What it is like.

Back to the Medical Ward. Yay.


NOT.

My 13 hour night shift was due to end  at 0700; at which time I have to be ready to give report to the oncoming Nurse.

Starting  at 5AM I had to:

Start a magnesium infusion, give calcium gluconate and  start an IVI with K then an addiphos infusion and take off a whole load of other doctors orders for a patient with deranged U+E's.  The addiphos probably won't go up till day shift. He could have crashed at any moment with a K that low and I didn't want to leave him.  He had bloods done over night and the results came back at 04:30. The doc wrote the new orders just afterward.  I had to run around like a nut just to find some magnesium to start and of course document every aspect of all of this.  All had to go through a central line.  As you know this is time consuming. 

I needed to get vital signs and obs on all 19 of  my patients by 7 AM.  If you wake the patients up before 6 to start getting all their obs they get angry.  If I didn't start before 6 they would never got done and we would potentially miss the signs of a deteriorating patient.

I had to IV fluids on someone with renal failure.  I had noticed his rubbish output at midnight but it took until 04:30 to get the doctor as he was the only doc on for multiple wards.  Bloods hadn't been done for days on this patient and I needed to draw them.

I was also trying  to keep the 02 on another patient, a confused patient who was desaturating without it and kept taking it off his face.  He has disorientation secondary to sepsis so he could not understand me when I asked him to keep it on.  He needed a mask rather than a nasal cannula.

At this time I also had to obtain,, mix, and administer 15 (yes fifteen) IV antibiotics for 8 patients that were prescribed them.  This has to be done by 0800.  Day shift starts at 0700 but doesn't even get out of handover until nearly 0800 so they can't do it. I had to do them and finish them by 07:30 AM.

I had 5 patients ask for controlled analgesia during this two hour window.  This again is very time consuming.  The system for obtaining and administering controlled drugs is a joke.

During this window I also had to be up to date on the current status of all my 19 patients. For example any little thing that changed with them on my shift I need to be onto right away.  Examples of this include changes in observations, neuro observations. fluid balance, blood sugars etc.  I had 5 diabetics.  I need to act on every little thing and document it and it all needs to be done right now.
I had to act on the fact that I just noticed that my patient who is being treated for a UTI is completely unresponsive with a low BP.  Had to call the doctor and wait for him to get around to calling me back.  Fast IV fluids ordered as well as a million other things that needed to be done ASAP.
Two patients who needed IV antibiotics woke up and pulled their IV cannulas out.  Two others pulled out their urinary catheters.  It was like a blood bath for all 4. 

I needed to monitor the patient on the IV insulin infusion closely.  His blood glucose still isn't right.  Something is wrong about this.  Her consultant wanted her to stay on this infusion over the weekend.  All night long I had told the house officer that the insulin infusion and the iv fluids that get hung with them were running out and that he needed to prescribe more so that I could hang more on the patient.  The only time the doctor came was at 4:30 in the morning.  I handed him the chart but he put it down and "forgot" to prescribe it before he got bleeped away somewhere else.  Called him again and he said that he couldn't "come back to your ward" for awhile.

I had to deal with the fact that a patient woke up in agony with a blocked catheter.  It needs irrigating.  It was draining a few hours ago.

Remember all this is what got thrown my way between 5 AM and 7 AM. I was the only RN for double digit patients.

There were two lots of IV frusemide to give. 80mg. They need to be set through a pump.  Got to watch those BPs because even though they are borderline (and I wouldn't give it if they were a smidge lower) these two chaps really need it.

I didn't want to leave the side of any one of these patients.  But my god.  Just standing in the treatment room mixing and preparing all these IV drugs is extremely time consuming.

I had to leave a few of the antibiotics for day shift.  Day shift was so busy that they didn't give the 8AM meds that I didn't give until nearly noon.

I got a phone call at 0600 to take a direct admission from A+E as there are no beds anywhere else.  The A&E nurse gave me report on my new patient. He is a drunk and combative alcohol patient who fell and hit his head. They  want neuro obs every 15 minutes.  He is sleepy but when he wakes up he knocks stuff over and hits. I didn't want to take this patient because the only empty bed I have is in a bay with 5 nice but frail confused elderly men.  He will need a lot of admission stuff doing as soon as he gets to the ward i.e. paperwork to get his admission orders sorted..  The rest of the admission paperwork and all other legally required documentation I will knock out after my shift ends by staying over unpaid.

And that is just some of it.  If I went into all the knowledge I have to have to manage those things we would be here all day.   If I fucked any of that up just this much I could be held responsible for someone's death.   Nurses are legally responsible for delivering the orders given by a doctor and monitoring patients.  And my list reflects my doing just that.

That was my lot to carry and carry alone.  I was the only qualified Nurse for those 19 20 patients There is no way that I can articulate on this blog how long it takes to prepare and mix and infuse and flush etc etc all those IV meds that were prescribed and due.  It takes a lot of time away from the patients.  Real hospitals have 24 hour pharmacies that make it their job to stay on top of new orders and mix and prepare and get to the Nurse these IV meds when they are do to be given.  My NHS hospital DOES NOT have this.  Even during the 9-5 hours that they are open they do not do that.  They just develop more paperwork for the Nurses to fill in so that we can actually get the drugs and not get fired for a med error by omission (not giving a prescribed drug to a patient on time).

The only help I had was a teenage cadet called Beth.  There was nothing in the above list that she could help me with.  Nothing. She cannot even do observations/vital signs or check blood sugars.  She is not a Health care assistant or a Nurse. I wish I had that lovely HCA from the surgical ward with me.  He was mint. Beth  refused to empty the catheters so that we could monitor an accurate fluid balance  because "that's gross".


Between 5AM and 7AM this is what Beth had to do:

Change a few beds
Help people to the toilet.
Answer call lights and tell patients that the Nurse will be there as soon as possible.  This confuses them since they think that she is a Nurse.  She is wearing the same uniform as me after all.
Serve hot drinks at 7AM (she puts a trolley together and just blows past anyone who appears to be asleep rather than waking them up and encouraging fluids). 

I would rather just do the drinks myself but....you have seen my list of jobs happening at this time.
If anyone pees or drinks she needs to measure it and write the value on the fluid balance chart.  She didn't bother because she doesn't understand the point. As a matter of fact I asked her to do just that whilst my arms were loaded with IV meds, vital signs equipment, and new admission orders.   She just rolled her eyes at me and said she was "too busy" because she was "serving drinks".Doctors and Nurses could kill a patient if they don't have an accurate fluid balance.  Serving drinks took her all of 5 minutes since she ran past any patient who was sleeping or quiet.  Then she sat at the station on her mobile.


Beth cannot help me with anything on my list as she is not a Nurse.  But I must help her change those beds on top of everything else otherwise we get the cries of "those damn new fangled to posh to wash RN's leave all the real work to the care assistants".  And I just don't want to fucking hear it.

And at 07:30 she will be out the door on her way home regardless of what is going on in that ward.   She is not a Nurse, she is not licensed.  What does she care?  I will still be giving report.  Giving report on 20 patients takes a long time.  Who is looking out for my patients while I am handing over?  Beth will be on the Bus.  She doesn't understand what I have on my shoulders with those patients...she doesn't even understand what addiphos, deranged U+Es, hypoglycemia and sliding scale insulin means.  She has no idea what a Nurse does she just sees me flying in and out of rooms.   She tells the patients that she is a "real nurse" and a "nice nurse" because she is the one who serves them tea.  And they suck it up.  Most of what I am doing for them goes unseen by them.

Cadet Beth is real pissed off because she had to do the bed changes on her own mostly.  She will piss and moan to anyone she who will listen about how she was left to do all the real work (8 out of 14 bed changes; I managed to assist with 6 of them) because the Nurse "wouldn't help her".  The patients will tell her that she is the "nice nurse" who was kind enough to provide them with a drink and say "some others cannot be bothered with that because they think they are so high and mighty".  And the patients will say this too Beth whilst looking daggers at me.  They have absolutely no fucking clue what needs to be done to keep them alive and who is doing it.;  They get that the doctors are the brains who prescribe treatment.  And they get that nice nurses  staff like Beth "care" enough to give them a drink.  But they totally miss the knowledge bus on everything that is smack in between of that.  The bus took off and the patients are still at the station.


Beth was on her way home at 07:30.  I was still there on the ward tying up legally required loose ends at 9:30.  They stopped paying me at 07:30.  I think that without the new admission I may have made it out of there by 8:30 but nevermind.  My daughter was late for school.  Again.

Fuck this shit.  I want a clipboard job.  And when I leave I will be replaced with another cadet. And when that happens there will be one RN to 40 beds rather than one RN to  20 beds.

I love bedside Nursing but this is just too damn much.  It isn't Nursing that is the problems it is the working conditions.  The day shift nurse will be in for it.  When the consultants come in and see that the fluid balance charts are blank from the night shift (thanks Beth, you worthless slut) they will smackdown on the Nurse who happens to be standing the closest to them.

Imagine how different things would have been if this was the scenario:  Instead of just Beth and I for those 20 patients IMAGINE IF we had the recommended ratio of one nurse to 4 patients.  Imagine if each of those 4 patients were sharing one Nurse rather than all 20 sharing one Nurse and one cadet?  Imagine if each Nurse was able to do total care for her 4 patients......everything from dealing with IV infusions to changing their beds and encouraging a drink of tea.

I would stay in the job if that was the case.  But it will never be the case here.  NHS hospitals do not want to hire qualified Nurses to work at the bedside.  They do not want to pay for that.

When I finally left the ward at 09:30 I was near tears.  I was so rushed during those hours I was terrified that I made  a mistake and killed somebody.  I was afraid that maybe I hung the wrong meds on the wrong patients. I was afraid I missed somethingm like a low BP or a patient who had stopped fucking breathing.  OMG I hope that patient finally kept his 02 mask on.   I was afraid that one of the patients would go down to PALS and tell them about how I was the mean nurse who ran past them as they were shouting for help (I had to).  Oh but that Beth, she was lovely and made us tea....

Had a Blast on the Surgical Ward. part 2

I just remembered one of the best things I experienced during my little shift on the short stay surgical ward.

His name was Sam.

No no no stop thinking like that.  Nurse Anne is a happily married woman.

Sam is an utterly fabulous health care assistant.  By the end of the day I called him Saint Sam.  Nurse Anne is a bit rusty with Surgical Nursing but I couldn't have failed with Sam on my team.

He was good with the patients.  He could do observations, blood sugars and he cared enough to let me know of any problems he felt were arising with a patient.  He even brought people back from theatre.

A good HCA is worth their weight in gold.  They may not be able to help with drugs and all that kind of stuff.  If I am the only Nurse on a medical ward for the shift I may have over 80 IV drugs to give.  That takes hours.  And Nurse's make drug errors and cannot get to their patients when they have that many IV's to do.  So even if I had a hundred Sam's working with me in a situation like that I would still be struggling and short staffed.

But if I  knew that Sam was keeping a careful, knowledgeable and watchful eye on my patients whilst I was tied up with Nursing stuff it would make me feel a whole lot better.  I wish we had people like Sam on our medical wards.  It would be a real help to know at least there was someone reliable to look at my patients whilst I was preparing over 80 IV meds and getting dragged on doctor's rounds and to the phone.  But we do not get Sam types on the medical wards.  We used to have Sam type HCA's but as they quit and retired they were not replaced.  And we got the kids instead. Sucks.  We have a couple excellent HCA's left in medicine but the rest of the care assistants are all kids/cadets/apprentices/auxillaries with serious knowledge and common sense deficits and a whole lot of attitude.

I asked Sam why he doesn't do his Nurse training.  He gave me a wry smile and laughed out loud.  " I am happy as I am.  From  my vantage point Nursing looks like a nightmare.   I used to work on a medical ward as an HCA and I know how the qualified nurses suffer.  As an HCA I don't have to fuck about with drugs, assessments, orders, doctors or take any responsibility.  And on the surgical wards things run more smoothly than on a medical ward. I just enjoy interacting with the patients and helping them out.  And it is great.  Why would I want to give up a job I love ?"

Our medical wards need to have good RN's and health care assistants.  I think the ideal ratio is 80% RN's to 20% health care assistants in the composition of ward staff.

But the current ratios we are working with are something like 30% of staff are RN's and 70% are cadets/kids/apprentices/axilliaries.  

The hospital lies and tells people that on any given shift their medical wards are staffed with 65% Nurses and 35% care assistants.  This is a lie. 

Anyway I tried to get Sam to beg for a transfer to my ward and he nearly fainted because he laughed so hard.

Forest Gump GPs and hospital Consultants all across the land are telling anyone who will listen that the problem is "degree nurses who don't want to work on the wards".  Bullshit.  Managers are turning away both older trained and newly qualified Nurses when they apply for jobs as bedside Nurses on the wards.  They would rather hire kids.  Cheapo cheapo productions.

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.

Judith Potts is at it again

I am actually really embarrassed for her.  She really isn't  doing her research before she writes these pieces.  Her ignorance is astounding.

http://blogs.telegraph.co.uk/news/judithpotts/100073144/do-hospice-nurses-show-more-empathy-than-general-nhs-nurses/

Managers who support the pay freeze:

From this wonderful blog.

Salaries of NHS bosses who back increment freeze


Twelve senior NHS managers wrote to the Health Service Journal on Tuesday saying that staff should have their annual increments frozen for two years as part of a government cost-cutting programme.



The deal offered is that in exchange for the increment freeze, there will be no redundancies at Pay Band 6 or lower.



There is no such guarantee on offer for those on higher grades.



In effect this means that anyone on Pay Band 7 which starts at just £30,460 will be at risk of redundancy.



The increment freeze will come in addition to a two year pay freeze already imposed on NHS staff.



The managers say in their letter: ‘it is important that there is a considered debate about the issues based upon accurate information and we are seeking to encourage employers to have that debate with their staff and their staff sides’.



In the interests of providing accurate information and to encourage just such debate, here are the current salaries of all 12 signatories.



Maggie Boyle, Leeds Teaching Hospitals

£220 - 225,000

(Source: Annual report2009/2010)



Sir Robert Naylor, University College Hospital foundation trust

£260-265,000

(Source: Annual Report 2009/2010)





Jo Cubbon, Taunton and Somerset Hospital foundation trust

£165-170,000

(Source: Annual Report 2009/2010)



Peter Cubbon, West London mental health trust

£135-140,000

(Source: Annual Report 2009/2010)





David Dalton, Salford Royal hospital foundation trust

£220-225,000

(Source: Annual report 2009/2010)



Stephen Eames, County Durham and Darlington hospital foundation trust

£185-190,000

(Source: Annual Report 2009/2010)



Mike Farrar, north west strategic health authority

£200-205,000

(Source: Annual Report 2009/2010)



Andrew Foster, Wrightington, Wigan and Leigh hospital foundation trust

£160-165,000

(Source: Annual Report 2009/2010)





Julian Hartley, University Hospital of South Manchester foundation trust

£180-185,000

(Source: Annual Report 2009/2010)





Simon Pleydell, South Tees Hospitals foundation trust

£185-190,000

(Source: Annual Report 2009/2010)





John Rostill, Worcestershire Acute Hospitals

£165-170,000

(Source: Annual Report 2009/2010)





Chris Sharratt, Sheffield Children's hospital foundation trust

£145-150,000

(Source: Annual Report 2009/2010)

Keep in mind that we have already had a pay freeze in effect.  Keep in mind that we are already paid a lot less than Nurses in other first world countries.  Keep in mind that we have a much heavier workload than Nurses in other first world countries  because of poor RN to patient ratios.  You wouldn't believe how many thousands of pounds I have had to pay out to childminders during the course of my career to watch my children during hours I worked that I never got paid for.   Keep all this in mind.  What kind of state would the NHS be in if they didn't exploit their frontline professionals?

Ward Nurse Suspended...

I received a cry for help in my email inbox this week.

It was from the husband of a registered nurse who has been qualified and working on the frontlines as a direct care Nurse for 30 years.

Recently she was left as the only experienced/qualified nurse for a very large number of ill patients on her ward. Like my hospital, her hospital as probably ignored the Nurses' complaints about short staffing of real nurses on the wards.

Her least ill patient was a man having minor surgery.  He was fine.  Never complained to her or about her.  He recovered well and went home.  All of you who work as acute care nurses and find yourselves as the only RN on a large ward know that you cannot give time to well patients without killing your sickest ones.

After this patient was discharged his wife  wrote a nasty note to the hospital complaining about the fact that she did not feel that her husband received enough one to one care. 

The Nurse who was on duty that day (my correspondant's wife) was suspended because of the complaint.  She has had over 30 years as a Nurse without a mark against her.  Sounds to me like she is at the top of her pay band as a bedside Nurse and they want her gone to replace her with a totally green and inexperienced newly qualified or a kid.  They are on lower salaries.  You see a lot of this in Nursing.  I had a good friend (and mentor) who was qualified for 40 years.  She was top of her pay band as a bedside Nurse.  They got rid of her over something completely made up and replaced her with a newly qualified Nurse on a much lower pay band.  Hospitals have been playing these games with bedside RN's since the late 80's when they decided that professional Nursing at the bedside wasn't worth spending money on anymore.  Once they decided that it has been nothing but cut cut cut.  Not only do they get rid of their most experienced bedside RN's but they don't replace those who quit or retire with staff of equal value, training or experience.   Many will blame well educated Nurses for the shitstorm that is hospital nursing care these days.  But the truth is that well educated qualified Nurses KNOW that they need to be at the bedside with their hands getting dirty in all aspects of patient care.   Hospital management does not give a shit know this. 

I have seen this kind of thing in my hospital.  Management won't accept liability and they won't deal head on with problems at ward level (lack of qualified staff).   And a Nurse or a Doctor becomes a sacrificial lamb.  I have no doubt that this Nurse will be reported by her hospital to the board of Nursing that she is licensed with for patient neglect.  In which case she is guilty until proven innocent and gagged from talking about how her ward was staffed and what was going on with her multiple other patients.  I have seen it happen.  I hope this Nurse has a lot of money put aside for legal fees.

Even though I detest Unions and think that they are worthless for health care professionals I do hope that this lady is unionised.  But then again, what will the union do about it?  Hospital chiefs laugh at the Nursing Unions.  We have absolutely no leverage and cannot strike.  I don't know how to advise the husband of this Nurse.  I hope that they can afford a good lawyer.

This post makes me think of a fantastic book by a journalist named Suzanne Gordon. She is not a nurse but she studies Nurses and has spent years shadowing qualified Nurses at work on hell wards.  She understands what is going on.  Her book is called Nursing Against the Odds but I think a better title would be "Oh My God what the FUCK has happened to Nursing care on the Wards" or perhaps "Don't Blame the Nursing Profession, asshole".

Great book if you get a chance to read it.

Another article on Hospital care.

Should we bother writing to this woman and explaining how unrealistic her expectations were and how greatly she misunderstood the situation?  She is right about hospital care.  But yet she completely misinterpreted the situation.

Do you think she actually wants to know and understand or do you think she just wants to moan?

http://blogs.telegraph.co.uk/news/judithpotts/100070484/my-mother-in-laws-shocking-experience-at-scarborough-hospital-and-what-it-says-about-the-nhs/

As I work in medicine at a district general hospital I know how long it takes to get new patients sorted.  I know how difficult it is to do the right thing with elderly people and how slow the system is to act.  But I think this woman just has it in for the frontline professionals.  She lacks insight and sense and takes it out on the Nurses and Doctors rather than the shitty system they work in.

The GP had been called to the residential care home in which she lives – Sylvia has severe dementia – because she had not been eating or, more importantly, drinking for 24 hours and was virtually comatose. The GP diagnosed possible pneumonia and asked that Sylvia should be put on a re-hydration and anti-biotic drip within two hours

The GP had to know that there was no way that she could be admitted and started on those orders within two hours. He must have been covering his ass. Tests have to be done in hospital and the hospital consultant has to see the patient in AAU long before anything can be started. A lot of ducks have to be line up in a row for a diagnosis to happen and the right treatment to be initiated.

Unfortunately, no assessing of Sylvia’s condition was carried out for several hours. I understand that recent policy in the NHS requires patients to be held for no longer than 4 hours in Casualty. Clearly, this does not apply to the “assessment” ward.

That is of course why they have assessment wards (AAU). There are not enough beds, staff (the right kind of staff) or facilities to meet the targets and avoid the hospital getting fined.  Management did this.

After waiting three hours, I approached a female nurse and explained about the GP’s wishes. Standing under a poster warning patients and their families not to abuse hospital staff, the nurse sarcastically answered me. “With all due respect, darling, it is for the hospital doctor to decide on diagnosis and treatment not the GP.”

That is 100% true. No hospital Nurse or hospital doctor can act on orders by a GP. The GP did not make a definite diagnosis. He did not have the diagnostic tests at his disposal to do that. It would hurt patients even more if the hospital staff did what this author believed that they should do. Hanging the wrong IV fluids or IV antibiotics could kill a patient very fast and a doctor's rule is "first do no harm". The Nurse of course can NOT hang IV fluids or IV antibiotics until the consultant has seen the patient and one of his doctors has prescribed the darn things. These places are so short of qualified staff (not unqualified staff ....lots of them hanging around) that I think they did well to get it sorted within 24 hours.

Eventually a doctor appeared. He was perfectly polite and, after examining Sylvia, took us to one side, explained that there were “quite a few things going on with Sylvia” and asked for our decision on resuscitation. Not having realised Sylvia’s condition was that serious, we were very shocked – not least because she had been left untreated

That is a bit silly. An elderly woman with severe dementia who has stopped eating and drinking could be at death's door regardless of pneumonia, IV fluids and IV antibiotics. Those treatments might have worked or they might have sent another organ system in her body totally screwy. Doctors are clinicians not psychic mediums. Medicine is not a cut and dried science that always follows a logical planned and steady algorithm. I bet her renal function was also a mess. Anyone (me, you, etc) could drop over dead at any time. An elderly person who is sick enough to get admitted to hospital is very likely to just crash at anytime regardless of anything the doctors and nurses are or are not doing.

He was correct to ask about rescus status. At this point there was no way for the medic to know how things would turn out for Sylvia.  I once worked with a young healthy nurse who fell over and died of a stroke in the middle of the shift.  If that can happen to her it can happen to an elderly lady at anytime, regardless of IV antibiotics and fluids.

The whereabouts of the consultant was a mystery. Neither he nor his team were in attendance, despite the fact that there were two other elderly ladies with chronic dementia on the ward.

Believe me when I tell you that this consultant would have had over a 100 patients with confusion, dementia and multiple other medical problems on many, many, different wards all over the hospital. It takes these guys something like 10 hours in a day to see all of these people just one time. Plus they have clinics and everything else. It is offensive for you to imply that he was bunking off and ignoring his patients.  If you tried to keep pace with his work day just once you would collapse.

Next morning I rang again – quite prepared for Sylvia to have died in the night – to be told that she was absolutely fine and could go home.

This is how it is with elderly people who have dementia. It is never cut and dried and you don't know what will happen. If they sent her home the next day it is highly unlikely that she had pneumonia, as the GP led you to believe. Older people with dementia often stop eating and drinking and have alterations in levels of consciousness. It may be an acute medical problem that needs IVs and other treatments or it may just be the kind of quick deterioration that happens to all older people as their bodies start to shut down. They often seem to rally, then get worse, then rally again. Not eating and drinking etc is normal for people when they get to end stage of life. And all elderly people are at the end stage of life and their bodies are going haywire and shutting down.  Fixing one problem causes another to start. If some IV fluids helped her come around  this time then that is great. But it doesn't mean that she is "cured". 

Pleased though we were, we wanted an explanation. Nothing tallied.

She is elderly. And elderly patients are complicated. There is no cure for old age. She was admitted to hospital. They did some tests. She came around and they determined that she was medically stable and they sent her home.

There is nothing else to tell. You are wanting instant answers and diagnostics and a cut and dried plan of care instantly. This is impossible in general medicine especially with elderly patients.  In other words, nothing tallies because you have no experience or education in health care.  If the hospital doctor and nurses explained this to you as I am  explaining it to you would not have liked it.

However, Sylvia was not sent home that day because she became unwell again.

Yep. Elderly patients go up and down like this because they are at the end of their lives. Doctors are brilliant but there are two things that they cannot do. They cannot cure old age or stop us from being mortals with bodies that give out.

I would imagine that she will deteriorate, rally, deteriorate, rally, deteriorate, rally many more times before she passes. All without a concrete diagnosis. That is normal. It is no different for elderly people in the United States, Canada, Australia etc.

I have numerous questions including – was Sylvia apparently ignored? Why is there no communication between the GP and the ward staff – and is this nurse’s opinion, of the GP’s ability to diagnose, commonly found in NHS wards?

It wasn't the Nurse's opinion.  The Nurse was telling you a fact.  A fact that should be obvious.  Even if the GP had wrote out orders (which he did not) and faxed them the Hospital nurse still would NOT have been able to act on them. The hospital doctor has to write the orders. The GP did not have the information to give safe orders.   A doctor cannot prescribe IVs etc without blood tests and xrays. The hospital doctor will prescribe what needs to be prescribed when he has all of his ducks in a row. If Nurses are to give IV fluids or IV antbiotics the order has to be written on a hospital drug chart by hospital doctors. Otherwise it is an illegal order and  cannot be given. Sylvia was not ignored. She was under the care of Nurses and Doctors who were already 4-5 hours behind on doing what needed to be done for the patients that they already had when Sylvia came through the door.

Why was there no polite, informed communication between the ward staff and me – I was not the only person sitting beside an elderly relative’s bed, not knowing what to do?

Did it very occur to you that:

 A. An RN cannot delay treatment for the 15 people she is responsible for to chat with relatives
 B.  The five unqualifed staff sitting at the Nurse's station cannot help me implement doctors orders or communicate with relatives.  A Nurse has to handle that all by herself all at the same time.  And there is only one Nurse for a large team of patients despite how many techs you see hanging around.
 C..That there was nothing to tell? It gets very frustrating when relatives sit around with nothing to do obsessing over every little detail and inventing these paranoid scenarios where everyone is trying to neglect and kill grandma and hide information from them.  Open your eyes a little.

there was no evidence of shortness of staff; indeed a lot of eating and chatting was going on at the nurses’ station.

From what I hear, Shitborough has some of the worst direct RN to patient ratios in the galaxy. It is lack of RN's that are the problem, not lack of techs and unqualified staff. 
You know not what you see. I know how wards are staffed in these places. Many of the staff you see at the station are not Nurses and Doctors. They are care assistants and techs. And even if I had a hundred of them working with me I would still be too short of nurses and doctors to get things done in a timely fashion. I once had a bag of IV fluids run out on a patient and it took me 5 hours to chase down a doctor to get him to prescribe more so that I could hang a new bag A few techs sat at the nurse's station drinking tea and chatting does not change how long it takes the doctor to get results of diagnostic tests so that he can order the correct treatment. I could have a thousand techs working with me on a shift. But whether they look busy or are sitting around at the station does not change how long it takes to get orders written by the doctor and implemented by the Nurse.



I think you are either very unrealistic or are simply shit stirring.  And please keep in mind that no hospital Nurse can act on orders or start any kind of IV therapy unless it has been prescribed onto the hospital system by the hospital doctors. Not under any circumstances ever.

I am also surprised that a medic told her that someone would ring from the ward with an update!  As a ward Nurse I am almost never in  a position when I can abandon those IV fluids and meds that I am hours and hours behind on starting on all those people to call relatives.  The only help I have are techs and assistants and they cannot make calls to relatives NOR can they  continue with my workload as I am sat around ringing the relatives of 15 different people to give an "update". 

And that's probably all there is to tell Mrs. Potts.  Hope that helps.

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