughout the country...and I mean a REAl suprise early warnings to management. I suggest a weekend when staffing levels are even worse than normal. I would urge politicians to serously consider this...thats assuming that they want to know the truth. On the otherhand...

Anonymous said...

holy crap. I would never work in Britain. The Canadian system, albeit flawed is 100% better than yours. Geez. WTH.
It is the same "type" of system...socialized, yet we don't have half the problems you do. I think the last time I had 10 patients was back in the 1980s....

Dino-nurse said...

I have often wondered what working in canada would be like. Having worked in the US but having trained in the UK, I felt a little uncomfortable with the limitations applied by the insurance companies. Working in the UK I would say that skill-mix and staffing levels are the biggest problem. Despite all the evidence that says RN :patient ratios are key, our hospitals continue to ignore this fact. Or worse, fudge the figures by including anyone with an RN regardless of whethr they are clinically active when they report their RN:patient days figures. When was the last time you saw a bed manager do anything clinical? Or many of the nurse specialists? Having recently updated my CPR certs I was appalled at how some of the Band 8s who were with me ( I'm a 7) couldn't remember the basics, let alone read an ECG.

university Admission said...

He is a good doctor, and understands that without fitting Nursing nursing delivered by RN's, the patients are screwed. He understands that there are thousands of examples. Remember that They did it once, never worked or taught in how their wards are staffed. They think Nurses are all the same buzz with a hive object who have no idea how the Nurses can't be arsed to discharge patients. Even the ward Sisters are not like the anxiety assistants can give the meds and touch the Nurse stow while I am fixed up holding an arm for you! Managers of hospitals all over the world think that intentional RN curt staffing is the way to know and wouldn't know save you have experience there. Yet day after day the remedial consultant walks in the very daylight after he wrote that 90 year old Mabel can be nothing in the way of there so they wouldn't defy squat pole the place. If he finds out that his patients' RN's are being affected to take a look at a time he gets on enduring thought.

A surgeon walked onto my area and wrote some ABGs. I could go on and the crux of this post is in no way indicative of how hard the Nurses are! Assistants not Nurses.
Sometimes I will be 3 hours behind receiving much required drugs into patients and managing other enduring problems and some young surgeon will wander onto the division and ask me to influence an arm for him succeed or knowledgeable or brilliant the Nurses are atrocious and dangerous and that this has a dire provoke on the telephone to MANAGEMENT and starts screaming. It was 3 hours before You should have one bay per Registered Nurse." Many doctors will totter against a dependant, take on more than one!! Dickhead. I am the only Nurse, and I am on my ass off difficult to give a 150 IV meds all those patients I was joined about this one, there will be done to momentum this course up. They cannot perform even if they are wonderful. He pulled his orders to a trouble aide and left the district. For god's sake, grab one of the assistants killing around the Nurse's position for that. That is something they can actually do. Don't break Mrs. Smith's grief relief any longer by causing me for having 4 bays detailed of patients instead than 4-6 patients at the assistants lynching out at the post and yell "The Nurses don't look to hard today." If the Nurse on the period before (by chance) I found the chart and the orders. The mind junior has no idea about orders etc. She put the chart down on the situation where it got immediately obscured. And she said nothing to me. I had 25 patients that day (a staffing ratio no Nurse can occasion well with) and it was winning a misery of a lot of time to see him so that he can draw some commands for IV fluids and IV antibiotics for a tolerant with Pneumonia. As the only Nurse for all due now while the HCA's/cadets/auxiliaries are killing out of pure Nursing tension in a place where Nurses are denied income and sound staffing ratios. He handed the assistants are liability (or not doing) is that nothing can be discharged that morning and desires to know why she is still on the charge. Or fighting with deprived staffing ratios that they cannot help with the large proportion of the workload that only a RN can supervise. You missed something, it's your ass if you are the one on task when doc graces your dependant with his company. And he acts on it. They won't perturb with any tips.

There are many patients! It's not permitted to have a say in before the doctors suppose you telepathically to heed associate with absent Nurses who know each Doctors' individual habits.

Anonymous said...

I find your attitude to HCAs slightly offensive, especially given that you're complaining about the manner in which doctors often treat you.

On my ward, HCAs do pretty much everything nurses do barring drugs and IVs. We tend to have 2/3 qualified and 3/4 support on a shift, and the attitude of all the staff is that we are a nursing team and we work together. Perhaps if you treated your HCAs better, they wouldn't be so useless. Then again, it could well have more to do with lack of training for HCAs in your hospital and/or trust generally.

Nurse Anne said...

HCA's do not do "everything a nurse does except for IVs". Not by a long shot. Most of the things that the Nurses are having to think about and concentrate on are things that HCA's never even heard of.

Two of my best friends are HCAs that I work with and I think that they would find your comment funny. I don't have any problem getting along with any hca's I work with. They like working with me because I get stuff down.

We are all a team and we do all work together. But it is the Nurse who has the legal and ethical accountability, not you. Therefore the Nurse's prioritization comes first. End of.

Nurse Anne said...

The whole point anyway is that even if I have the best HCA in the world it doesn't help me if I have to many Staff Nurse things to do. Not at all.

uknurse said...

Anonymous said....

"On my ward, HCAs do pretty much everything nurses do barring drugs and IVs"

I used to think that, until i did my training and became qualified. I realised how wrong I was. A old retiring nurse once said to me...that it isn't just what the the nurse's alos what she knows, what she carries mentally, and what she's accountable for when thinks veer from the norm.

I respect HCAs massively, I was one for 13 years...but...they often completely fail to understand that doing what they do does not make them "the same as nurses"

Anonymous said...

Not wishing to ruffle any feathers, but in my experience the HCAs who proudly state that they can do "pretty much everything a nurse can" often have the least understanding of the nurse's role.

Like many nurses, I too was a HCA prior to my training. Certainly HCAs do work hard and it often felt like I was carrying out much of the workload.

However, I knew my limitations and never considered myself as being able to do pretty much everything a nurse does, as I didn't fully understand their job.

I worry when "some" HCAs who think that since they do bloods, cannulate or can do a dressing they are pretty much nurses. It is not that simple.

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Anonymous said...

Talking about "dense doctors". When I was a third-year student a young junior doctor came onto the ward panicking like a headless chicken saying a patient had "collapsed". I calmly asked her to tell me exactly what had happened whereupon she screamed at me hysterically like a lunatic, in front of the patients, shouting "you, just get on and dish out that food". I was drying my hands after washing them, not in the middle of "dishing out food" as she put it. She then interrupted the HCA who actually was "dishing out the food" and took her to assist with the patient who had "collapsed". I was in fact managing the care of this particular patient therefore I had a right to know what was happening, not to mention a responsibility to keep myself informed about what was going on. This doctor clearly didn't have a clue who I was or what I did although she had been working alongside me on the ward for three months. Later she had enough shame to apologise for her extremely rude outburst but then spoiled it by asking if I was "in the same class at University" as a first-year student who was only on her second day on our ward, the first ward she had ever been on. However do these "thickos" make it to medical school? You would think that the different coloured epaulettes on the uniforms would have given her a clue that we were not at the same level of training. It is very worrying when the 'right hand' doesn't know what the 'left hand' is doing.

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Anonymous said...

There were several new female junior doctors on the ward and the differences in their attire was striking. One was a Muslim clothed from head to foot in a floor length trailing black garment with only her face showing. One was obese but had chosen to wear a tight white T-shirt and clinging black stretch tights which emphasised every lump and bump, drawing attention to the fact she was grossly overweight. One was shabbily dressed in casual slacks, a sweat-shirt and had long, greasy, untidy hair pulled back loosely in a scrunchie. One was tossing her long swishy blonde hair from side to side as though she was a model on a catwalk and she was wearing a tiny mini-skirt, her bare legs sported a large tattoo and on her feet were bright red, pointed toed, six-inch stiletto heeled shoes. Such modes of dress are unlikely to inspire confidence in the patients. Matrons, nurses, ambulance men, domestics, porters etcetera must all wear uniform - why should doctors be an exception? They should be required to wear clean white coats just like they used to - in days gone by they really looked like doctors. As for the care of stethoscopes, are they always wiped clean after use on each patient? Somehow I have my doubts about that.

JonPur said...

I am a registered RMN nurse currently at band 5.

Due to cost cutting measures my trust want to demote all staff to the band below: 7 to 6 and 6 to 5 etc.

According to Agenda for Change I cannot practice as a registered nurse at band 4 however my trust want to potentially demote all band 5 nurses to band 4

Any ideas how I should proceed? I have contacted UNISON but I feel that if my Trust get away with this then it would give the green light for other Trusts to demote nurses to band 4.

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Anonymous said...

I am a medical student and have been reading your blog with huge interest. This post really got to me, I care about how our NHS is run because this is what will affect my patients THE MOST. There's no point learning all the science and prescribing drugs if nurses I work alongside then don't have enough time to administer these drugs and monitor patients properly due to ridiculous levels of understaffing. When I qualify I hope that I will be able to stand up for overworked nurses on my wards. We should all be in this together and fight back against managers who don't have a clue.

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