Safe Ratios Save Lives

Here I am repeating myself. Again. I have a million articles about nurse patient ratios saved. This one is getting posted on here because it is an easy read. If you want to see more research estimates, look back at the beginning of my blog or google nurse patient ratios.

The research that has been done into the effects of short staffed unit has shown that no patient on an acute ward is at all safe if his nurse has more than 5 other patients. In the UK his nurse has at least 10 to 12 or many many more other patients. That is why nursing care sucks here. It has nothing to do with nurse training, or nurse bitchiness, or bad attitudes ,or a lack of training. Even if it was, the piss poor ratios would still have a larger impact. "Dignity Training" can only help so much if the nurses are overwhelmed. Overwhelmed is an understatement for what British nurses are going through. Everyday in Britain, hardworking, well trained caring nurses are giving terrible care.

It's all about the ratios.

read this

Nursing ratios save money and lives
By Suzanne Gordon
July 9, 2008
BEFORE ITS legislative session ends in July, the Massachusetts Senate has an
opportunity to protect hospital patients as well as the nurses who care for them
by approving the Patient Safety Act that was passed overwhelmingly in the House
a month ago.

The ratios bill would require that the Massachusetts
Department of Public Health implement enforceable limits on the number of
patients a registered nurse can be assigned, thus providing patient protection
in all acute care hospitals. As the Senate debates this measure, it should
consider the positive effects that legally mandated nurse-patient ratios have
had where they've already been enacted - in California and Australia.

In California, since 2005, no nurse on medical surgical
floors can be assigned more than five patients at a time. On equivalent
units in Victoria - the second largest state in Australia - the minimum required
staffing for every 20 patients is five RNs, backed up by a "charge nurse" who
has no patient load of her own and is thus free to assist other RNs.

In
both California and Victoria, ratios were originally introduced because
excessive RN workloads were putting both nurses and patients in jeopardy, while
adding to overall healthcare costs. More than 60 studies have documented
that hospital understaffing results in more patient deaths, plus more
preventable complications like pneumonia, urinary tract and catheter infections,
and medication errors. A study done in 2005 by Michael B. Rothberg in
the journal Medical Care put a price tag on these problems, concluding that a
nurse who had time to prevent a case of pneumonia "saved $22,390 to $28,505, or
$4,225 to $5,279 per additional hospital day." When nurses prevent an adverse
drug event, they save the patient from an "added 2.2 hospital days at a cost of
$3,344." On the other hand, if understaffing leads to complications after
surgery, the resulting patient stay can be 8.1 days longer than normal, adding
nearly $11,000 to the total expense.

Unmanageable workloads have also
created an exodus of nurses into other fields or nonpatient-care jobs. According
to a study by L.J. Hayes that appeared in the Journal of International Nursing
Studies, hospital nurse turnover in 2006 - outside of California - ranged from
15 to 36 percent per year.

A study by economist Joanne Spetz, just
published in the nursing journal Politics, Policy, & Nursing Practice, finds
that ratios in California have increased RN job satisfaction and reduced
turnover. According to Spetz, nurses are happier at work because they now get to
spend more time at the bedside - particularly on patient education - which has a
positive impact on nurse turnover and thus on the quality of care.

Researchers at the University of Pennsylvania have compared nurses in
California with those in Pennsylvania and New Jersey - states without minimum
staffing requirements. California RNs reported greater job satisfaction, leading
to less burnout.

More nurse patient ratio research

The nurse patient ratio laws in California and Victoria are by no means perfect. They are relatively new and more research needs to be done. Like all new things there are a lot of bugs that need to be ironed out. How these ratios were implented by each different hospital makes has a huge impact on outcomes.

But it is a start. And we need these laws in Britain.

You certainly won't hear patients in California say that they were left hungry, cold, and in agony. They won't be left waiting for a bedpan or pain pills. They are clean, their nurse answers their call bell and spends time with them. Their nurse maintains their dignity and provides basic nursing care, she uses her knowledge and training to prevent complications and keep her patients safe. This is done without neglecting basic care. And all this care is done by highly educated nurses who only have 4- 6 patients at a time.

Now lets look at the current situation in the UK where the vast majority of the nursing staff on the wards were trained back in the "good old days" and have 15 patients at a time, sometimes more.............

Need I say more.

Nurses want no part of it!

This blog was written by a doc in the States. It discusses some issues regarding nurses vs primary care physicians across the pond. He knows that the money hungry and greedy powers that be want to see nurses taking over primary care and he also understands that nurses want no part of this. It's true, we don't. I'll post some of DrRich's quotes and then head off on a tangent.

Occasionally some of us will escape the hell that is ward nursing and go into advanced roles...but most of of are escaping healthcare and/or the country all together.

This blogging doctor has A POSITIVE attitude towards his nursing colleagues. That's the main reason I posted this. He also "gets" that many don't want to do the noctor thing. Seems as if he isn't quite as paranoid and misinformed as his British counterparts.

http://covertrationingblog.com/medical-ethics/on-respecting-nurses


Some Excerpts:


"Much of what Gina (Code Blog), Strong One (My Strong Medicine), and Mother Jones (Nurse Ratched’s Place) have to say about the nursing profession is not all that surprising. That nurses are often disrespected and stereotyped by god-like doctors and poorly-informed patients is, sadly, an old story. But DrRich is struck by two things in Val’s podcast."

"Thanks to a) the growing nursing shortage, b) the inability to accommodate all the people who want to enter nursing, and c) the fact that those who have made it into the nursing profession are very smart people with “disturbingly” high ethical standards, we find that the healthcare system will soon need to re-evaluate its strategy in regard to primary care medicine."

Thanks. It is also very competitive and difficult to get into Nursing school in the UK. Too many applicants and not enough slots. A large number of the applicants have degrees in other fields and still are not getting in. The universities are able to pick the best applicants. Of course high quality people going into nursing is pointless if there is no jobs and they end up responsible for too many patients.

"First is that there is a long, long waiting list for entrance to nursing school. DrRich had no idea. He finds it uplifting that so many young Americans are lining up to enter this still-noble profession, especially at a time when nurses are so needed. It seems likely that at least some of this enthusiasm reflects the fact (and it is a fact) that the nursing profession is entering an era where the stereotypes and the disrespect seem ready to be torn down. While he has no special insight into the matter, DrRich finds it very likely that nursing school slots will be rapidly expanded (and nursing instructors will be adequately rewarded to staff these new slots), simply because there will be little other choice for our healthcare system.


Well that's a little naive but okay. The funding is not going to be there to train more nurses in the UK or the USA. Once they get onto the wards 2 out of 5 will burn out before their first year is up anyway. In the UK, managers think that 16 year old cadet nurses can just take over ward nursing while the ward nurses become pretend GPs. Yes we need more nurses but we are not going to get them or retain the ones we have in these hell hole wards. That's a fact here in the UK as well across the pond...............Anne

Second, it is striking that nurses seem to have figured out already that taking over primary care medicine from the rapidly-dwindling primary care physicians is a losing proposition. They are avoiding the opportunity in droves.

That, if nothing else, should tell us how smart nurses really are"

Yep...........Anne


"The healthcare system has done all this precisely to drive physicians out of the primary care business, for the explicit purpose of opening the primary-care doors to a profession it believes is more tractable than physicians - namely, the nurses."

Not only tractable but cheaper...........Anne

" The healthcare system sees nurses as professionals who (once they are duly certified in primary care medicine through respected testing organizations), will have just enough training to diagnose and treat the average patient (i.e., the ones with high blood, low blood, fat blood and sugar), and who will cheerfully, unquestioningly follow whatever guidelines are handed down to them from on high. And they will do all this for less pay and with less lip than the now-obsolete physician PCPs. These new practitioners of primary care medicine will be a perfect fit.
Except for one thing. The nurses want no part of it".

Ding Ding Ding. That is correct. We just want decently staffed wards, resources and a little back up so that we can do our jobs. If we don't get that we go, but not necessarily into the hell that is doctor land........Anne

The ultra paranoid british doc bloggers think that nurses want their jobs. This is bullshit. The truth is that even though we are being pushed that way by the powers that be the vast VAST VAST majority of us know that it is not a good idea. I am so happy that there is a doctor out there, somewhere who understands. How does DrRich know this? Go to his page.

The man is listening to and talking to real nurses.

The Daily Express: WTF planet do they live on?

Just came across an article by Victoria Fletcher of the Daily Express.
I am so glad I don't take these "journalists" seriously. I really am. Ms. Fletcher is one of the better ones actually as far as "health" articles go. Sad isn't it.

Yes we know that patients are suffering horrifically. Nurse Anne and her loved ones also suffer a great deal when they are patients. Do they really think that patients are suffering because nurses and doctors don't understand these "commandments". Idiots. The NHS managers who think that dignity cards are going to improve things need to educated... or perhaps they need to be stopped from trying to pass the buck.

Here is an excerpt:

http://www.express.co.uk/posts/view/46067/NHS-staff-given-commandments-on-care-of-elderly

In some hospitals, investigations found that some patients too ill to feed themselves were ignored and then had the food taken away from them, causing them to become malnourished.

Last year an investigation into an outbreak of a hospital bug that claimed 90 lives in Maidstone and Tunbridge Wells NHS Trust revealed patients were told to soil their beds because staff would not take them to the toilet.

Last week it emerged that TV chatshow host Michael Parkinson, 73, will lead a new campaign to boost respect for elderly patients. He regularly visited his mother Freda in her last days in hospital before she died aged 95 last year.

He said: “I came across an extraordinary mixture of care – some nurses who were utterly dedicated and wonderful.

But there were others who treated it a bit like they were a jailer, treated people in their care as inmates. There were distressing signs of elderly people being left weeping who were still there half an hour later, and that’s not right.

“I used to worry about leaving her on her own.”

THE 10 DIGNITY RULES

1. Have a zero tolerance of all forms of abuse.

2. Support people with the same respect you would want for yourself or a member of your family.

3. Treat each person as an individual by offering a personalised service.

4. Enable people to maintain the maximum possible level of independence, choice and control.

5. Listen and support people to express their needs and wants.

6. Respect people's right to privacy.

7. Ensure people feel able to complain without fear of retribution.

8. Engage with family members anDd carers as care partners.

9. Assist people to maintain confidence and a positive self-esteem.

10. Act to alleviate people's loneliness and isolation.

Well duh.

Not only am I concerned about the sanity of our NHS managers but I am also seriously concerned about Victoria Fletcher's. I have seen a few articles by her that were so way off base it is sickening. This one is obviously slanted to have a go at frontline staff and it's enough to send me over the edge.

I thought journalists were supposed to do research and commit to getting their facts straight. Vicki seems to think the the patients' dignity is being compromised and that cold trays are food are being left out of reach because the nurses are thick and lazy. Not one quote from a ward nurse. Vicky, my dear, you need a reality check and you need to start doing research. It would help to talk to people who work on the wards rather than people who only have a narrow simplistic view.

"Staff would not take them to the toilets causing them to soil their beds". Did it ever ever occur to Vicky that these nurses are in a position so precarious that they cannot always just stop and constantly toilet people? The nurses do not want things to be this way. They don't have a choice. If they are caught fucking up meds/orders or not noticing changes in condition because they are constantly toileting they are going to end up in front of a judge.

All we are constantly told is to prioritize prioritize and prioritize. The IV medication to stop that seizure comes first before the bedbath. The blood transfusion must be done before the commode. The man who can't breath must be sorted before the pain meds can be given. But the thing is, the top priority stuff never goes away long enough for us to do any basic care. If I am doing basic care someone else is not getting their blood, pain meds, or their hypoglycemic attack noticed and sorted. They die. Things move that fast.

Can you imagine my saying "sorry doc I cannot squeeze/infuse that gelofusion into your shocky patient or do anything else for him right now because 10 people need the commode. See you in about an 2 hours because I need to wash the commodes when I am done and then others will want it, and then I will wash it again".

That would go over like a lead balloon.

Vicky, we need more goddamn help and less of your ignorant bullshit.

Vicky would sue my ass off if I was caring for her loved one dying of sepsis and I left him to take someone to the toilet. What about when I am running up and down the ward trying to round up the supplies etc to implement the doc's plan to save Vicky's septic loved one? Should I stop during the course of that everytime someone asks for the loo? That would keep me away from Vicky's loved one for hours. Does Vicky think that another nurse would magically appear to help me out? Does Vicky think that those situations just disappear so that I can run around toileting everyone.

No one wishes for that more than we do.

Does Vicky think that the managers care and the nurses don't? Jesus Christ. How misinformed can a person be? The nurses and doctors care more than anyone. The "bad" ones may have just been caught up in the middle of something that they cannot control. This is what causes patients to wait. I have never seen a nurse make someone wait intentionally.

If anyone would listen to the nurses we would tell you why people aren't being fed and nursed.

Do your research. Visitors, etc see that the situation is damn bad but they have no insight into what the nurses are struggling against. They cannot see past their own grief enough to understand the situation on the ward as a whole.

Arghhh.

I really think I need to go to anger management or something.

I nearly choked on my starbucks coffee when I went into specsavers the other day.

They had no less than 10 staff there, and 3 fit and well customers.


It will be a cold cold day in hell before management allows us to have 10 staff for a large ward full of ill, vulnerable people.

Just needed to get that off my chest, for my sake. My blood pressure is going sky high.

I feel better now.

Surrounded by Idiots: The Complaints Manager.

Received a phone call from a colleague fairly recently. I am going to document what she said on this blog.

She also works on the same ward that I am/did.

Not too long ago she was one of two RN's for the whole ward. She was the RN for one side and sister was the RN for the other side.

They were running their assess off, constantly interrupted and overwhelmed and by 11 AM everything was fucked up. Half the meds weren't given, gent levels etc weren't done, discharges weren't going anywhere because the nurses couldn't sort them out, patients were filthy, and no call lights were being answered. Their were 2 care assistants who were trying to bed bath everyone, and answer bells. Nightmare.

So around 11:30 AM this moron from the complaints department struts onto the ward and proceeds to glare at the nurses with complete contempt. She tells them that a another complaint came in about nurses not feeding patients.

This is a regular occurance:
http://militantmedicalnurse.blogspot.com/2008/03/protected-meal-times-what-fucking-joke.html

Moron collars the sister, and pulls her into the office and demands that she sits there for 2 hours answering questions about the day the complaint when in, what staff members were on, do they not understand that nutrition is vital etc etc. She made sister formulate a response right there and then. Kept her in that office well past dinner time. Moron also had the nerve to roll her eyes at Sister when Sister declared that she needed to get back onto the ward ASAP. I don't even understand why moron bothered, her official response to the complaints will only be lies.

That left one RN and 2 care assistants to cope with all the patients, alone. We really, really needed Sister back on the ward. When she came out of the office, moron collared her again, insinuating that sister wasn't interested in the complaint or the situation.

The dinner trolley appeared at noon and the three staff were trying to feed 10 plus people themselves whilst managing care for the other 19. Moron would not get off Sister's back. People were not getting fed.

The staff nurse was in a blind panic because so many orders from docs that needed to get done stat were not getting done. She told me that she really thought someone was going to die. Listen people you can have the most brilliant doctor in the world but if you don't have a nurse that is able to implement and coordinate all these orders you are fucked.

Some visitors were on the ward at this time. We are not strict about visiting times when people are extremely ill and family cannot get there during the set hours. The lay out of the wards is such that they can see everything, even sister in the office engaged in discussion with moron.

While sister was being held in the office, and the 3 staff that were left on the ward were struggling to cope, two of the visitors walked downstairs to the patient complaint services office to complain about "oblivious" nurses not feeding patients. Never mind the guy with the pre-renal failure who hadn't even had any fluids started yet and that the staff nurse was trying to stop him from pulling his cannula out.

So at least 2 more complaints came in on that very day at that very lunchtime. If the people who were complaining or perhaps the managers were not completely fucking retarded maybe we would have been given more nurses instead.


If I hadn't witnessed these kinds of experiences myself all the time I would never believe it.

EDIT: I understand that the term retarded as used in context here is very offensive, crude and not at all politically correct. I apologise for that. I am even offending myself right now.

I am sitting here wondering if there is a better term to use to describe the behaviour of these people. There is not. They just have low IQ's. They retard the nurses efforts to care for the patients.

Productive Wards and Releasing Time to Care

Dr. Crippen (and many other bloggers) has written about this already. If you need details regarding what "Productive Wards" is then google it.

So when this bullshit came to my hospital they decided to make all the ward sisters attend a series of lectures about it.

A ward sister is an RN obviously and they will not pay more than 2 RN's to be on our large ward at any time. If we have 3, one gets sent away to staff a more "important" unit.

Ward sister was ordered to leave the ward to attend these lectures on "Releasing Time to Care" for the duration of her shift.

This left one junior RN in charge of the whole ward with 2-4 care assistants. The shift was 0700 to 1500 hours and the lecture thing that sister had to attend was pretty much the whole shift.

This is a 25 (sometimes 35 if the fuckers open the other wing even though they cannot staff it) bed acute medical ward where every patient needs constant support and just finding prescribed meds and/or setting them up to infuse for that many people can take 50 minutes out of every hour.

The hospital refused to pay for any nurses to cover the ward while the ward sister was at the lectures.

This meant that a junior RN was not only in charge of her 15 patients but sister's 15 patients as well plus charge nurse for the ward. Alone. The morning drug round alone takes 3 hours for that amount of people and that's if she doesn't stop everytime a patient shouts out for help or begs for a commode.

Even if she carries on without allowing herself to be interrupted, the patients will not get the drugs they need on time or anywhere near on time. It is just too much. Blood work gets fucked up as a result of these drug errors, people get hurt, people suffer etc. Time is extremely important with drugs. She will also get constantly interrupted by phone calls and doctors during this time, and they will not give a damn about the patients that they are not responosible for...

A consultant will show up (not at a set time but at a time it suits him, usually during our drug round) to see a patient in bed B.

The nurse will be getting pain meds out for bed A when doc decides to grace us with his presence. You would not believe how much of a long, time consuming process getting morphine up and out, ready to deliver is...

Doc will expect the nurse to drop what she is doing to shadow him on his visit to bed B. Immediately.

He does not care about the Nurse's patient in bed A because bed A is not his patient. Only bed B is his patient. He doesn't give a shit about the fact that the nurse would have to leave bed A in pain to attend his round. He doesn't give a fuck about the fact that there are no other nurses on the ward to help bed A. He probably doesn't know and he doesn't care either. He has other problems and the nurse's problems are the nurse's problems.

Either we end up with a screaming, tantruming consultant whinging about his precious time or a patient left to wait for pain medication. There is no other Nurse because she is at the "releasing time to care" lectures and management won't replace her on the ward. And yes she has to attend the lectures or management will fuck her up. There are only care assistants and they cannot attend rounds or infuse pain meds. The care assistants are struggling at this point just to get everyone fed, washed and answer bells without making them wait for hours, suffering in agony.

But no. Management will not get another nurse in to cover absences due to the productive ward lectures. The nurse not on the lecture that day will be left alone to be abused.

...by the way if Nurse Anne was in that situation she would just tell the consultant to fuck off because someone she is responsible for is screaming in pain.

And yes, I do understand that ward rounds are extremely important and so is the consultant's time. I would still tell him to fuck off. Unless of course I had another nurse. Then one of us could get the pain meds and the other could be dutiful and attend rounds.

Too bad management doesn't think that way.

Sick sick bastards all of them.

For the Docs (especially the junior docs: we like them better)

Just a few quick thoughts.

This blog was started so I could blow off steam. It is entirely nurse-centric. Nursing is all I really know.

I am always complaining about how tough nursing is right now. It's because I want things to get better. This does not mean that I do not understand how bad things are for other health care professionals. I am talking about the doctors mainly. Junior doctors especially. Consultants are just a mystery. I just try and avoid consultants 100%.

From what I can see it looks as if junior doctors are actually going through living hell. We do feel bad for them. We feel bad when we can't help them out. We feel bad when we have to keep bleeping them for stupid shit. But yeah, we have too. We feel bad when we find out something about a patient that needs a doctor review 8 hours into my shift rather than 2 hours ago when the doctor was actually on the ward. Now he/she has to come back here AGAIN when many other wards are trying to get him/her to see their patients. We haven't bleeped you 3 times an hour to be a bitch or make things harder for you. We are just constantly missing things because we have no time to read notes and assess people properly. It's bad. Honestly, we don't want to fuck up your orders or land you or ourselves in hot water.

We know that you had to be highly intelligent just to get into med school and that you have an extremely high IQ. We know this even if you just asked a silly question. We know that your hours are shit compared to ours. We know that you have more patients and are constantly dealing with acute stuff.

We actually worry about the junior docs...and take cash bets on which ones are going to keel over and die from stress before age 35. We get pissed off when we see consultants talking down to their juniors and yelling at them in front of everyone.

We think that it is a damn shame that you can't get anything done without that bleep going off. I would have thrown the fucking thing out the window. Obviously we respect the job you do. Even so, I am still going to run in the other direction and not make eye contact when you walk onto the ward. That's probably because I haven't yet been able to implement those orders you gave me over an hour ago. Yeah oops.


There is always going to be some nurses that hate doctors and give them a hard time. My experience is that the majority of us are not like this. The majority of us do not want to do your job either. No thanks. I really wanted to be a nurse, despite all the shit (literally and otherwise). I like the idea of nursing people, NOT spending my days diagnosing and prescribing. That doesn't sound like any fun to me. But that is just me. More power to those of you who choose to go down that road.


But the whole point of this blog is to explain things from the nurse's point of view, that's all.