Friday, 10 December 2010

Nursing in the NHS: A Comparison

Having worked both abroad and in the NHS I noticed a few things.     Man oh man have I noticed a few things.

  Nurses in British hospitals do not have the support or resources to do their jobs. No amount of caring, compassion and old fashioned training can fix that. The are constantly put upon by pharmacy, porters, secretaries, housekeeping and supply departments in order to make the working lives of those people easier. I spent 3 hours out of my shift yesterday running around the hospital in a frantic search for the drugs my patients were prescribed. This left my patients nurse-less and un monitored.. It can take up to 8 hours to find and obtain common drugs that Boots could dispense in 5 minutes. 

I want to go back in time...back to my old job in a setting that seems futuristic compared to the setting I am working in now.  I decided to ask Doc Brown and Marty Mcfly for some help with this.  They will loan me the DeLorean or Darth Vader from the planet Vulcan melts their brains. Their choice.
 In 1995 I was working in as a qualified Nurse in another country. I worked on a 28 bed ward. There were 8 RNs on duty for a shift. One of those RN's was in charge. One RN floated between teams and covered lunch breaks. We had 3 ward clerks from 7AM to 3 PM and two ward clerks from 3PM to 11PM. This was essential to keep notes and information organised and deal with all the phone calls and enquiries. If my patients' doctors ordered some IV antibiotics I wrote the order  on the drug chart or entered it into the computer. The ward clerk then faxed it to pharmacy. If she didn't do that immediately she was in trouble. Hundreds of orders like this are flying at qualified Nurses every hour and we need support to stay on top of it.  Otherwise patient care gets completely neglected.

Pharmacy had a duty to get that drug to me when it was due, prepped and ready to go. If it was a STAT med, they had 5 minutes to get it to me or they were disciplined. Pharmacy was open 24 hours and they assigned a pharmacy tech to each ward. It was THEIR JOB to ensure that the Nurse had the drugs she needed at her disposal and ready to go as soon as they were due. There was an individual medication drawer for each patient and when you opened it you would find what you needed for the upcoming drug round as well as prescribed as needed medications for that patient. If you didn't find it and had to go and chase around looking for stuff, you wrote up pharmacy for a disciplinary. Pharmacy had faxes of all the patients drug charts. Every time that drug chart was updated with a new order the ward clerk faxed it to them immediately. Or else.

Each Nurse and support worker in that place carried a hospital mobile phone clipped to her pocket. I could stay with a patient whilst calling a doctor. I could stay with a patient whilst calling another Nurse for assistance. If a family member, pathology lab or a doctor called for me the ward clerk would transfer the call to my phone. That way I didn't have to leave what I was doing to answer a call. In the NHS I have to abandon the patient and walk past a score of them crying for help just to get to the ward phone. Then I have to stand there and que for the phone. Then I bleep the doctor. Then I have to stand there looking like an idle simpleton and wait for him to call back. Then I can walk back past scores of people crying for help and go back to what I was doing. If stop to help the people shouting for it, I may not get back to the man on the sliding scale fast enough to stop him from developing hypoglycemia and going into a coma.

We had hospital social workers to organise discharges and care. We had security.

These people were very well aware not to interrupt the Nurses unless it was an emergency.  Most of the time they complied.  In the NHS these people do not have a clue.  If a social worker, a phlebotomist, or a porter etc interrupted Nurse during her drug round to ask a stupid question (i.e are you the Nurse looking after Mr Jones) they would have been disciplined. If they want that question answered they could look at the big board that had the room assignments, the patients name and the name of the Nurse written next to it, or they could ask a ward clerk or a tech. In the NHS people constantly walk onto the ward, right past the board that shows what Nurse is assigned to who and asks if I am looking after so and so. I get interrupted on average every 2.5 minutes with this shit all day long in the NHS. There is no respect for the Nurses here, they are not left alone to do their jobs even for a minute. The supporting departments in NHS hospitals think that the ward Nurses work for them.

I shit you not.  In the NHS these people walk up to a staff Nurse whilst she is with a patient, concentrating on drug calculations, medicating a dying patient and holding the hand of a distraught give her "instructions" about what THEY need to make THEIR job easier. Porters do it.  Pharmacy does it.  Kitchen does it. House keeping does it.  Our pharmacists started screaming at one of my colleagues the other day.  He came onto the ward with some CD's (a miracle in itself, usually we have to fetch them).  The only Nurse there was unable to stop what she was doing and check those meds in because she was with a patient so he had to wait 5 minutes.  He went apeshit and tore her apart.  While she was still with the patient.  Our domestics go mad if the night nurses haven't started the domestics AM duties for them.  On nights there is only three enough and I am NOT going to release the HCA,myself or the other Nurse from patient care to collect and wash cups and jugs.   Nursing management knows about this, and they seem more keen to side with the domestic managers.

Great scott!
 In my 28 bed ward overseas in 1995 we had 24/7 housekeeping. If a patient got discharged I called the maid on her phone and she readied the room for the next patient. If I left a patient with a GI bleed to clean a room myself I would get struck off for sure. Oh sorry I let your dad bleed to death because we were getting a new patient and I needed to clean the room in order to prove that I am not above such work, Yeah right. That would go over real well. There is never a time in a Nurse's day when she isn't caring for someone that sick. The maids made sure that the Nurses were not dealing with that stuff in order to ensure that patient care was not compromised.   The housekeepers here will walk up to a Nurse whilst she is in the middle of clearing someone's airway and tell her that a room needs to be cleaned.

Only next of kin is legally allowed to get info about the patient in both North America and the UK. Any relative who rang that hospital had to give the next of kin password to the switchboard operator before they were put through to the ward. This helped the Nurse to avoid getting into a long winded conversation with someone who isn't allowed to have information.   Patient care comes first before relatives. A legit caller could also be put through to the charge Nurse for information while I continued on with my job.   The switchboard operators here do not even attempt to protect the Nurses from unnecessary interruptions.  They just put the drunk and belligerant caller through. 

In the NHS there is no charge Nurse free of a patient assignment who can talk to these people.  All day long I have multiple neighbours, friends and extended relatives calling constantly demanding test results etc.  When the Nurse is running to the phone every 2 minutes, it leads to a whole lot of patient neglect.  Management should be protecting Nurses from unnecessary interruptions.

1995. Since then patients are even more ill, more complicated and there is increased throughput.  And in the NHS we are working with a lot less than we had when I worked in North America in 1995.

Let's talk more  about working in the NHS in 2010. It sure is a step backward from 1995 in North America.

Here in the backwards future In the NHS we are often 30 beds with 2 Nurses and three care assistants. That is all. No charge nurse. One of the staff nurses who is the most experienced has to take charge even though she is the sole nurse for a team of patients. Fail.  It cannot be done.  Every time she gets stopped to answer relatives' questions and answer their phone calls her patients go without a Nurse and are neglected. 

We get a ward clerk for 0900 until 2:30 from Monday until Thursday and that is all.

The ward clerk can't even handle all the numerous calls coming in for all those patients. If we have 5 relatives calling multiple times for 30 patients all day long it gets to be too much.  We cannot even get a free phone line out to call a doctor in an emergency.

So she gets stressed and goes for a coffee break and the Nurse has to cover the phone whilst doing her job Nursing patients. The NHS ward clerk will ask the Nurses who are 3 hours behind on their drug rounds to file paperwork for her as one ward clerk for 30 beds is too much. It is too much. But I am in no position to help her. She also spends half her day looking for notes because doctors do not even have the decency to put notes back where they found them. This causes things to get lost. She cries a lot and disappears off the ward.  Sometimes she is covering two wards.

If a family member phones the ward clerk walks over to me whilst I am in the middle of inserting a catheter and trying to maintain a sterile field and tells me that Mr. Smith's daughter is on the phone. Then the ward clerk walks away.

This leaves Mr. Smith's daughter on hold until I can get to the phone, really pissing her off. Or I can just stop what I am doing in the middle of a procedure to answer the phone. 9/10 it is an enquiry that the ward clerk could have answered if she would have bothered to ask what the caller wanted.  These kinds of interruptions are constant for the Nurse in the NHS.  With less staff and poor management and almost zero modern gadgets to help us out with today's increasingly ill patients we are fucked the minute we walked onto the ward.

We have two phones on the 30 bed NHS ward here in 2010. They are at the Nurse's station.  There is no such thing as hospital mobile phones or pagers for the Nursing staff. It is a long walk past lots of needy patients to get to the phone. I have to stop what I am doing and answer a whole lot of phone enquiries whilst trying to Nurse my patients. I have to stop what I am doing and abandon patients to make calls to doctors or to fight with pharmacy and supplies to get what I need.

 I have to leave the patients and go looking around for another member of staff if I need assistance. It was faster and more efficient to be able to ring the Nurse on the other end of the ward directly.  A phone call from the little phone clipped to my pocket direct to the little phone clipped on her pocket.  But not in the NHS.  I have to hunt her down. Then I get delayed as patients shout for help as I walk past. Or I can ignore them, hunt down a colleague for assistance, ignore them again as we head back to the patient I just left etc. Call bells are worthless as no one has time to answer them. I spend so much time walking to and fro looking for staff and stuff, and then getting shouted down for help by patients as I am walking past, that I never can get on with anything.  Patients and relatives stop you as you are walking past, show no regard or consideration about what you might be in the middle of for another patient and expect you to attend to them immediately.  It isn't fair on the other patients or the Nurse.

Holy Shit Doc.  This is heavy. This sounds worse than 1955.  Who in their right minds would expect Nurses to be able to be there for patients and not make mistakes in these conditions.
 NHS Pharmacy. The bastards. They  are open 9-5 Monday through Friday. But they stop taking requests at 4:30 PM. It isn't until after 4PM that the junior medics get released from their rounds to prescribe stuff, review stuff, and write discharge drug orders. If I can get them to write stuff up in time I have to take the drug chart with me, leave my patients and leg it to pharmacy. If it is 4:31 pharmacy tells me too bad, that they will not fill the order. Then I have to search the hospital to get what I need. But I won't be doing that unless it is an emergency because I probably cannot leave my patients to go on a drug search yet again

Pharmacy also closes for an hour between 12-1PM. That means if I need a STAT med at that time I am stuffed unless I abandon my patients during lunchtime to go on a search throughout the hospital.

NHS pharmacy does not stock us up properly. Basic common medical drugs that a BOOTS could dispense in 30 seconds are AWOL on my ward. Each of my 15 patients are each on 10 drugs each due at 8AM and four other times throughout the day.  Of these ten drugs for each patient: three of them will usually be in the drug cart or the patients locker. 3 of them will be completely AWOL and I will have to order them from pharmacy and the rest might be obtainable if I leave the ward to go on a drug hunt.

I can usually figure out what I need by 10 AM and I order them at that time.  I do not get the drug chart back or the drugs until about 5PM when pharmacy goes home and cannot answer any questions. Right before they go they send out the packets to each ward with all the stuff we ordered. They do not dispense anything ordered that day until after 4:30 unless you walk down there constantly and beg. They barely answer their phone either. The other 4 drugs I will usually be able to locate if I ring other wards and walk down there to get them. This is very time consuming and an 8AM drug round that should take an hour takes about 4 hours.  Pharmacy in the NHS DOES NOT prepare IV drugs for the Nurses.  Nurses here have to dilute the powdered med and prepare the infusions.  This is very time consuming.  I may have 9 patients prescribed to have IV BenPen 2.4 grams 4 times a day.  That means that at 8 AM,12 noon, 6 PM, and 10 PM I have to spend well over an hour diluting,mixing, and preparing each one for infusion.  In decent hospitals pharmacy does this for the Nurses and sends up the bag ready to hang. 

The constant interruptions from patients asking where their drugs are and relatives phoning slow me down even more.  If I stop to help those shouting for help it slows me down even more than that. And still there will be ordered drugs not given despite doing my best.  In order to even order the need drugs, pharmacy has paperwork for the Nurse to fill in.  Then we have to run said paperwork down to pharmacy ourselves.   For each and every drug.  If pharmacy even thinks that the drug may be someone on your ward or on another ward in the hospital then refuse to supply it.  And send a nasty message suggesting 6 or 7 places where you should look or it.  Sorry but I am too busy getting screamed at by patient's relatives over late drugs and other things I cannot control.

Great Scott Marty. England's hospital pharmacies of the future fucking suck. Are you sure this is 2010 and not 1910?

NHS Hospital Pharmacy's favourite lines are "It is the Nurses job" and "We are going home at 5 and it is 4:31 so we will not help you" and "Did you search other wards for it first before you bothered us".

Woe to the patient who is waiting for their discharge drugs. Woe.

The doctor will tell them that they can go home during his round at 9AM. He will be unable to come back to the ward until about 4PM and then he has to write and prescribe all those discharge drugs, as long as he doesn't have really sick patients elsewhere who need to see him again. No way he has time to do it during the day while on rounds. And in the preceding days writing discharge orders just isn't priority. Then we have to beg pharmacy to accept the orders that late in the day. Then they fuck it up but by the time we realise they are closed and have gone home.

NHS housekeeping. We have two domestics from 7-2. Then one from 5-8.   No 24 hour domestics here.  in the NHS we just have part time domestics who think that the Nurses work for them.  They don't give a rats ass of the Nurse gets struck off for neglecting her own duties.

If a patient gets discharged the bed is now free. AAU is chomping at the bit to get one of their patients into my bed. Domestics will not sort the room. I have to stop my endless search for drugs and do it, or pull the care assistants away from trying to do basic care to do it. This has to be done right away or we get held accountable for any breaches in A&E. The domestics are too busy trying to clean the floors and toilets and serving tea. They will often interrupt the Nurses in the middle of emergencies to ask for help collecting in cups and jugs for washing. They will walk past a care assistant on commode duty to tell a Nurse that someone needs the toilet. While the Nurse is in the middle of calculating a drip. Great now my concentration is gone and I need to start over.  And the patient's treatment is delayed. We have a 15 minute window to feed 30 patients or we inconvenience the domestics. They just go and collect the plates in whether or not we have been able to get the patients fed.  We have resorted to begging them not to do this but if they delay the collecting of the dinner plates back in then they are slowed down with their work.  I don't think that they have any concept of the difference between HCAs and Nurses. 

The NHS Equipment library expects the Nurse to clean and tag any equipment we have used before we send it back to them. The Nurses haven't been doing this properly because we have so many patients that need help, so many things to do and we are so behind....and scared for our registration and our patients lives. If I haven't seen crying incontinent patients for 7 hours because I am hunting for medications and trying to keep the acutely ill alive I am sure as hell not going to fuck around cleaning and tagging equipment. So it wasn't getting done properly or at all.

Equipment library made us a nice little poster showing step by step (at least 10 steps in all) how to clean and package an air mattress for them etc. They hung this little poster on our ward wall. They also made us a nice little instruction booklet regarding how to label and tag said equipment. *Every line has to be filled in for the equipment library, and this is the responsibility of the ward staff.*booklet.   I can't speak for every hospital in North America.  But I do know that the support staff in mine would have never dreamed of asking the Nurse to disregard patient care to do their job for them.

 That equipment still isn't getting cleaned, tagged and packed up properly or at all.  So equipment library made us another nice poster with pictures so that we can understand how to clean and tag their equipment properly. One of their staff even modeled for it and they showed her doing each of the 20 things that needs to be done to clean and repack and tag and air mattress.  I hope someday that fucking bitch dies because her Nurse is elsewhere packaging up an air mattress nice and neat.

Fucking drug carts and keys in the NHS.  In 1995 in North America I had a drawer in a pyxis device for each patient.  My hospital was one of the first to trial this kind of device.    This drawer had every possible drug I could need for this patient as ordered by the doctor.  I was able to access and unlock the drawer by keying in my personal identification number.

Don't even get me started on kitchen staff, IT, social services or bed managers in the NHS.  Just don't.

Nursing is tough enough without having to search for drugs, staff, answer the phone and package equipment for staff who do nothing but work 9-5 Monday through Friday and take lunch breaks every day.  Lazy bastards.

If I have 10 patients that means I get 6 minutes with each patient every hour.  Now take into account the answering of the constant stream of phone calls, the drug hunts, the relatives etc.  The one patient going poorly who needs 40 minutes out of every hour.......

Anyway it seems that Doc Brown has the DeLorean up and running!  And if that doesn't work I will just keep on trying to get abroad.

Pyxis drug machines,24 hour pharmacy and housekeeping, multiple ward clerks, ward staff mobile phones, supportive support staff.....hell yes when this baby hits 88 miles per hour Nurse Anne is going to see some serious shit.


Nurse Anne said...

Sorry guys I was just watching my favourite 80's films along with some wine.

Nursing Student said...

What the fuck am I letting myself in for?

Nurse Anne said...

Not all hospitals here are so bad. Hold out for a modern one even if you have to move.

I have heard rumours of NHS hospitals that have computerised drug charts etc etc.

Maybe we will get lucky and someone will come along and post on here and say "But my nhs bospital is more modern then that!"

We have to hold out hope that there are modern hospitals out there in NHS land.

Anonymous said...

It was also like this back when I trained in the 70s HOWEVER we had loads of student nurses and Aides etc who did most of the running around and all of the cleaning - so they havent changed the system just reduced the staff - brainiacs.

Nurse Anne said...

"just reduced the staff"

Yes and we have sicker patients these days to boot. Everyone is on mulitple drips etc.

We have students and aides BUT the people who demand that we do the running around often demand that it is a Nurse that does it.

I can't send an aide or a student off to the emergency drug cupboard to search for drugs etc. They would probably bring back the wrong thing.

I can send them for blood and supplies though.

Nursing Student said...

I doubt I'll be holding out for anywhere once I graduate. It looks (as if) I might be heading to the states not longer after, though I would have to go to school over there for a semester or two to make up paeds/maternity/psych, which royally fucking sucks, but has to be done because idiot universities here cannot teach the common foundation year properly and as a result I don't have the required hours here in those subjects to qualify for NCLEX. Blows.

When I graduate I'm looking into prison nursing (perhaps with primecare) or BUPA somewhere for the meantime. I know it's a long shot for a graduate and in this economic climate and with my experience but I don't really want to work in medical or post-op. I could do theatres, they seem to have an abundance of scrub/recovery jobs at band 5 for nurses but only in some parts of the country so I would have to see. I could go back to A&E, but the hours absoloutly ruined my life.

I really loved acute stroke. Great place to learn, sucky place to work. 30 beds on a late shift and 2RN's and 1 HCA, then me? No thanks. Like a circus.

Nurse Anne said...

Have you considered Australia? I think it is light years ahead of the United States in most provinces.

In the US things can be very bad in certain states...... To the point that it makes the NHS look rosy.

If you are going to the US avoid places like florida and texas like the plague. As a matter of fact avoid the south full stop with the exception of North Carolina.

Avoid big cities like detroit (especially avoid detroit) chicago etc. Philadelphia has lots of amazing hospitals but they only hire BSNs and lots of new grads in that area cannot find jobs.

New england is pretty good.

Just do your research.

Anonymous said...

I feel for you and all the others nurses in the NHS today. I am lucky enough to enjoy rude health and private health care, but I have a friend in hospital at the moment with a semi-serious condition (enough to keep him hospitalized for 3 weeks plus). Everything you said has rung true and it scares me that the longer my friend is in hospital, the more likely he is to catch a HAI. I wish I had the answer, but if somebody dies (e.g. North Staffs NHS) the staff will get the blame, not the politicians or managers. Good luck in your search for a new post and keep the faith.

Anonymous said...

Annie, I wondered whether you'd read this?

Nurse Anne said...

Not good when you consider that medical wards that take chronic, acute, dependent and elderly patients are currently working with less than half the amount of staff nurses that they require...

And the elderly population is about to explode along with a dramatic increase in acute and chronic conditions and disability as a result of poor lifestyle choices.

Most of the elderly people I take care of are strong, dignified,and took care of themselves in their youth. They generally had healthier lifestyles than the baby boomers. The ww2 generation is the greatest generation.

The baby boomers are fat and nasty.

Seriously all hell is going to break loose in a few years when those who are in their 30's,40's and 50's right now are elderly. Hell, many of them are getting old before their time because of the mcdonalds and the alcohol. And holy hell are they demanding.

We had one of these people demanding that her family bring her mcdonalds every day (they did)as well as biscuits, chocolate etc. Then she blamed the hospital staff when her blood glucose was through the roof. When we all tried (repeatedly) to explain why her sugar was high we were told to piss off. She would walk outside for a cig every few minutes and then come back in and demand that staff change her tv channels for her IMMEDIATELY. When one of the HCA's served her with a tray of healthy food for dinner (roast chicken and veg) this patient threw it at her.

You won't see any members of the ww2 generation behaving like that.

And I am glad that I am going to be long dead when generation Y gets old. Hell I wish I could be dead before the baby boomers get any older and sicker.

Nurse Anne said...

In short, a member of the ww2 generation with dementia and double incontinance has more dignity and class than your average 50 year old these days.

Gosh I went off on a tangent there....

Anyway yeah we need as many RNs as we can get so they shouldn't be cutting funding to nursing schools. The baby boomers will want one to one nursing care at all times but will not want to pay for it....

Good times ahead. Not.

Anonymous said...

Hi, Was thinking about going back to nursing after a 3 yr break. I was getting stressed out there just a fraction of the way into your shift. Keep telling it like it is,and maybe one day it will be how it should be. Protest Central London anyone ?

Nursing Student said...

I think a protest in cardiff central would be more appropriate anonymous, that way Nurse Anne can be the rebel and climb on the statue of Aneurin Bevan. How appropriate would that be? Lets try and avoid the water canons and flying police batons though.

Anne I know all about Australia but unfortunatly I went to visit there a few years ago and I absoloutly hated it. I visited Melbourne, Brisbane and Cairns (cousins lived in first 2 and brother in Cairns) and I wanted to die in each city. It was dry, the accents I found annoying, the landscape was just grim and yes, spiders and other bugs everywhere. My brother eventually moved to spain which was a relief as he never had enough money to come home and I was adiment I would never visit Australia again so I was certain I'd never see him again or for a very long time!

We are thinking either the Boston area, Baltimore City or Penn state. Though St.Louis on the cards too, which is a bit mehhhh for me, but I suppose I don't have to live there forever. Perhaps you can give me some insight.

Oya's Daughter said...

I honestly cannot agree more; I was shocked when I first came here and dealt with a GP receptionist; they rarely know how to work their computers. They don't know your case or where the file is. They barely know how the phones work. If I that inefficient back in the US I would have been fired so fast my chair would have been spinning from the impact of being kicked out the door. Say that, however, and one is just "being American" whatever that means.

Nursing Student - Minnesota (where I'm from) is good but the winters may floor you and the summers are very hot. The midwest tends to take care of its own however just because they're so bloody grateful if people can stick out the weather!

admin said...

"Then I bleep the doctor. Then I have to stand there looking like an idle simpleton and wait for him to call back."

please ask someone in the HR or nursing department within the hospital to contact us, we have a very powerful tool that will remove this wait and reduce the risk to patient safety. We will do everything possible to support your organisation

Nursing Student said...

^^ Fantastic, another electronic "system" cunningly disguised as an aid to the health service when actually it's a hindrance. Bleeping systems are designed to alert doctors, not lay them off. Nurses dont have time to text/type out EWS scoring either. Another responsibility for us when we could be at the bedside.

Anyone else find EWS scoring compleatly redundant too? I know bad obs when I see them, and it all depends on the patient. We had a HCA pull the emergency button twice in one shift on a patient with a low pulse and high bp.... the ews scoring said the patient was in danger and medical attention asap, so the HCA see's none of us around and pulls the buzzer... no the patient has AF and with all things said was sitting up trying to enjoy a cup of tea in peace!

And I have seen some students been told to page a doctor in an emergency which they have done before and should be able to do... these are second and third placement students... telling the doctor on the phone "the patient has an EWS score of 5".... 5 of what!!!

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