Sunday, 31 January 2010

RCN Nursing Counts. Does the RCN believe in Nurses?

Look at what the RCN has come up with recently.

I would really like to see them do even more to get across to the public what it is that bedside registered nurses actually do.  But encouraging nurses to be politically active is a good place to start.

Many of the problems that we currently have with nursing care is that bedside nurses are not valued. They are abused, overwhelmed, exhausted and frustrated over not being able to even remotely do their jobs well.  They run away from hospitals and managment loves it because they don't want to pay them to be there.   People think that an airhead with a good heart can be a good nurse.  They don't understand why a bedside nurse needs a good education on top of vocational training.  It's well known amongst nurses that a nursing student is going to have to hit the books a lot more than many other university students.  It is also well known that when they qualify that they are going to have a level of responsibility that most people cannot even fathom. But people think that nurses hand out tablets and hold hands and clean up.  That statement on it's is such a sick oversimplification of what we do that it is actually quite distressing.  The Media is at fault for this and the main culprit is TV.

I would like to see the RCN really push a campaign to show the public what BEDSIDE nurses actually do, how complex their job is, how much life and death responsibility they have and how analytical they need to be to not kill anyone.  Then show how hellish it gets when they are trying to do all this for too many people.  I have some ideas about how to get this across.  No time to post it all today though.

I guess that maybe  Nursing Counts  is a very good start.

Check it out and let me know what you think.

If anyone reading this is from the RCN let me tell you something.  Your photo of the nursing helping a patient to stand up with her zimmer sucks.  Show a nurse standing over the bed of someone with multiple drips calculating IV rates and assessing for heart failure or something...then you should have little information boxes nearby explaining just what it is she is doing.  From head to toe, show everything that the nurse needs to keep on top of for that patient.  Everything from changes in mental status and associated causes to pressure care, IV rationales, hydration etc etc.  Oh wait, you muppets have been away from the bedside for so long that you don't even know.  Not only does the public need education about the value of a bedside RN but so does the RCN apparantly. Stop it with the hand holding "my only job is to wheel patients around and give them pills" fucking shit in your photos.  It is damaging.  This is better:

That pic is not of a doctor or a nurse specialist.  It is a picture of a bedside nurse. She is supposed to handle all those drips and a million other things for multiple multiple  patients.  She cannot restrict the number of patients that she has. She is expected to always hold their hands as well and clean the ward without making mistakes with those IV drugs.  Drugs such as that need constant checking and supervision. Mistakes with those drips kill, and she'll have charges brought against her if she makes a boo boo.

But instead of nurses being depicted by pictures like the one above, we get this fucking shit below:

No wonder people think that a moron with a good heart could be a good nurse.  No wonder they think that untrained teenagers staffing the wards are nurses. These kinds of images depict one small aspect of nursing while disparaging all of the other things that real bedside nurses do to keep their patients alive.

Stop saying that nurses are better these days because they can do all these things that doctors used to do.  Forget that rubbish.  Promote bedside nurses.  I once had an office job as a nurse years and years ago.  It is easier than bedside nursing mentally and physically but we had more respect than bedside nurses.  Most things are easier than bedside nursing but attract more respect.  We need to respect nurses at the bedside, not pretend that leaving the bedside is advancement.  It may get you more money to leave the bedside.  But the work is easier away from the bedside and the cognitive strain is less .  Why people who leave the bedside to sit in an office and  create rubbish like productive ward are deamed cream of the crop nurses is beyond me.

The strong, knowledgable and smart nurses are at the bedside getting shat upon from a great height.  The specialist nurses, the discharge  bed magnet specialist bullshit nurse etc can't handle the bedside.  And that has nothing to do with being too smart and educated to handle shit and piss.  It has everything to do with the fact that they cannot mentally handle all that information overload and quick thinking that one needs to have as a professional nurse on the ward.  That is why they leave.  They are not better nurses or super nurses.  Bedside nurses need more in the way of education and brains than a discharge planning specialist pen pusher nurse sat in an office does. The infection control special nurses have memorised a lot of misinformation that they have been spoon fed and they know how to regurgitate it and bully any dissenters who actually think..  But other than that, they are as dumb as a bag of rocks.  They have no ability for independent thought whatsover. They aren't bright enough or tough enough to handle ward nursing.  That's why they have an office job. 

Here's a pic of the chief nursing officer. 

She couldn't handle the stuff that the bedside nurse in the first picture above is handling.  If I am wrong I apologise but I would imagine that she has been away from proper bedside nursing for years.  Yet she is considered the higher level nurse?  WTF?  I have seen nurse specialists, nurse managers, and matrons come to the bedside.  It ain't pretty.  They'll make like 50 drug errors in 30 seconds.  The trust told them they had to do shifts at the bedside.  They did it once, ran away screaming, and never came to the bedside again. That was 5 years ago.  Why they are the nurses who get respect is beyond me.  Why they are held up as an example as to why nurses need an education is beyond me.

If you listened to the RCN bleat on about nurse education you would actually believe that a nurse needs an education only to leave the wards and "advance".   The RCN is making out that we need smart nurses merely for these advanced roles. That is wrong. They need an education to work on the wards, and tend to stop thinking or needing their brains when they move off of the wards into these silly posts. The wards are where you will fry your brain.  We just have a hard time demonstrating our knowledge because we have to take short cuts and move fast.  Specialist nurses don't have that problem.  They can take all the time they want to perform a task.

These devalutation of bedside nursing is what has led to things like Staffordshire.  Society tells nurses that they only way that people are going to appreciate your brains is to get off the wards. The only way you deserve to be paid for the hours you work is to get off the ward.  Then managment refuses to even considering hiring registered nurses to work on the wards and replaces them with untrained non nurses on minimum wage.  The few nurses left on the wards are trying to do everything, since the untrained non nurses can do very little.  They burn out and they leave and managment loves it.  One of their favourite tricks is to lose bedside RN's through "natural wastage" i.e. retirement and burnout.  Then they bring in untrained carers leaving the nurses with even more patients to nurse.

This country is clinging to backward ideas about bedside nursing and it's killing the profession.  I hope that the RCN completely wakes up.  Right now they seem to be somewhere between fast asleep and the period you enter just before you wake up.  I hope that someone throws a glass of water over their heads and gets them completely awake before it is too late.

Oh my god. They just don't learn do they.

Years of research and numerous studies show that a lack of well educated registered nurses at the bedside not only causes patients to suffer and die but results in good nurses leaving the profession.  Years of research and numerous studies have also shown that the expensive complications and poor patient care that results from a lack of real nurses at the bedside are violently expensive and costs more money than investing in registered nurses. 

It doesn't matter how good your doctor is  at diagnosing and treating a disease process people. If the registered nurse at your bedside is not on top of his orders and your situation you will suffer and you can die. You will come out of hospital worse than you came in.  If your nurse has 15 patients and only untrained carers to help she will not be able to stay on top of your situation, your care, nor will she be able to implement and observe your doctor's plan of action.  Doctors are not at your bedside making sure that you get those IV drugs or that you are not becoming septic or bleeding out internally.  The nurse is looking for all that when she cares for you.  If the nurse doesn't pick up on those things then they don't get picked up fast enough.

So what are the fuckers going to do now?

Will someone buy my house so I can get out of here faster?  Thanks.

And don't be dumb enough to believe those stats about the number of  registered nurses at the bedside increasing under labour.  They. Have. Not.  Labour's policies led directly to things like staffordshire.  Read my post below this one to see what happened there and why.

New Article about Staffordshire.

Staffordshire is not alone guys.  Not by a long shot.  Could these managers be any more creepy?

Hospital trust branded the worst in Britain 'tried to gag whistleblowers'

A report into the management of hospitals in Mid Staffordshire will highlight a culture of secrecy about poor working conditions that may have contributed to more than 1,000 patients dying

Rajeev Syal, investigations editor The Observer, Sunday 31 January 2010

A hospital trust branded the worst in Britain by the NHS regulator actively discouraged staff from expressing fears about the safety of patients, an independent inquiry is expected to conclude.

Senior managers at Mid Staffordshire NHS Foundation Trust, where poor working conditions may have contributed to more than 1,000 deaths, will be accused of promoting a culture of secrecy, according to sources close to the inquiry.

The disclosure of a key finding of the report, expected to be released this week, comes as campaigners for patients who suffered neglect in Stafford and Cannock Chase hospitals call for a judicial review into the trust.

An official close to the inquiry told the Observer that it will conclude that staff were discouraged from bringing problems to the attention of managers and NHS authorities.

"Staff have known about the problems on the wards for many years, but there has been no means by which they can bring them up. Those who have tried to do so have been shot down. Some have been ordered to ­withdraw or hide their allegations," the official said.

The inquiry was launched in September by the health secretary, Andy Burnham, following a Healthcare Commission investigation that delivered the most savage indictment of any NHS organisation in the commission's five-year history. Its report condemned "appalling" standards of care at the trust's hospitals in Stafford and Cannock, particularly involving emergency admissions, which may have contributed to up to 1,000 deaths between 2005 and 2008.

The inquiry, chaired by Robert Francis QC, has heard evidence from a number of members of staff that they had been actively encouraged to ignore serious problems in frontline services.

One senior Stafford hospital official was suspended last week after documents from the inquiry allegedly showed that she tried to cover up damning comments about the care given to a 20-year-old who died just hours after being sent home from the accident and emergency department.

Kate Levy, board secretary and head of legal services at Mid Staffordshire NHS Foundation Trust, is being investigated over allegations that she encouraged a doctor to rewrite a report into the death of John Moore-Robinson.

Staff in accident and emergency failed to spot that the telecommunications worker had a ruptured spleen following a mountain bike accident on Cannock Chase in April 2006. He died at his home in Coalville, Leicestershire, less than 24 hours after being sent home with painkillers.

A report by Ivan Phair, an A&E consultant, into his treatment said: "The premature death of Mr Moore-Robinson in my opinion was an avoidable situation. I feel that an independent expert would criticise the management afforded to him by the staff. There is a high probability that the level of care delivered to Mr Moore-Robinson was negligent."

After reading the report, Levy wrote to Phair asking him to erase the comments. Her letter stated: "As reports are generally read out in full at the inquest, and press and family will be present, with a view to avoiding further distress to the family and adverse publicity I would wish to avoid stressing possible failures on the part of the trust."

The report was not presented to the inquest. Mr Moore-Robinson's parents only found out about Levy's letters when copies were given to them by a lawyer at the inquiry.

Frank Robinson, the dead man's father, told the Observer that there had been a "culture of cover-ups" at the hospital. "Nothing can distress us more than losing our son. So for this woman to claim that hearing the truth would distress us is a heartbreaking and cruel insult," he said.

"This is a hospital trust out of control. The place needs to be overhauled."

Staff have claimed that they have been intimidated into silence when they have raised concerns. Pradip Singh, a ­senior consultant who gave evidence to the inquiry, used the protection of the ­Commons all-party health committee last year to explain what went wrong at Stafford hospital after what he called a "savage reduction" in levels of nursing. "Over the years, many clinicians had noticed deterioration in the standards of patient care, which became particularly acute approximately three years ago when major cutbacks were made in staffing numbers. This included a ­savage reduction in the number of nursing staff," he wrote.

He means bedside Registered nurses.  You can't throw untrained kids at the wards and then say that you have lots of nursing staff.  But this is what management does because that is how badly they devalue bedside nursing........Anne

Singh, a gastroenterologist, said that he and other consultants had complained to senior medical managers and the trust's management, but those who complained had been ignored and branded as troublemakers. He said that a "palpable culture of intimidation" in the trust deterred others from speaking out publicly.

The culture of secrecy at the trust has been reinforced by a written "whistleblowers" policy that discouraged an open discussion of problems, according to one charity that made a submission to the inquiry.

Cathy James, deputy director of the charity Public Concern At Work, said she had found the written policy wanting. "In health, more than almost anywhere else, a closed culture will breed silence. Mid Staffs is a warning for all. I hope that this will push the other trusts to review their policies so that staff believe that it is safe and acceptable to speak up."

Whatever the final conclusions of the independent inquiry, campaigners whose family members have received poor treatment at the trust's hospitals believe that the parameters of the inquiry were too narrow.

Julie Bailey, founder of the patient group Cure the NHS, said that more than 100 families who support her organisation are now pinning their hopes on a judicial review.

"The inquiry was done in secret and seems to have gone through the same evidence as the Healthcare Commission report," she said.

"We need a judicial review to look at the failings of the regulatory bodies – where were the primary care trust, the strategic care authority, the Healthcare Commission, local MPs and the Department of Health while people were dying?"

Mid Staffordshire NHS Foundation Trust last night declined to comment until after the findings of the inquiry are officially released.

"We will be happy to comment on the conclusions, but wish to wait until it is out in the open," a Mid Staffordshire spokeswoman said.

A spokesman for the inquiry did not wish to comment.

Friday, 29 January 2010

Latest from the Daily Mail and more insanity on my ward.

Here's the latest from the Daily Fail.

Shock.  They actually mentioned the staff shortages.  They actually came close to recognising that one RN to 18 critically ill patients who need one to one monitoring may not actually be able to bed bath a patient without killing someone.

But their readers are still fucktwits.  Look at the comments sections.  "Nurses won't bedbath these days" "Can't be bothered".  Whatever.

Let me tell you what happened to me yesterday or  sometime thereabouts.  I was one RN to  WELL over 10 patients.  I had a student on his first placement, second day.  He worked as a retail manager before attending nursing school and holds a degree in English lit.  He is bloody marvelous for someone who is such a novice.  I had him on shift with me and a teenage carer.  It was her 2nd day on the job..  She has no training.  This was her induction. That was the ward staff.

Let me start by saying that degree students  ARE NOT FUCKING SUPERNUMERY.   Not really. They can't be.  This guy jumped straight in and did a hell of a job.  He had about 2 minutes to pick up how to do obs, blood sugars, and basic care. And he did it like a champ with a few minor fuck ups along the way.

My plans for the shift was to bring him around with me, show him a bed bath, let him watch me give meds etc.  The usual first placement stuff.

But of course reality got in the way of that. Details have been changed.  The following are not real patients.

I was running around like a headless chicken and the student had to work off his own initiative.  I had to do all the meds, interventions and treatments and orders for all those people.  The phone was constantly ringing.  Early in the shift they sent me a critically ill patient.  The ward he was on "couldn't handle" him.  There were no beds in ITU.  I had to take him.  I really kicked off with the "But it is so unsafe and I can't handle him either".  I had no choice in the matter, just total responsibility for any bad outcomes. After my shift ended I reported the manager who forced this transfer on me.  I'm in the process of complaining to high heaven.  This bullshit was not fair on the critically ill patient. the other patients, the student, or the carer.

This new patient was in a bad way. He needed one to one monitoring, and my arse parked at his bedside to survive the shift.  He needed multiple infusions, cardiac monitoring, suctioning, etc.  He was  going badly into CCF as they transferred him to me.  His 02 sats were in the shit long before that because of pnuemonia and COPD.  His observations  were a mess. I had to send the kids running around the hospital searching for those elusive IV pumps so we could deliver his medication to him.  The junior doctor on duty was having a pyshcotic episode/nervous breakdown  weepy moment in our staff room.   Had I not been so busy I would have hooked the doc up with some coffee and chocolate.  Some retarded specialist nurse had laid into doctor for no reason and was trying to dump a lot of rubbish onto the doc.  The poor doc was on his/her knees already because he/she was carrying that fucking bleep, trying to prioritize 1000 jobs..  Told doc not to worry about that cuntface who yelled at her because we all hate her. She yells a lot and is always barking up the wrong tree.

Our new patient was very elderly.  Very elderly.  Still for resus if he crashed and died however.

Guess who took care of all the other patients on their own with no supervision while I was up to my eyeballs in this?  Newbie one and Newbie 2 did.  I use the phrase "took care of my other patients" very loosely.  They are incapable of having anything to do with medication, IV's, NG's, catheters, noticing any real changes in condition etc.  They cannot answer questions from family. They couldn't even manage to change the bed linen for a large bedbound and incontinant patient because they didn't know who to react when she started biting, screaming and hitting and they couldn't move her around the bed.  Most of my patients are like that woman.  

The student was surprisingly on the ball and helpful and gracious even though he was thrust into a situation from hell when he is supposed to be learning.  He reported crappy vital signs, blood sugars etc.  He figured out that one patient was uncomfortable because she was in retention (I hadn't even laid eyes on that poor patient).  He must have done his homework because he picked up on stuff that I would have never picked up on during my very first placement.   I wanted him with me so that he could have some really good learning experiences.  He told me he had never even down a bedbath.   I was going to show him the right way to do one and how we assess patients and tie that information into their situation. I want to mentor people properly, not use them as free labour.  Not until they know what they are doing anyway. But he had to help me out by being my eyes and ears.  He certainly didn't think that he was above getting his hands dirty.  He ran right over to the little old lady who was wandering to the bathroom and pooing on the floor as she went.  He cleaned her, cleaned the floor and made her a drink.

Don't let anyone tell you that students are supernumery.  Don't let anyone tell you that they don't want to get their hands dirty.  In my opinion, that is not the case at all except for the rare bad apple.  I must be lucky because I have yet to get a bad apple student.

I'll tell you what I did accomplish during that shift.  I tore the cleaning schedule that identified all the things we were to dismantle and clean during that shift and I shoved it into the shit eating machine.  Had the infection control tickboxing lardo specialist nurse been around I would have shoved it up her bottom.

Wednesday, 20 January 2010

How does it keep getting worse? Total Insanity.

Our staffing levels and skill mix continue to be a joke- a sick fucking joke.

I thought that we were slated to get some new staff nurses.  I was wrong.  We  are getting more kids to replace the ones we are losing. They really are kids and they have no training or experience in a health care setting.  They will not be trained or orientated.  They will show up to work and just have to muck in, without knowing what they are doing.  No one has time to explain or teach anything.  The kids from last year are still fucking a lot of things up.  Goddammit I want RN's.  I can't handle being a nurse for this many patients whether I have 5 carers with me or fifty of them.  90% of what is going on in a ward is way over the care assistants heads.  They just don't realise it.

A nice little surprise awaited my arrival onto the ward to work a day shift recently.  I'm not talking about the staffing levels.  Those were as shitty as expected for the shift.  We were going to have 3 staff nurses and 2 carers.  But they sent our third staff nurse to cover another short ward.  So we had 2 staff nurses and 2 carers.  And then they sent us this agency carer who cannot speak a word of english and has been in the country a short time.  No previous experience in healthcare.  But she was wearing a nice pretty uniform that says "Nursing staff" on the front.  No wonder the patients and the visitors are confused.  I told her not to leave the cdiff mrsa patient's room without washing her hands.  I told her not to share equipment between those patients and other patients on the ward.  She gave me a beautiful smile and said "yes matron" to me and kept going.  She did the same thing again 2 minutes later.
 I think the only words the poor child knew were "yes matron" and "I happy to".  Not a clue about what we were saying to her.  Not a clue.  Sweet girl though.  I did complain to the site manager about it.  Her response was "you should be grateful for having an etc set of hands".  Uh, you took our trained nurse away and gave us a total novice.

Just for the record (in case any fucktwits are reading this) that girl is NOT a foreign nurse.  Foreign nurses have education, qualifications and registration with the NMC.  This girl was not a nurse and not registered with the NMC.  She was a foreign employee, not a nurse.

So those were our staffing levels.

Back to my surprise.  There was  a list of "orders" orders from management that greeted me when I arrived for duty.

They wanted us to take apart a whole lot of equipment and clean it all, on the floor on our hands and knees.  They wanted us to assess all these things for faults and fill in about ten forms for each item.  I am talking about large items like beds, mattresses, etc.  They wanted this from 2 staff nurses and three carers covering 25 patients who all require constant care.  They don't want to pay domestics, but they don't want another  Basildon.  They don't want to hire nurses or staff nor do they want to be in the papers.  I was told that threats had been made against the nursing staff if these things are not done.  Look at how basildon hospital responded to complaints about the care at their hospital.  They know what the situation is , but they blame the nurses.
In a letter to Mr Wood's family he wrote: "I am sorry that the standards of cleanliness were unacceptable during your father's hospital stay. All the clinical areas should be cleaned daily. There is no excuse for dirty bed linen to be left in the lavatory. The ward would like to apologise that the care they gave has left your family feeling that expected standards of care have not been met."

Now I am all into cleaning and stuff.  I quite enjoy the whole domestic goddess thing.  But what I couldn't figure out was this: who the fuck is going to take care of the patients?

We worked out how long it would take to knock out all the things on the list.  It would take 6.5 hours out of an 8 hour shift. They wanted it done on that shift. It takes about 6.5 fucking hours to get through the 8 AM drugs for a ward full of confused and acutely ill patients.  

We have many, many patients all sharing two toilets and management also demanded that we spend 8 minutes exactly scrubbing out each toilet between use.  Then they wanted a form filled in and signed after each and every cleaning session.  How? How?  At any given time we have more patients that need the toilet than there are toilets. And they get real nasty if they have to wait.  Really nasty.  We worked out that we would have to spend 50 minutes out of every hour just scrubbing toilets in order to do what tthe powers that be wanted.  It usually takes the care assistants (with the help of a nurse when she finishes the work that only a nurse can do) until about 1PM to finish all the AM hygiene etc for the patients when there are 6 of us on duty.

So they wanted this all from us without any additional staff. When RN's don't spend enough time with patients and focusing on the things that only a nurse can do patients die.  Those things are all encompassing and take more time than we have. What are these managers thinking?

Stupid us we tried to accomplish it.  My vote was to send an incident form to management saying "direct patient care and patient safety comes first, this is impossible so fuck you".  But the other staff nurse  on duty  outranks me and she is a Nerdy Nellie, always wants to please.   They had threatened us with a spot inspection that shift.  We had to make a go of it.  It was a disaster.

So by 10 AM I am 1/3 of the way through my 0800 drug round.  Half my patients are spitting their meds out on the floor or refusing to take them.   Half the beds are half dismantled. The phone is ringing nonstop and we are having to drop what we are doing to answer it, otherwise the public complains that we aren't "bothering" to answer the phone. And it's at this time that one of my patients goes bad.

The drug I need to stop the "bad" is always supposed to be kept in the fridge. It wasn't there.  This is happening almost every day.  Pharmacy has no staff either, and they are never open when we need them.  If something isn't there it is the nurse's problem.  Problem was, they left us without an emergency drug and they were closed.  My other staff nurse had an emergency on her side.  The two care assistants were half way through  bathing a patient who requires two people spending 20 minutes with her to get it all done.  The other staff member couldn't understand english, although she did show concern over the fact that I was standing in the medication room in a rage..  I had to ring 7 wards to find the drug and then walk my bottom down there to get it.  But I got it, and patient survived.

When I got back to the ward it was still chaos.  Patients were crying because they wanted to get back into bed.  But the beds were all apart waiting for the staff to check them over and  copy equipment numbers that are located in hard to find places.  It all was ordered to be done in the morning.  And there was so much going on that there was no way we were getting back to those beds.  I went to help Nellie with her poorly patient once mine was okay.  My drug trolley was just parked in the middle of the ward.   Patients were getting concerned that their drugs were so late and that they couldn't even crawl back into the bed to deal with the pain.  I reminded Nellie that the dismantled beds were her fault and that we should have gone with my incident form idea. Ha.

Nellie's patient now had a pulse of 200 but was alert and comfortable.  All other vitals were fine.  The phone rang.  I answered it hoping that it was the registrar (senior doctor) I had just paged about Nellie's patient.  I thought for sure it would be him calling back.  But it wasn't.  It was Mrs. Jones daughter screaming at me because her mother phoned her to tell her that she hasn't had her morning meds yet.   I told her that I was in the middle of an emergency and that I needed the phone line free NOW.  I told her that I would get her mother her tablets as soon as I could.  It went over her head.  She kept threatening me.  If the senior doc was ringing us back he wouldn't be able to get through because this woman was keeping the line engaged with "Don't you fucking tell me that you couldn't find time in the last two hours to give my mother her pills".   I had to hang up on her.  We have one working phone line. Then I heard a shout from Nellie and the next thing I knew I was putting the crash call out to get the cardiac arrest team to us immediately.  Her patient had just crashed. We didn't get her back.

Later on in the day I had more family fun with my patients relatives.  I had a patient on a drug that needs to be given at regular intervals through out the day.  I managed it but one of the doses was 10 minutes late.  No big deal.  Two hours late would be a problem but not ten minutes.  I have looked after thousands of people on this drug.  Her husband decided to give me a lecture and a computer print out from the internet about that particular drug because "you nurses are obviously too stupid to know that it needs to be given on time".  How he could think he understood WHY  that drug was late.  He didn't have a clue as to what was going on in that ward.  I should have got a fucking award for getting it to her when I did.  That on it's own, took a lot of manuevering.  If your loved one has a drug due at 0800 so do many of the nurses other patients.  Getting everyone everything on time is physically impossible.  I would have to be in 15 places at once literally.  If I have say, 10 patients all due a drug at 10 AM I will start at 9:30 with the first one and get to the last one at 10:30.  And run past people calling for help to accomplish that.  There is no other way.

It just got worse as the day progressed.

We had some fun with the doctors as well. .  Some of them are just creepy. The first thing that happened was a surgeon showed up onto the ward to see one of my patients. He wasn't her main doctor but he was asked by her doctor to see her.  He arrived on the ward unexpected shortly after the cardiac arrest.  The aftermath of one of those things is massive.  He went over to the patient and when she told them that she hasn't seen a nurse in hours he responded with "have you complained about anything-they'll be extra mean if you complain".  I wasn't surprised.  My patients have told me that many consultants tell their patients this.  In all my years of nursing I have never seen a patient get treated extra badly because they complained.  Never.  Everyone gets neglected whether you are nice to the nurses or not.

About a half an hour after the cardiac arrest a relative called me.  She asked me if I would give her mother a bath and wash her hair in the next hour, before visiting.  I looked at the ward in disarray and remembered that I was hours behind with about 1000 crucial jobs. She wanted her mother to have an hour soak in the bath.  This would require a member of staff staying with her for an hour as she cannot be left alone in there.  The other 4 members of staff were doing about 20 jobs per second, other patients were crying out for help and were being ignored.  The ward was a mess. No one could take the dirty linen away.The non english speaking staff member would not be able to get this woman in the bath safely as a hoist thing was required.  None of us had the time to show her.  I had this girl specialing a confused wanderer that was trying to get out. I told the caller that I would probably be unable to get it done today because of ward conditions.  She went onto tell me how important it is for patients to have simple things like their hair washed and how nice it is to do something like that for someone.  I was perplexed.  How could she think that I, a registered nurse, could not understand something like that. 

Ask any patient who has been in hospital unable to care for themselvs what meant the most to them while they were there.  They won't say it was the doctors or nurses, nor appreciate the meds or the treatments or the labwork we did.  They will tell you that the number one thing that they appreciated was a bath and a hair wash.  I have known this since 1992.  Of course it is a wonderful and important thing to do for patients. Things like that actually help patients heal because they feel positive when they feel that they look nice.  But the other other things going on at that time were all time consuming and higher priority.  It dawned on me that she didn't understand that.  She thought that I simply didn't want to be bothered washing her mother's hair.  She thought that nurses these days don't understand the importance of the simple things.  It is a triage situation on these wards, and the public have no idea.  And they are conditioned to think that nurses are uneducated slags who don't want to be bothered.  I have no chance of getting the reality of the situation across to her.  She has been socialised to have completely unrealistic expectations from the nurses.  I told her I would try my best (and I did ) but I didn't think I would be able to.  I left it at that. She wasn't happy. 

I got out of there over an hour and a half late, unpaid.  And not one job was completed properly.  I heard later on that it got even worse.

On my way out I was greeted by a nice person, the partner of a long term patient who is bedbound and unable to care for himself following a RTA (info changed to protect confidentiality).  This patient was medically stable but needed much in the way of total nursing care.  He has been with us a long time and comes in frequently.  We adore him and we adore the family.  We know them well. The spouse handed me some chocs and says " I just wanted to say thank you for everything you have done for soandso, you nurses are amazing".

Just what had I done for so and so? I hadn't laid eyes on him in 5 hours.  I spent about 2 minutes helping the care assistants wash him and had a quick look at his skin.  I resited his venflon.  I gave his IV meds an hour late.  I ordered an airmattress. That was all.  I didn't have time to spend with him and didn't do half of what I should have.  I was in and out of that room at the speed of light. It makes me sick.  The spouse knew this because she was there.  She knew we were having a rough time and was trying to build us up.  The tears were about to start so I walked away mumbling yeah thanks. 

So can see if you are mean to the nurses we get upset, and if you are nice, we get upset.  You are not going to win really.

What a mess.  Our staffing numbers look like crap over the next few months and management is hellbent on this cleaning regime and associated paperwork.  Some of the stuff they want done multiple times daily.  They won't even consider bringing more domestics in or giving us someone to answer the phone.  We have one shift that is set to be staffed really really well. And that means that a staff member on that shift will be sent elsewhere. 

I just have one question.  "How?"

I am hearing through the grapevine that frontline staff nurses are set to be scapegoated if anything goes wrong with the cleaning etc.  They are all ready all over us for the cleaning forms not being filled in.  It doesn't surprise me after reading this.- nurses being questioned by police.  The physical layout of the ward does not allow for patients to be isolated properly, we don't have enough handwashing stations etc etc, we cannot even wash our hands properly without getting told that we are not responding to patients quick enough.  Sometimes I will just turn on the water to wash my hands after finishing with one patient and the patient in the next bed will start shouting. "get over here now and get me the toilet"  "I am just need to clean the commode and wash my hands and I will be right there"  "Get over here now or I will wet the bed and it will be your fault".  Imagine if I took the time out to fill in the form saying that I cleaned the commode during that scenario.

We are not up to date with our knowledge.  Meanwhile David Cameron is running around like a twat worried about overeducated nurses not wanting to care for the patients.  The problem is no nurses David, not education of nurses.

Half my shift is spent at the nurses station sorting out systems problems or running around the hospital looking for drugs anyway.   Can't wait to get out of here.

Thursday, 14 January 2010

Hell In Staffordshire Revisited. They are indeed blaming nurses for management failures.

I really didn't want to have to do another blog linking  a Nursing Times article yet again.  In my opinion they are lying shills who do not know how to find decent sources to quote in their articles. But I cannot help myself.  You have to keep in mind that the woman quoted in this article (Julie Hendry) will not have any experience taking on 15 medical patients on a large ward as the only RN these days.  This is a situation that would suck the caring and the empathy out of Mother Theresa.   If she did understand it, she is solely working under the direction of the management twatterati. So basically, she doesn't have a clue or she is hiding it. She is scapegoating nurses just as her management overlords have instructed her to do.

 It's no big secret that nurses are acquiring much in the way of trauma and psychological damage as a result of the ward conditions, and their inability to care for their patients as a result of lack of trained staff and managements refusal to address safe trained nurse to patient ratios.  Ratio stats.

We know that the problems in Staffordshire with nursing care were down to trained nurse to patient ratios that wouldn't be legal in a third world country.  I recently did a shift with only 2 of us for the whole ward.  Management did not care about the staffing levels.  One of my biggest nightmares is seeing patients developing pre renal failure etc as a result of dehydration.  I am commited to seeing that patients are hydrated properly.  But I didn't have a chance.  There was not one second during that shift where I was able to assist someone with a drink.  Not at all.  And it was all down to factors that were out of my control.

If you have not yet heard about Staffordshire look here. And here.

Here is a story from the BBC.

My take on it here.

Here is a comment from Nurse who actually worked there. She commented on my blog.

Anonymous said...

Nurses with 'tude?
I started to develop a bad 'tude at Shitford General. This was a mad busy surgical ward, horribly understaffed and with some very acutely ill patients.
Because of the pressure in ITU we were taking HDU patients all the time. These patients were not really stable enough to be nursed on a surgical ward having had major ops like gastrectomy and oesphegectomy.
These patients needed at least half-hourly monitoring. Some had trachys. All had multiple drains, feeding tubes, catheters, stomas and multiple IVI's and IVABx. You might have two of these HDU patients to your twelve-bedded bay.
In your bay you might also have recovering colosomy, appendectomy, amputation patients with the usual complement of diabetics and complicated medical problems.
I got an attitude all right. One day a patient newly back from theatre after having extensive bowel surgery developed obvious cardiac signs (low BP, tachycardia) and was going down the tubes fast. I bleeped the team and we swung into action.
In the midst of the emergency another patient stuck his head round the curtains and demanded I do his toe dressing RIGHT NOW. The Registrar yelled at him to get out.
We saved the post-op patient. He went to CCU and all was well. I left that shift four hours late then had two days off.
On my return the ward sister pulled me up for not doing the toe dressing, the patient had complained and had said I had a "bad attitude"
Fuck him and the selfish horse he rode in on.

Well said. HDU and ITU patients are critically ill.  If a nurse is responsible for these kinds of patients she cannot see her other patients.  At all.  Full stop. So why was shitford hospital forcing their individual nurses to take these kinds of patients on top of 10 other patients, shift after shift, and day after day? Unless you are one of these clueless visitors to the hospital or a member of the media you, of course, understand that if you have a critically ill patient for 12 hours THEN YOU CANNOT SEE ANY OF YOUR OTHER PATIENTS FOR 12 HOURS. And here in the NHS you DO NOT get another nurse to help you care for those other 10  patients.  You will have to go to the  nurse's station to check orders, order equipment and get/give information about your critically ill patient.  It's probably a good idea to ignore anything else but what you are doing for that critically ill patient whilst you are at the station.  You do not want to get delayed getting back to him because you were talking to a relative of another, stable patient.  The relatives of your other patients will, of course, accuse you of ignoring their loved ones to hide at the station.  They don't understand anything.

Who wouldn't have a bad attitude when you are up to your eyeballs in life and death stuff, afraid that people you are responsible for are going to die because you can't give them the time.  You are dehydrated yourself and 9 hours without a meal.  Your sickest patient just got worse and you have seconds to implement the actions that you need to ensure his survival.  And just at that moment in time someone gets in your face and demands that you stop what you are doing to change a toe dressing.  There is not a human being alive who would not explode in that instant.  Nurses handle it better than others could, and they bite their tongues more often than not. 

You're welcome.

Edited to add:  Don't forget to add your comments over at the nursing times as well.

Wednesday, 13 January 2010

Our favourite agony aunt was attacked by nurses!!

I just read this and it made me spit my coffee out all over my keyboard.  You have been warned!

What the Hell is Wrong with David Cameron

He thinks that nurse training is "too academic". 

No David, the wards are fucked up hell holes, the students do not really function in a supernumery manner, and returning nurse training to hospital schools of nursing won't change a goddamn thing. 

We need a lot more highly skilled and experienced RN's on the wards.   Not more novices. Novices are all we have.  Give us more trained nurses on the wards and the students may actually learn something, rather than running around like a headless chicken answering callbells and taking shortcuts so that she can deal with 20 patients per second. 

Look at the lack of trained staff on the wards.  Look at nurse ratio statistics. Look at nurse education statistics.  Look at what the hospital managers have done to deskill the nursing workforce by bringing in too many untrained carers while skimping on trained staff.  What they have done isn't cost effective because of the high costs of patient complications that result from lack of RN's.  What they have done just hurts patients and ruins nurses.

Let's all write to him and set him straight.

No way is a bedside RN who didn't train at university at least on some level ever coming near me or my sick relative. 

The degree students do work on the ward and they jump straight in and get their hands dirty.  Supernumery my ass, no way are they actually supernumery. The ward environments are  so completely fucked up that you couldn't teach Kerry Katona to snort cocaine properly on them.  It wouldn't matter if she was doing a degree course on it or the "good old" nose hands on training.

But I guess he can't be any worse than Gordon Brown.  What do you guys think?

Tuesday, 12 January 2010

A Journalist who Understands Nurses: Suzanne Gordon

Wow.  I have renewed faith in journalists after reading this interview with Suzanne Gordon.

 I would really like to see Suzanne Gordon, Minette Marin  (who has described us as " fallen angels" for the Daily Fail), and Claire Raynor have a debate about nursing issues televised on the BBC or something. 

Check this out:

What Journalists learn when they let go of nursing stereotypes and do their homework.

I can't make you read her book, or repost the whole book here.  But this interview is a good start.

And this is nice. 

Another interview here.

Good Things are Happening. I think.

So the first thing that I learned today is that starting tomorrow my ward will be using signs and tabards to protect the staff nurse from interruptions when she is trying to do a complicated and time consuming drug round for a ward full of medical, surgical,elderly, and neuro patients.

 It cannot come soon enough.  Time to try this idea again.

 I hope to god that the visitors take note of it.  Interruptions during drug rounds are one of the major causes of errors that hurt hospital patients.  When the nurse is with that drug trolley she is concentrating on about 100 different things.  She also has to move quickly and medicate/assess a large number of often uncooperative and confused patients with lots of prescribed drugs in a short amount of time.  Every patient on the ward is going to be due their drugs at the same time.  It can take 2 hours to get through 12 patients for their 8 AM medications.Then 4 hours later they are all due again.  Leave her alone unless it is an emergency.  Twice I have seen fatal drug errors as a result of the nurse being got at by  other patients' visitors (with minor issues/questions and then abuse when they didn't get the answer that they wanted) during drug rounds.  It wasn't pretty. 

I know it is hard for people to accept but when you are sharing your nurse with lots of other people she cannot be there when you think that she should.  I have had many visitors interrupt during drug rounds.  If it is an emergency than fine.  But they interrupt to ask when Aunt Lola's nursing home will assess her.  Then they rationalise it by saying "It's not convienant for me to talk to the nurse later because I have a nail appointment."  Um. No.  What is not conveniant is the nurse making an error that hurts or kills a patient because you are in her face. 

This is even more important to get across to social workers and other health care professionals who do this to the nurses.  And these people should know better.  I understand the visitors not realising but there is no excuse for any hospital employee to behave like this. Social workers will walk past 3 health care assistants making a bed and tell a nurse who is concentrating on pulling drugs that someone needs a pillow.  I am just as happy to fetch a pillow as anyone else but if you stop me during a drug round to request it and I go on a hunt for it and lose my focus, someone might get hurt.   Yes, it is so intense that simple requests for pillows could screw it up and do harm, even if you don't want to accept or believe that. Not so with the healthcare assistant however. Not ever.

I have also heard a rumour that we are going to be getting 1 (possibly 2) new staff nurses to replace the 5 we have lost.  Real staff nurses.  I have heard this before.  Let's hope they give them a job this time. 

So we have some good news.  Nothing major but a step in the direction.  It's always good when management does positive things, even if they are small steps.

Should I start a poll to see how many of you think that visitors and allied professionals are going to ignore the tabards and then cry out for the nurses' blood when a drug error occurs?

Monday, 11 January 2010

Glossary of Terms and Mythbusting: The Nurse Image

I always find it very difficult to get my points about nursing, staffing, and patient acuity across to your average Joe.  This is the case no matter how I present my point of view.

Why is this?  Let's look at what Joe thinks he knows about hospitals, nursing, and doctors.  If Joe has never worked as a real nurse  or spent an huge amount of time in an out of hospital just where the heck has he learned about nurses, doctors and hospital structures?

He has learned what he knows from the media.  Most likely from the entertainment industry.  This is absolutely tragic.  No  medical TV show, film or novel has ever even come close to depicting nurses in an accurate light.  Shows like ER, House, and Casualty stay stuck  on ancient and ridiculous stereotypes when they portray nurses and their professional relationships with doctors.  Children's books that introduce pre-schoolers to the concept of who is who at the hospital depict nurses as angels who hold your hand and doctors as the boss who is in charge and delivering every aspect of your hospital care. Again, this has no basis whatsoever in reality.   It merely promotes stereotypes.  Journalists and hospital administrators are a victim to this way of thinking.  They just really don't know any better. Nurses themselves have never been able to verbalise just what it is we are responsible for or what we do.  Probably one of the most important things that we could as a profession is let go of the angel stuff and focus on explaining that compassion is important but not anywhere near enough of what it takes to be an RN.  An RN needs knowledge, high level skills, analytical and critical thinking skills and further education all the time.  We know that a lack of these characteristics in an RN kills patients regardless of how caring he may be..

 So why do we never get these aspects of our jobs across  to the public?  Why do we merely focus on the angels with wings stuff when that describes such a small part of who we are and what we do.  I am going to throw together some ideas for educational posters and adverts that promote nursing in a realistic light later on.  Until people understand what an RN does we have no chance of getting them to understand why a person who has been an HCA for 20 years is nothing like a nurse, and why short staffing kills.

But for now I am going to add a glossery of terms for average Joes who are conditioned to have a poor view of nursing secondary to woefully inaccurate media portrayls of nurses and doctors.  No wonder they think the hospital nurses are mean and uncaring?  Casualty has taught them that nurses work for doctors, hold hands, and if they are not doing as they are told it is because they cannot be bothered! Joe has a poor image of nursing and then he comes into hospital and the nurses are not doing what he expects. Then Joe thinks that nurses are crap.  TV either depicts nurses as evil murderers,  poorly educated empty headed waitresses who give injections, or they go in a whole other direction and try to make out that nurses are smarter than doctors.  All of these things are extremely destructive to nurses image.  We are not stupid.  We are not smarter than doctors.  Further education in nursing does not equal "closer to becoming a doctor".  We are educated in nursing, not medicine no matter how far we go with our education.  We are not angels with 19th century notions of virtue to uphold who are above being held accountable.   We are highly educated and skilled professionals who also need to be caring. So are doctors and social workers.  We all just do different things in healthcare.  And if we screw up just this much they'll haul our behinds infront of the nursing boards and possibly a judge in a courtroom.  So we are most definitely not angels  with halos who exist in a realm of lovelyness way above censure and the law.

Back to the avertising ideas later.  I want to have a militant medical nurse glossary of terms.

Registered Nurse:

A highly educated professional who has completed three years of practical and theoretical training. Research has shown repeately that the more education a bedside nurse holds the better equipped she is to save the lives of her patients as a bedside nurse. Look up degree nurses at the bedside doing nursing care and patient mortality rates.  But nurses require vocational training as well.  Completing your training as a nurse at a well respected school of nursing is not enough to call yourself a registered nurse.  You have to cough up some serious money and become registered with your country's (or state/province) board of nursing. You must do this at regular intervals (annually in the UK and cough up some cash) or you are no longer a registered nurse and cannot work as one in any healthcare setting.  IF your registration lapses it doesn't matter how many degrees or certifications you have, you will completely be unable to do things such as administer medications etc in a healthcare setting. 

You have to do copious amounts of continuing education and prove it to the board to renew your registration. Your board of nursing can strike you off the register if you harm a patient or take an unsafe assignment and don't blow the whislte on staffing. This is regardless of the fact that your employer is utterly hell bent on not staffing and resourcing wards, forcing their RN's to take too many patients, and forcing other kinds of unsafe assignments on them.  Non Clinical managers cannot be struck off of any kind of register.  They are merely put on leave and paid large amounts of cash or they are put into another highly paid bullshit job.

Registered nurses take on a group pf patients when they arrive to work and are legally mandated not to abandon those patients until another RN relieves them of duty and receives a handover.   They are responsible for understanding enough about disease process and pharmacology to monitor for deterioration in condition.  They need to understand enough about disease and human anatomy to ensure that the ill patient does not get worse as a result of things like immobility and poor nutrition.  They need to ensure that the physicians plan of treament to diagnose and treat a disease process is implemented correctly and they need to be able to implement these things without killing patients.   That on it's own requires a lot of education.They need to know what drugs can do what damage and what to look out for in the unwell patient.  What happens if you push to much fluid into a congestive cardiac failure patient?  If your patient with an infection suddently crashes out his blood pressure and becomes tachycardic what needs to be done?  The RN is with the patient 8-12 hours a day.  The doctor is with the patient 5 minutes a day.  I can learn a 100 things about your and your nursing needs by walking you to the toilet or asking you about the weather or how you liked your dinner.  This has a huge effect on what I will need to do with your plan of care and what I need to communicate to the doctors.

Many patients have anywhere from 2 to 6 different doctors involved in their care and it is the responsibility of the nurse to coordinate and communicate between these doctors to ensure that the patient is getting the right care and that everyone knows the plan.  Many times (especially out of hours) we are communicating the patient situation to an on call doctor who has never before seen the patient and does not know that particular patient.  IF you are not able to grasp what is going on and cannot communicate this to the doctor your patient is screwed.  If you are worred about dehydration, cannot get the patient to drink and are calling the doctor for orders for fluids you must make sure that you mention that the patient has a history of CCF otherwise you could overload him with fluid and kill him.  If your patient is more hypoxic and short of breath than usual and your are calling the on call doctor your must be sure to tell him if the patient is a COPDer etc etc etc.  Otherwise you could make things worse by blowing 02 at the patient.  A nurse needs to know how drugs interact because she has multiple doctors prescribing things for one patient without looking at what the other guy is doing.  If a mistake happens with that, the RN gets nailed. Keeping on top of this stuff is not medicine it is nursing.

You need to know when to withold prescribed drugs due to an unexpected change in condition that causes the prescribed drug that was at one time necessary, to now be dangerous.  The RN is with the patient, not the doctor.  It is her job to catch this stuff and her ass if it all goes wrong. I could go on forever.  I am not doctor, a mini me doctor, a wannabe doctor, etc etc.  Nurses are hired and fired and discipline by the nursing directorate and NOT doctors.  Doctors are not ward based and although they are brilliant at what they do, they do not know enough about nursing to have a say about nursing.  We are not a subspecialty of medicine.  We are a different profession entirely.  We cannot function without doctors and they cannot function without us.


I am probably about as ignorant about doctors as they are about nurses (and believe me, they don't understand nursing at all).  But here we go.  A doctor is an extremely highly educated individual who has at minimum something like 5-6 years of training at school and than years of training after that.  They are 100% in charge of officially diagnosising a disease process and prescribing treatment.  The amount of stuff that they have to know to recognise and treat illness is insane,.  They are scientists of the human body.  They spend very little time with the patients, especially on general wards.  They do not know what goes into implementing the orders that they give or how a nurse stops a patient from getting worse or dying as a result of their illness and treatmentsjust  by using basic nursing care.  They do not know that nurses have responisbilies other than assisting them.  They think that the nurse is only caring for their patients and ignore the fact that she is handling 10 patients and 16 different physicians who are AWOL.  They are brilliant at medicine.  But diagnosing and prescribing is only one (large) peice of the puzzle that keeps you alive in hospital.  You can have a brilliant, perfect doctor but if your nurse is stupid you could die.  The nurse is at your bedside, monitoring you for change in condition,  ensuring that your diagnostic tests are performed and that the doctor is made aware of any results or changes.  If I ditch these things to spend my time mopping floors and holding hands I could get someone  hurt or killed.  This is the reality of how hospitals are set up.  I bet you thought that doctors were always with the patient managing all aspects of care with  nurse there to assist him and that the doctors hired and fired nurses!  You saw that on the TV show Scrubs didn't you? 

Doctors have, for years, pushed the stereotypical view of bedside nurses as being nothing but useless waitresses in order to inflate their own egos.  They have aided and encouraged the poor and misleading media portayals of nursing.  They were the first people to do this.  The situation has deterioted so badly, that even our own nurse leaders, who left the bedside years ago, are denying that bedside nurses are important.  Even our leaders are focusing on the angel crap and not educating the public about how important bedside nursing is and how knowledgable you need to be to do bedside nursing.  Everyone has been conditioned to have disdain and disrespect for bedside nursing.  Even nurses. Even nurse academics are pushing the idea of bedside nurses being "losers" and refusing the admit that it is indeed a difficult and challenging occupation that requires skill and knowledge  Nurse academia only seems to know how to "promote" nursing by portraying nurses as mini doctors.  Now people hate nurses even more.  Doctors have contributed heavily to this situation and now they are moaning and whining about nurses leaving the bedside to become noctors and penpushers.  Hey Doc, thanks to you leaving the bedside to practice a science that I am not qualified to practice is the only way to get a raise or a shred of respect from anyone. Why can't we all just admit that bedside nursing is crucial to patient safety, and that bedside nurses needed to be highly skilled and educated?  We, as a society, won't admit this and it has led to cost cutting hospitals denying the importance of real nurses at the bedside and replacing them with unskilled and uneducated care givers.  Make no mistake about it, this is lethal and it is not cost effective.  They savings they are making on labour costs go out the window when patients are experiencing expensive after expensive complication as a result of lack of RN input. It ruins the bedside nurses who are left with so many patients and information to work through that they cannot function and it harms and kills patients.  And that brings me to my next group of people who work in the hospital.

Healthcare assistants/ unlicensed assistive personnel/ care givers:

Hospital administration is no different than your average Joe..  They don't understand or value professional bedside nursing so they felt that there was really no need to keep paying all these nurses.  They lost nurses via natural wastage and replaced them with carers.  Now a nurse has 15 patients to keep track of and nurse rather than 5.  Health care assistants or nice,  often  hardworking, they do basic care and many of them are bright.  Some hold degrees in history or English lit etc and were never able to get a job in that field. Others are pre-med or pre-nursing students trying to earn some money.  Others can barely read or write and have no interest whatsoever in becoming a nurse.  They are simply there for the paycheck. If you walk onto a general ward these days and see 6 members of staff in Nurses uniforms, at least 4 of them will probably be care assistants.  They won't have had any nurse training.  They are not licensed and cannot be "struck off".  The RN takes the fall for anything that one of these carers does wrong.

 Healthcare assistants may now be staffing the wards instead of real nurses but they cannot take over for nurses.  They can only do small aspects of basic care.  This isn't even close to being a snapshot of the whole picture of what a nurse does.  Sometimes they bathe all the patients because their RN has critical patients.  They do some blood pressures and maybe change a dressing.  Then they declare "hey I am just like a nurse, I do most of what she does".  Not so kiddo.  Not so.  About 90% of what is going on in that ward is way over the heads of the care assistants, even if they have been a care assistant for 20 years. Most of the things that I, as the nurse, are responsible for or  am troubleshooting are things they have never even heard of nor do they understand what I am doing and why.  They don't get why I can help them with baths some days but not others.  They think it is because the nurses don't want to be bothered.  They see their jobs as 90% of what nurses do, even though it is really only 10% barely. I don't think some of them could even pronounce the word acuity.  They are doing basic care without the additional assessing and planning that goes with all that and not pulling the information together.  I do work with smart care assistants however and I do listen to them.

Lets look at the 30 bed ward I worked on years and years ago.  We might have 6 registered nurses and 2 auxillaries on duty for a day shift. Yeah really.  The most senior nurse took charge.  The other five of us staff nurses each took on 6 patients each.  I had 6 patients, to assess, monitor, medicate, care for, and keep track of.  The auxillaries helped out rather than taking charge of hygeine and basic care.   I was there also doing the bedbathing and basic care too.  I needed to in order to get a handle on my patients conditions.

Fast forward to a 30 bed medical ward in  2010.  Now if we are lucky we get 3 RN's.  99% of the time we have 2 RN's.  Sometimes (and this is getting worse) we have one RN.  Over the last decade hospital administrators have decided that nursing is so retarded that untrained people can do it.

Let's go with the typical staffing  these days of 2 RN's and 3 care assistants for a large general ward.  If there are two RN's we split the ward in half and take 15 patients each.   Now I have 15 patients to monitor, assesse, medicate, and keep track of with no charge nurse back up.  And patients are sicker these days and they are in and out of hospitals quicker so we have to do more with less time.  I am so over my head with all the drugs, information, monitoring, family member questions, multiple doctors for each patient etc etc that I am left completely unable to deal with the basics.  That side of things are getting left almost 100% to untrained and unregulated care assistants.  They can do a bedbath but they cannot extract the knowledge about the patient condition and act on it like a nurse can. Things get missed.  Some carers don't take things like pressure ulcer prevention and nutrition seriously because they don't understand the consequences nor can they be held accountable.  And they have too many patients to feed anyway.  We have more care assistants but they are still always going to be outnumbered by patients who need help.  I can't get on top of those basics eitherwhen I am the sole RN for so many patients.

This has been a fucking disaster.  It is a mess.  You walk onto a large general ward nowadays and you will not be able to find anyone who has a clue about what the hell is going on.  The care assistants are not really able to explain rationale for treatments, or drugs, nor do they read notes.  Most of what is said in shift handover goes completely over their heads.   They are merely concerned with who is allowed to eat and who is incontinant and telling anyone who will listen that they are the "real" nurses doing all the "real" work.  And  still there are more patients to feed and clean than there are nurses and care assistants.

It is a mess and until people start understanding the importance of knowledgable bedside nurses and why staffing is important  it is a situation that is going to deteriorate even further.

Mark my words.  If something isn't done the level of basic nursing care on the wards is going to get worse.  And no amount of magic red trays to "help nurses understand" that some people need help with meals or dignity lectures is going to help.

If by sheer luck anyone reading this is a member of the media or involved in the entertainment industry please realise that every time you depict nurses as nothing but compassionate brainless angels, handmaidens, servants,  or mini doctors you are contributing heavily to this problem and you are hurting patients.

If you want to learn more about this from a real writer/journalist who has been studying issues in nursing since the early 80's I suggest you check out any book ever written by Suzanne Gordon especially nursing against the odds.  She is the only non nurse I know who really gets it.  All I have done is this post is rehash a lot of what she is saying based on my personal experience.

Saturday, 9 January 2010

Feeling Nostalgic and Sad.

I'm reflecting on the past and feeling a bit down.

 Is it because I want to go back to the days where the wards were resourced and staffed  so that Nurses could do their jobs? 

Am I getting sentimental over the days when Matron showed some kind of interest in the wards and patient care? 

Am I reflecting on what the wards were like when patients were less ill, stayed in hospital until they were better and market obsessed management weren't pushing as many acutely ill and frail patients through the system with as few nurses as they could get away with?

Am I sadly longing for the days before  management consultants who have no understanding of health care dynamics brought in crap ideas from America to restructure wards and staffing thus destroying nurse care, ruining nurses themselves and killing patients?

Nah That's not what is bothering me at the moment.  Those days all disappeared in the very early 90's.  A little before my time as a Nurse.  I think I had two good months before it went south. Can't miss what you don't know.
I am sad right now because I miss Dr. Rant.    He hasn't blogged in a long time and I don't think he's coming back.  Breaks my heart.  Nu-Labour probably raised his blood pressure and caused him to stroke out and die.

Click on the following:



Dr. Rant.


Thursday, 7 January 2010

Calling all general ward NHS RGN's: Some questions.

Not to leave out all the CCU,ITU, and A&E nurses but your units are a completely different structure.

I am hoping to hear from RGN's who work in (or recently worked in) general surgery, general medicine, geriatrics, --any large ward really.

I have learned a lot from my own blog via comments/emails etc.  I have learned that things on my ward are much easier and better than some other wards.  I have learned that we are a hell of a lot worse off than some others.  In short there are wards functioning well in the NHS and others that are hell on earth.  I am in the middle-purgatory perhaps.

I will start this.  Please continue in the Comments Section on this Post.  I hope I get some replies!  This is totally anonymous, I have no idea how to find out where or who you are.

1.Qualification: RGN

2.Ward: Acute Medicine/general Medicine/Geriatrics/Surgery

3.Beds: 18-30 depending on if they open our second hallway in a bed emergency or if they give it to surgery.

4.Real Nurse staffing per shift: sometimes one RN, sometimes 4 Rn's. We might get lucky and have 4 nurses to 18 patients show up one day but one will usually get taken away to staff another unit.  I have seen 1 RN to 30 in my time.  2 nurses  to 18-30 patients is the most common number.  Not good considering 1-6 is safe only for non confused non acute patients.  My patients are acute and confused.  Mostly confused.

5.How many HCA's do you have per shift including cadets? Is your ratio of untrained to trained staff  increasing? We have either 1,2,3,or 4 HCA's per shift.  One will get sent away if we have 3 or 4. And as with nurse staffing, these numbers have no bearing on patient acuity.  We can have 30 beds,with really sick dependent patients with 2 nurses and 1 HCA or we can have 18 stable geriatric patients  with 3 nurses and 3 HCA's.

6.Does your ward staff by acuity?  Do you get another trained nurse to care for your other patients if one of your patients becomes critically ill and needs to be specialed?  If you have sicker patients on the ward than usual do you get another RN? Or more HCA's?  If you move from 2 patients who need to be fed to 18 patients that need to be fed does your staffing adjust for this? 
Not on  my ward. Not by a long shot.

7.Do you ever get sent to staff areas that you are completely unfamiliar with and get expected to take over as the primary nurse for a group of patients? Yes

8.Does your hospital have a good, solid plan to cover sickness ,staff absence, increased acuity or dependency without pulling from one ward to another or using agency? No. Mine only gives us untrained carers from agencies, not nurses.  To cover RN sickness they pull staff and leave one ward short to cover another short ward.

9.Have you ever in your career worked an 8 to 12 hour shift without a break due to  chaotic, unpredictable, dangerous ward conditions? Are your patients in danger in any way when you do take a meal break? Yes. I recently ditched 12 hour shifts because I am getting to old for this shit. When I do take a meal break it leaves like 2 or 3 staff on the wards, not all nurses.

10.Do you have a senior charge nurse (without her own patient assignment) on every shift to coordinate and back you up.  No.  But research shows that I should.  I used to have a senior charge nurse without her own assignment coordinating and supporting the staff nurses about 5 years ago.  Makes a huge difference.

11. Do you ever see your Matron or get guidance and support from him/her? No Mine does not approach the wards.

12. Are you pressured into leaving very ill patients to push multiple discharges or take admissions (which are time consuming and complicated).  Does this happen during meal time? Drug rounds?  Yes. Yes Yes.

13. Are you given any kind of block of uninterrupted time to see your patients and care plan for them?  No. Not at any point in an 8 or 12 hour shift.

14.  Have you ever seen a patient suffer a complication (dehydration,pressure sores) or failure to rescue because you or a colleague could not get to him fast enough? Yep.

15.  When you fill in incident forms about short staffing is anything done? Not really.  They might band aid for awhile or send a letter saying how they are hiring another 18 year old with no experience.

16. Are you able to mentor nursing students,new staff, untrained carers with no experience properly on your ward? No. Hell no. And I am very dedicated to doing just that.

17. Does the physical design of your ward work against you and cause inefficiency?  Mine does, it is ancient.  But other wards at my very hospital have a good design. It makes a huge difference.

If anyone can take the time to give me honest answers here I will really appreciate it.  If your ward is great, let me know and if not let me know.

Tuesday, 5 January 2010

The Policeman's Answering Machine applied to Nursing.

I am feeling a little silly today.  We need one of these answering machines for Staff Nurses.  Especially considering we never get to answer the phone. Disclaimer:  This post is meant for a laugh.  I know that the stress of having a loved one in hospital will make the most respectable person lose it and lash out.  It's okay.  Really.  Unless you hit me.

Police Department Answering Machine

Here is the Nurse version.  All said in a highly annoying customer service type  generic computer generated North American accent. A voice that is just way too happy and joyful.

Thank you for calling Godhelpus Hospital.  We are unable to answer the phone right now because management won't pay for a ward clerk and the horrifying low numbers of nurses have patients so sick that we cannot leave them to answer the phone.   There is one working ward phone and it is a long way away from the patient area. Please select from one of the following options.

If you would like to complain about a nurse with 20 patients not giving your father one to one care or being there everytime he kicks off a slipper or needs the toilet Press One.

If you want to yell and say things to the nurses such as "I pay your wages with my taxes" whilst ignoring the fact that nurses also pay taxes and work a hell of a lot of unpaid hours which helps save the hospital money and they get the same level of care  then Press 2 now.

If you want to call an ambulance to bring you into A&E to fix your sore toe and then scream at the short staffed a&e staff, all 3 of whom  are working their tits off trying to save a 9 year old with multiple stab wounds and complain about "being made to wait by uncaring staff" Press 3

If you want to disregard the laws and rules that forbid nursing staff to give information to anyone over the phone except designated next of kin and demand information about your friend and then accuse the nursing staff of being a bunch of worthless whores who want to withold information just to upset you off Press 4.

If you think that being someone's neighbour for 20 years, their brother, or their best friend automatically allows you to designate yourself the next of kin over the phone despite the fact that the patient's wife is the designated next of kin  Press 5.  And don't forget to call the nurses miserable cows from hell because they couldn't (for legal reasons and ehtical reasons) tell you the results of your mate's scan.

If you want to complain about the fact that there are never any nurses in sight except at the nurses station, and then complain about the fact that the one nurse to multiple patients with no ward clerk to help isn't always answering the phone quickly  when you and everyone's else's relatives call Press 6.  I can either be at the station answering hundreds of phones calls or chasing up info to answer your questions OR I can be down there with the patients.

If you want to call the nurses lazy and uncaring because your 102 year old grandmother had a massive stroke, is now unable to walk, talk, and swallow and has to go into a nursing home because she cannot be rehabilitated Press 7. Don't forget to remind us that if only we had bothered with her she would have recovered.  We did bother.

If you want to ask questions we cannot possibly answer  in an area as complex and chaotic as general medicine such as "when is the doctor coming to do his rounds" and "When will Gramps be discharged" and "When will he have his scan" Press 8.

If you think that nurses and doctors are immune to becoming ill, do not understand what it is like to have elderly relatives in and out of hospital, children with disabilities, spouses dying of cancer, cancer ourselves, etc etc and want to accuse us of not understanding the other side Press 9 now.  Don't forget to call us lazy, uncaring, ignorant bitches.

If your best friend/brother/neighbour/inlaw etc is on the Hospital Board of directors and you want our names so that he can sort us out press 10.

If you want to threaten me with a lawsuit for not ignoring our other, sicker patients to be your relative's personal servant Press *1.

For all other queries, stay on the line.  And be prepared to stay there for until flying cars and vacations to the moon are the norm .

Yeah, they pretty much sums up the 45 minutes out of every hour I spend running to the ringing phone and getting pimped by family members.  Maybe once in awhile we will get a polite genuine person asking a question.

Ahh I almost forgot. 

If you are social services, pharmacy, the discharge managers, a person who carries a clipboard, a retired nurse who last worked in 1983 and wants to give us a talking to,  a district nurse or  ambulance liason don't press any buttons and don't stay on the line.  Please hang up.

Thank you for calling  Holyshit Ward at Godhelpus Hospital. Have a great day and enjoy your health care journey.

Monday, 4 January 2010

Should they Bring back Enrolled 'ward trained 'Nurses?

Nope.  I don't think so. 

 I believe that under such a system we would still have "team nursing".  Team nursing sucks.  It worked great back in the 70's but there is too much information to keep track of as well as disorganised  chaos now all thanks to medicine advancing and higher costs  

Team nursing came about during WW2.  It is the system in which our older, traditional trained nurses are familiar.  It works properly only when ward structure is meticulous and well organised.  I happen to believe in primary nursing.  This doesn't mean that I am not a team player however.  I will drop everything to help a colleague who has a patient in trouble, or is in trouble herself.

Have you ever wondered why you have noticed loads of staff in nursing uniforms hanging about when you visit your mum in hospital...yet no one seems to have a clue about what is going one can give you any answers..... none of the patients are recieving their drugs on time.......and the only person who does supposedly know what is happening  (mum's RN) didn't realise that your mum just had a dangerously low blood pressure reading 10 minutes ago?  Does any of this sound familiar?

This all happens because Registered Nurses are running between too many patients, with less qualified staff to assist them.  It is a system that doesn't work.    Some people are saying that we should bring back enrolled nurses to help the RN's. EN's are an improvement over HCA's but a cost cutting NHS will just use them incorrectly, as they do with the HCA's.

I don't want enrolled nurses ( EN's  as they were known) around unless the hospital is going to add them in addition to safe registered nurse staffing ratios .

They won't do that, they will only use them instead of registered nurses.  Before you accuse me of knocking EN's please read on.

People generally seem to think that degree educated registered nurses don't do much in the way of ward training and that we need to bring back ward trained nurses (EN's) to improve care.  That is a motherload of crap.  We need to do lots of things to improve care, but not that.

Where do I begin.

The degree students have to do nearly 3000 hours of ward time/placements to qualify. The degree students are working shifts on the ward all the time.

During the weeks and weeks of their placements they are working full time shifts on the ward.

They are supposed to be supernumery but they ARE NOT actually supernumerary.

They are thrown right in at the deep end, doing all kinds of basic care. Take it from someone who is currently practicing as a staff nurse and who works with students. This is indeed how it is in 2010.........   current nursing students spend thousands upon thousands of hours mucking in on the ward.

The  idea of bringing back traditional trained nurses (or EN's) as well as degree nurses is a good idea on paper but it is a total fail in reality.

The reason for this is that TEAM NURSING DOES NOT WORK anymore.

Team nursing is what you are actually pushing by arguing that they should bring back EN's. Team nursing is when you have an RN's, EN's and auxillaries all caring for a large group of patients. It doesn't work. It fails because the RN has to be on top of everything that is going on for 30 people and no matter how many EN's or care assistants she has, the RN is overwhelmed.

Team nursing means the right hand does not know what the left hand is doing.

What we need is for a degree trained RN doing everything and having a small enough patient load to do EVERY aspect of her patients care herself. This is cost effective and it is the only thing that works.   Giver her a care assistant to be used only in case she runs intro trouble but my god, leave basic care to the RN's primarily.

I don't want an EN or an auxillary sharing my patient load because I want to do everything myself for all the patients. The majority of RN's I talk to agree. Primary nursing is the only way to stay completely on top of everything that is going on. 

If you throw more patients at me along with EN's and care assistants instead of Registered Nurses then fuck up after fuck up after fuck up occurs.

Yes, nurses having more technology, drugs, and medical stuff to do these days. We do indeed and staff nurses get held responisble for any screw ups with these things.

 But in order to do those high tech things well, I also need to be doing basic care myself. Otherwise I am not seeing the whole picture. And neither are the EN's or the care assistants. When there isn't anyone at all seeing the big picture, all hell breaks loose.

If I am delegating the basics to an EN or HCA then that means that I am probably the only RN on shift and I am overwhelmed doing drugs for the entire ward , doctor orders and rounds, relative enquiries, and fire fighting  for all 30 beds. This is overwhelming even if I have 100 care assistants/EN's to help with the basics.  

Just the sheer number of relative enquires either in person or by phone is overwhelming when you are an RN with  only 10 patients. The questions these people ask are usually only answerable by the RN.  If I have 10 patients I have 10 families on back and I can barely get any patient care done.  I can barely ge away from their phone calls and interruotions long enough to actually see any of my patients.  There are just so many interruptions. Constantly.

Under the plan to bring back EN's, the RN will be the lone RN carrying all the the things that the EN's and HCA's cannot do . She will be overwhelmed. Meanwhile the EN's and HCA's will be merrily making beds and gossiping without a care in the world.  Whenever a relative makes an inquiry or a patient becomes acutely unwell, the EN' s and HCA's will just dump that onto the RN and happily go on their jolly way making beds.  And the RN will be managing 5 critically ill patients that she cannot even get to because she has the relatives of her other 25 patients on her back.

I want 4 acute patients or 6 non acute patients maximum and I want a charge nurse without a patient load on shift to back me up and organise the ward . I want to do EVERYTHING, EVERY nursing intervention for my patients myself. Myself. I cannot do this with 30 patients no matter how many EN's or HCA's you throw my way. Even if I have hundreds of EN's and HCA's with me doing the basics I am still going to have too much information to process, too many interuptions and total cognitive overload.

A growing body of evidence is showing that a well educated RN doing everything for a small number of patients  is the only safe, effective, and cost effective way of doing things.  The WW2 ward structure planning is still in effect now, just with less qualified staff.

What I am trying to say is this: If you throw  EN's and HCAs at me instead of Registered Nurses then I have to keep track of everything for the entire ward as the lone RN. No can do.  Not these days.  It is impossible. 

And that is the case if I am sharing my 30 bed ward  with 1 EN or  100 EN's in a single day.

What they are doing right now in hospitals  is essentially team nursing. 

What we have now is the hospital managers saying this:  "It's okay to stick one RN with 20 patients because we are throwing care assistants at her.  She can  medicate, all 20 patients,  keep track of information for 20 patients, get interrupted to take questions from the families of 20 people with nothing in place to control the number if interruptions she is getting  etc as long as she has a few less qualified staff around to make her beds and wash her patients.  Do you really think that it would be any different if they brought EN's back? 

They would probably have one EN in charge of a 40 bed ward with no RN and a few care assistants to help.  That is how NHS management does things, the cheap fuckers.  Not only do they currently have a world war 2 era ward structure in place on the wards ......  but they have it with less qualified staff at a time when patients are sicker and the stakes are higher.  Even in the last ten years, patient acuity and costs have SKYROCKETED.  Nurses in 2010 are dealing with sicker patients and have to do more for them in a shorter amount of time, with less qualified staff.  Fallen angels my ass.  I actually think that nurses today are much nicer than their yesteryear counterparts.  The older nurses just had better ratios, resources, back up, and smaller workloads.

And this kind world war two era mentality  by managment and dinosaurs is why things are so shit.  The idea of bringing back EN's is a good one on paper but not actually implementable because team nursing is outdated. Let's move away from it entirely.  Staff the wards with RN's, and when RN's have safe ratios then you can add in the assistants to assist with care rather than taking over care  when they are not qualified to do so.