Tuesday, 25 January 2011

Had a Blast on the Surgical Ward.

When Gladys is admitted to hospital she ends up on a medical ward due to her chronic COPD, diabetes, and Anemia.  She is sick and tired of the way these general wards are underesourced and has decided to make her feelings known to management with a nice hand gesture. 

Lucky lucky LUCKY me.  I showed up to work a shift on my usual medical ward last week. 

But the surgical ward downstairs was short staffed.  And we had 3 RN's.  They had one. And it was my turn to "float".  So I was ordered by the bed manager to work on the surgical ward. He didn't have to order me to go there.  I ran away from my ward and ran down there skipping and laughing,  so full of glee and joy was I.

It was I thought it would be.  Bloody fantastic.

Surgical wards are fantastic compared to medical wards.  Less patients, less drugs, virtually no confused and total care patients.....all in all it means that the Nurse is more in control of her workload on a surgical ward and can do the job better.  Surgical ward Nurses are not as destroyed emotionally, physically and mentally as Medical ward nurses.

We recently discussed this over on a fantastic blog called Diary of Benefit Scrounger.  The author of that blog is a woman named Sue.  She had recently had experience of an incompent medical ward.  Not long after she was admitted to a surgical ward and was shocked at the difference in care.  She felt secure and happy on the surgical ward.

I weighed in on Sue's comment section with my opinion on why the surgical ward Nurses have it together so much  more than medical nurses:

Again this doesn't surprise me in the least.

We have talked a lot on militant medical nurse about medical wards vs surgical wards.

I once worked on a surgical ward. Never was I so happy. I was one RN to 6 young, sensible, reasonably healthy stable patients having minor to moderate surgery and we had all the equipment and to resources we needed. We had a charge nurse without an assignment to back us up and we always had clerical support.

Then that unit was shut and my colleagues and I were moved to medical wards. That is when I began blogging.

On surgical wards not only do the nurses have less patients but their patients are less confused, less ill and less demanding. If the surgical ward nurse with only 5 easy patients gets an admission of a demented elderly patient pulling out his lines and tubes and spreading shit everywhere she sends him to a medical ward where the Nurse already has 20 such patients.

Medical ward nurses are NOT allowed to dump a patient somewhere else because they cannot handle him.

If a patient becomes medically unwell on a surgical ward he immediately gets sent over to the overwhelmed already medical nurse who already has more patients and more difficult patients than the surgical nurse has.

There is a lot that surgical nurses don't have to deal with.

A drug round on a surg ward is simple since most of the patients are not as acute or chronically ill as medical patients. It took me 15 minutes to get through the 8AM drugs on my 6 patients in the surgical ward. It takes me over an hour to get through the 8AM meds for 6 patients on a medical ward. And I have about 16 of them.

Surgical patients bring money into the hospital. Medical patients cause the hospital to lose money. It was explained to me that this is the reason for the discrepencies.  This is why medical wards are so underesourced causing medical nurses to struggle.

Surgical ward nurses also think that they are superior to medical nurses since they get better patient feedback and make less mistakes.

I thought this too when I was a surgical nurse. My eyes were really opened when I went to work on a medical ward.

Once another surgical ward at my hospital was shut and their nurses were sent to my ward to work. They were making wisecracks about "now we are on a medical ward we will do nothing but babysit and hand out commodes" and "It will be like a nursing home".

I came in for a night shift the next day and two surgical nurses had been on for the entire medical ward alone during the afternoon and evening. They were in tears. They couldn't manage the demented, the high patient load. One of the patients deteriorated with a severe medical condition and they didn't know what to do. They couldn't figure out a lot of what needed to be done and patients really suffered.

The wisecracks soon stopped after they got a taste of general medicine.

Care assistants on a surgical ward have a smaller easier work load and get paid at band 3. Care assistants on a medical ward break their backs and get paid at a lower rate on band 2.

There are no geriatric wards anymore. Geriatric patients go to general medical where they are mixed up with critically ill patients, psych patients, hospice patients,surgical patients who had a medical emergency on the surgical ward and social admissions for lack of coping at home etc etc.   The staffing levels of Nurses on these wards would shame a third world country.  The real Nurses are few.  The untrained care assistants are many. 

In short there is less chaos in surgery and what chaos that exists is easy to control. The surgeons round twice a day on the surgical wards. The medical consultants twice a week.

So you perceptions are very accurate.

and I should add to this that surgical wards deal with the same thing and over again with little variation. They refuse to accept patients that dont fit into a criteria that they don't want or do not feel like they can handle. Medical nurses are unable to do this and have to take anything and everything no matter how overwhelmed they all ready are.

Surgical ward nursing was fun but general medicine has made me burn out and lose my mind.

Then DinoNurse, an ITU Sister who often comments on Militant Medical Nurse, gave her tuppence worth.  As usual, Dino was right on the money and did a better job of explaining it all than I ever could:

Medicine is the blackhole of well, medicine lol.

On a more serious note- google "medical ward" and "foundation trust" and the number of closed wards seems to be growing. My own foundation trust lost an entire ward when the former hospitals merged. Last winter we had to open 2 entire wards to cope with the influx- pushed our agency budget through the roof. This year, had the powers that be learned anything? Of course not- yet again medical wards are full to bursting and the backlog is impacting on everything else. Our admissions units are warzones, quite literally.

This is the same UK wide. If you really want to raise awareness Sue, you need to be pointing out that in general surgical patients are younger, fitter and spend on average a week or less in an NHS hospital bed. If you have a chronic condition, by and large you will be treated on a medical ward unless you need surgery. Our ICU emergency admissions are generally medical in origin- chest infections, GI bleeds, DKAs, epilepsy complications- the list is endless.

Most surgical admissions are either elective ( because they have need for 24-48 hours ventilationn) or due to unpredicted bleeding (although obviously life threatening, fluid resus normally sorts this out quite quickly and they come to us for monitoring and inotropes.)Surgical wards do not do inotropes...however medical wards are expected to manage.

Any surgical patient who develops a "medical problem" will be turfed to medicine...the chest infections, UTIs- generally elderly and mostly leading to confusion and agression... Generally speaking, medical patients take longer to recover and require more input from nurses, physios, social services etc...Surgery can make money for a trust and medicine cannot.

Medical wards literally suck the life out of you ( staff and patients). What we need is guaranteed SAFE RN TO PATIENT RATIOS. I cannot stress this enough. 1 RN to 6 patients would be a step in the right direction. Ideally this should be reduced to 4 in an acute setting. A little story happening in an average trust every day- allegedly...28 bedded medical ward has 3 RNs on duty along with 2 HCAs. So each RN gets just over half an HCA and 9 and a bit patients. Ward has 6 bays of 4 beds and the rest are siderooms. So each RN has 2 bays and the siderooms are shared, so to speak.

 In one bay we have a confused old man who keeps climbing out of bed, the trust have helpfully provided a buzzing mat that goes off everytime he does this. There is also a very sick young diabetic in DKA in the next bed with multiple drips, sliding scale insulin and he should be on half hourly observations (minimum). Thats just one bay. The RN for this bay will should basically never have to leave the bay. In the other bay she is responsible for we have a GI bleed who is actively bleeding, having transfusions and has just been started on inotropes. He also needs a MINIMUM of half hourly observations. So the RN will bust her tail trying to keep up to date with the GI bleed and the DKA and hope that the old guy doesn't fall out of bed. As for the other 6 or so patients she is responsible for, well....need I go on?

Oh, and halfway through the shift the ward will lose an RN and an HCA to "help out" on a medical ward with even worse ratios. In the "bad" old days we would have created an "obs" bay and put all the medically unstable patients here, next to the nurses station- and we would have had 6 RNs/ENs on duty ( alot more trained staff than we have now). The DKA patient would most likely have been transferred to the ICU. This is the biggest problem today- patients are older, sicker and more complex. Many of those on medical wards would have been in the ICU 20 years ao. Unless we get safe ratios we are heading for the biggest fall imaginable. The NHS will dissolve into "social enterprises" that are still private in nature...and if you were the CEO would you want to waste all your resources on the medical blackhole? Didn't think so....

My day at the surgical ward was fantastic.  I had 8 patients.  All of whom were stable.  I had two post op lap chole patients who were doing great.  I was able to spend a lot of time with them talking about post op care and ensuring that they were safe and comfortable.  I had several pre op patients and admissions who were healthy and compus mentus.  This allowed me to spend time making sure that everything was in order for their procedures and also explaining to them what they could expect.  The drug round took 10 minutes. 
I couldn't help noticing the wall behind the Nurse's station on the newly redecorated, modern and refurbished surgical ward.  They had trust awards for "best at completing careplans" and "best at completing risk assessments" and all that.  They even had an award for "least falls".  Probably because all of their patients are youngish, not confused and have no mobility problems.  Yes, managment actually gave the short stay surgical ward an award for "least falls". No wonder they don't have any falls.  They have no fall risk patients and lots more staff.

 My medical ward has no awards.  Our confused elderly patients outnumber the staff 20 to 1 and there are lots of falls.  And we sure do not have time to complete care plans or risk assessments because we have critically ill patients that need 150 IV meds mixed up and given whilst we are trying to stop the confused elderly ones from falling, peeing on the floor and attacking other patients.  My ward looks exactly like something out of 1950's Russia except that it is a whole lot dirtier.  The cleaners on my ward like to flip off the Nurses and go for tea breaks.
 God, I hope that when I am old and confused that I have saved enough money for my family to hire a one to one carer to stay with me when I am in hospital.  Lord knows that my poor  ward RN, with a 150 IV meds to give and more patients than she can keep track of won't be able to help me.  I do have a savings account set up for that you know. 
General medical wards: The red haired step child of the NHS.


Midnight said...

One nurse to give 150 IV meds???? Please tell me you are joking?

murse said...

...and whenever I am pissed off with ICU, this blog is always here to remind me that it was the best move I ever made. How are your repatriation plans going Anne?

Nurse Anne said...
This comment has been removed by the author.
Nurse Anne said...

I think I was being silly.

If I have 19 patients and 14 of them are on 3 IV meds including antibiotics every 4 hours....that is only 42 . So that is 42 of them every 4 hours to get, mix up and administer (mixing them up i.e. dilution and adding them to bags of saline. 84 during the course of the shift. That doesn't include drips that need managing like sliding scale with the 50 ml actrapid syringe that needs repriming etc etc.

So not quite 150 but still a lot.

I had a shift a few weeks ago where I had NO ONE on IV meds. And I have had shifts when everyone is on them...sometimes 5 or 6 meds due at once.

My moving plans are going good Murse.

Nursing Student said...

Great blog, Nurse Anne. Still devising plans as to what I will do when I qualify. Other half is meteorologist and american-born (his family still live over there) so if he gets a job out there, fab, but will mean I need to go to school out there for a few semesters if I'm newly-qualified to meet Nursing Board and NCLEX standards. Or I can suck it up and work in the NHS for a few years and then relocate. I'm becoming more and more conflicted over it as the months go on. I will only be 2 years from now. So in another year I will have to really start making the decisions. Perhaps I will get what I want for once and a Prison Nursing post. Chance will be a fine thing though.

If you're running off back to the states I might make a break for it in the shipping crate you send all your stuff off in!


Anonymous said...

The medical wards I work on have too few staff to feed and water the patients so the patients are then given expensive nutritional supplements or tube feeding when what they really need is someone with the time to feed them.

Excuse my ignorance, but why is there this enormous difference between the nursing of medical and surgical wards?

Anonymous said...

I normally work on a busy medical ward, not that dissimilar to the sound of yours Nurse Anne, and unfortunately am due to visit a surgical one this week for an op (providing of course its not cancelled, again!) and was kinda dreading it, though am weirdly reassured by your post!

Ryder02 said...

Despite having known a couple of nurses I never knew it was this bad on the wards.
They would go out drinking with me, get drunk and then descend into a crying mess - complaining about their jobs, the work etc. Despite being sympathetic a tiny peice of me thought maybe they should just suck it up.
This was reinforced by my exposure to hospitals, purely surgical wards (fortunetly only) as a visitor.

I have no doubt that you are telling the horrible truth about the reality in the medical wards - I now fear for our NHS and our country as a whole.
As a soldier I am horrified at the cuts that have been imposed on our forces over the years, destroying our abilities and security.
But I am just as worried about education and other more social matters, so much so I am now divorced because I was too scared to bring a child into this once great country.
Enough waffle - free drinks, pizza and as many hugs as you want to the next medical RN I meet. Keep at 'em Anne.

Anonymous said...

Very nice picture :))


Hanna said...

I disagree in some things that have been said about surgical wards.
I have worked on a colorectal surgery ward for 2 years, in that time our staffing level has increased from a dangerous level where patients were actually at serious risk of dying due to lack of staff to a more manageable level but that level is still dangerously low.
we have 28 patients and we never have empty beds, we have between 2-6 elective ops a day some big and some small, we also have emergency admissions.
We now have 4 trained and 2 untrained in the morning and we are supposed to have 4 trained and 1 untrained in the evenings and 3 trained 2 untrained at night-however we have recently lost another 6 staff nurses and my manager has yet to replace them so at the moment these numbers are never filled properly let alone by our own staff.
In theory yes I should be able to predict my workload but in reality that's rubbish!! my day starts at 7am-we don't have a full time receptionist and I am constantly interrupted to get telephones, the bed manager hassles me before I have even finished the drug round for whose going home. Then I have to give lots of IVs paracetamol and steroids to the patient with NG tubes or who are NBM for theatre. Also I have to prep the patients for ops, make sure everyone has up to date fluids running, get my 7-9 patients depending on how short staffed we are out of bed and washed beds made while our one or 2 if we are lucky auxiliaries start the heavy washes.
We have patients on Epidurals, PCAs, sliding scale, heparin, patients who come from SHDU. Not forgetting all the other tasks such as obs-which need to be done on time which rarely do due to workload, wounds, discharge planning, referrals. Post ops arrive after lunch if you manage to clear a bed as sometimes ttos are a real pain to wait for, sometimes you can have 4 each depending on the bed space they will be hourly and you are not forgetting that some of the rest of the patients will be scoring as they are very unwell-someone will also arrive very unwell post op who should have gone to ITU.
That coupled with being the nurse in charge and supporting younger colleagues doing IVs and CDs at night I can easily do 50 IVABX as we do two rounds. We rarely get breaks owed in the 12 hour days and rarely at night and I spend the rest of my time running around like a blue arsed fly! buzzers go unanswered for ages at a time. We do not have the time or staff to turn patients on time and quite often tlc patients get left in a side room due to workload on the ward. I daily have to leave wounds to be dressed for the next day as I just have no time to do them and I rarely leave on time. We cannot keep our staff and morale is low, and yet our matron says our staffing levels is sufficient!! the belief that surgical patients are independent is another myth! with a large percentage of our needing 1-2 nurses to mobilize. Keeping on top of pain is another issue-everyone is in pain post op trying to manage hourly morphine rounds in a nightmare. I leave late off every night feeling totally drained and I hate going into work just not knowing what I am walking into. One other major issue is stoma care-many of our patients have stomas fitted and need help and support on how to manage these I can honestly say that if an auxillary is not around then this does not get done its physically impossible!! quite often I have to go next door to the neighborhood wards to do their epidural obs and ivs as they are not trained to manage them!!!

Anonymous said...

I totally agree with how you described the medical ward. It may not be the same exactly but the situation is kinda like that. I am now working in the surgery ward and I can really compare the two. I just wish management would see the difference too and make the necessary adjustments.

xlpharmacy said...

These kind of stuff (adventure) really happens a lot in medical wards. The under-staffed wards are the places where the medical personnel tries their very best to provide service and at the same time keep their sanity.

Kenneth said...

All health care establishments should have adequate facilities and personnel to accommodate the needs of the patients. If the medical staff are not overworked they an perform more efficiently.

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