Wednesday 12 March 2008

Protected Meal Times: What a Fucking Joke

We all know that frail elderly patients are becoming increasingly malnourished in hospital. We all know that their trays get left out of reach, that no one comes to assist them with their meals. We all understand that it is the JOB of the registered nurses to ensure that nutrional needs of patients are met. The registered nurses understand this better than everyone. We even understand it better than those of you who accuse the nurses of not wanting to be "bothered" feeding patients. Fucking simpletons.

Good nutrition is vital. People who have inadequate intake of diet and fluid do not get better. They deteriorate. They are at risk of impaired skin integrity. Wounds do not not heal as well when one is malnourished. I have seen renal failure, electrolyte imbalances, dry cracked painful lips, mouths and tongues on elderly people who are not given drinks. They are so confused that they often pull out their IV cannulas making hydration via IV fluids impossible. I have seen frail
elderly people get even skinnier in hospital to the point that they appear to be skin and bones. Pressure sores form. You can see muscles and bone as the sore is so deep. The become more disorientated. Renal failure courtesy of dehydration. They suffer. It sucks. It should never happen yet it frequently does.

We are constantly interrupted every thirty seconds during mealtimes.  Everyone from relatives to pharmacy to doctors to physio does this. The registered nurses at my facility all got together and got on management's case. We pushed for protected meal times. We fought hard. Let's take the evening meal for example: At 6PM the domestics bring the food trolley out and it is the job of the nurses along with the help of the care assistants to get dinner served to every single patient. There are 25 patients and because we are a medical ward that has a high number of elderly patients most of our people are either too sick to feed themselves or too confused to just too old. Usually we have anywhere between 8 and 20 people who are identified as feeds. Each patient takes about 20 minutes to feed. Some are faster and some are slower but we will work with the average. Many have no appetite.

If I take 2 patients that is 40 minutes down. The other nurse takes 2 patients and that is 40 minutes down. The first HCA takes 2 patients and that is 40 minutes down. The other HCA tries to feed 2 but also tries and manage all the people asking for the toilet, ringing the bell during this time. There are 2 Registered nurses and 2 care assistants for 25 patients IF WE ARE LUCKY.

That means that the best case scenario is that 40 minutes after the trays have been dropped onto the bedside table only 6 people have been fed and the rest have had trays sat in front of them going cold for 40 minutes while they stared at it.  And remember that the phone is ringing off the hook at this time and we have no ward clerk.  Remember that pharmacy is showing up with controlled drugs and demanding that a Nurse instantly stop what she is doing to check those narcotics in....god forbid if the precious pharmacist gets delayed or GASP has to do it herself.

The example I wrote above is best case scenario. It really is. But the reality is this: People will become extremely unwell around mealtime unexpectedly causing me to have to haul some serious ass and stay focused on them in order to carry out the doctors orders and not harm them. If that situation occurs the doctor is going to have a shit fit if I leave him and his patient to run off and feed people. That leaves 2-3 to try and cope with all the feeds, and everything else.

The phone rings non stop during mealtimes. Non-fucking stop. We can thank the relatives for that as they get 5 people to ring for the same patient every hour. If you ask them to get one person to ring once day in order to minimize the nurses having to spend all shift running to the phone every 2 minutes they become nasty, abusive and most of all paranoid....accusing us of not wanting to share information. They also like to spend ages giving their dysfunctional family history i.e. "5 different people have to ring because so and so doesn't speak to so and so".

Ringing a ward during mealtimes when your loved one is stable and you have already rung 5 times during the day is very disruptive. The phone is a hell of a long walk away from the patients and the food trolley. I no sooner put the phone down and start the trek back up to my patient before the damn thing rings again. You have no idea how many problems we have with this.  No goddamn wonder they have trays out of reach and food gets cold.  If the patient is frail and confused we may leave the tray out of reach whilst hoping to get back and feed him in good time.  Leave the tray where he can get it and he will choke himself and throw it onto the floor.  We have to hand all the trays out before we can go back and feed.  Have to. Without interruptions this takes 25 minutes.  With all the usual interruptions it takes longer.

I can ignore the phone and try to carry on but the last time I did that management got a complaint from a relative about us not answering the phone for an hour and we got a disciplinary. No they won't fucking pay for a ward clark to be sat there on an evening answering the phone.

The other day the daughter of one of the 30 patients rang and demanded to speak to the Nurse immediately.  I was trying to feed 3 patients at the time as well as monitor a patient with a head injury.  She demanded that I come to the phone even though the HCA told her it was mealtime.  She scared the HCA.  I came to the phone.  The woman wanted to me to answer 101 stupid questions and tried to keep me on the phone.  I told her that I was trying to take care of patients and that it was mealtime it would be best if she rang back later.  "How dare you, I have an appointment later and it would be very inconvienant for me to ring later" she said.  I often tell my friends and family that you are in more danger from you Nurse's other patients' relatives than you are from a bad nurse or doctor.  I managed to get off the phone with this bitch and when I got back down the ward my head injury patient was on the floor again.

One of the ways I try and sort this is I really start moving my ass at 4PM...or as soon as I finish sorting out all the things that should have been done during the day. If I have been lucky I have sorted out all the day shift problems by that time. It is a losing battle but I try.

I try and knock out every med /IV and otherwise that is due between 4:30 PM and 6:30 PM. There are tons of them each with a problem. Half the time the stuff isn't there and I have to leave my patients to leg it to pharmacy.

I also spend that hour and the half giving pain meds to anyway known to have pain. I ask everyone if they need anything. We try and get everyone toileted. We try to turn and reposition and clean everyone who needs it. I try to do a quick assessment of all my patients (usually about 14)to head off any problems that may rear it's ugly head at meal time. I try to ignore all the interruptions in order to do this and I pray that I will be able to focus on meals when that trolley shows up at 6PM. But relatives and non ward staff piss and moan when they walk onto a ward and interrupt a Nurse and she doesn't drop what she is doing immediately to service their non essential problem. What I am trying to accomplish is impossible but it doesn't stop us from trying. I just want to be able to focus on feeding patients. We all do.

So 6 PM rolls around, the domestic arrives with the food trolley and I don my lovely pinny and start getting trays out. Never mind that I have critically ill patients who need their meds. I did them an hour ago but they want more.  We identify the patients who need help with coloured trays, but we already know anyway. I keep an eye on the health care assistants to ensure that they are bringing pureed diets to people with swallowing problems so that they don't choke to death etc etc. I make sure that the diabetics get a diabetic meal. I try to feed people. We run down to the kitchen getting stuff that patients want that are not on the food trolley. 

Now despite that fact that we busted ass from 4PM to 6PM trying to sort everyone out, that wall now is lit up with call lights ringing. Absolutely lit up. We can keep trying to feed or we can answer the bells. I will try and send one care assistant off to get all of the bells while the 3 of us try and feed. Most people are ringing for things like an extra pillow or a blanket. Things they didn't think of before. Many of them are elderly and confused and to be honest they just forgot that someone already walked them to the toilet 20 minutes ago, or they need to go again because the good old bladder just ain't what she used to be. But man will they hit the ceiling and complain if they wait awhile for the nurse to come.  Family members who rang at 4:30 ring back again to answer the same dumb questions.  For the love of god we have no idea when the doctor is coming, when discharge will happen, when pharmacy will bring those meds or when the ambulance will come.  FOR THE LOVE OF CHRIST THERE IS NO WAY FOR THE NURSES TO KNOW THESE THINGS.

The phone is ringing non fucking stop. I am ignoring it even if it means trouble later. I am determined to feed these people.
Five minutes after the domestic brought the trolley out the lady in bed 3 has had a bowel motion in bed and due to her dementia has spread it everywhere. This is a 4 time a day event with this poor lady. She is bedbound and weighs about 19 stone. Would you like the 4 of us (and it will take all 4) to take 20 minutes/probably more to clean her up and then go back to feeding? Or would you like me to leave her like that until I finish feeding the others? Who is feeding the patients whilst the 4 of us are trying to maintain the dignity of the lady who has had the accident? No one. The trays are going cold and the domestic will collect them back in. The bitch.

Oh oh. I do need to answer the phone at 6:10 because the sound of the ring tells me it is an internal call. It is pathology lab. The lady in bed 10 came in this afternoon and had blood taken. She looks like hell. But there is no obvious sign of bleeding. I haven't wanted to leave her side. She has an HB of 5 they say. Look it up. She'll die if I do not get a doc down now to assess her and probably order some blood. She needs obs doing, and tests etc. Then I have to go through a long and complex and time consuming process to get the blood and get it hung. If that was your mum would you want me waiting on that for another hour plus or so while I attempt to feed? Tell me what you think. She needs to be escorted off the ward for a test by a member of the ward staff. The endoscopy department does not care that this leaves 2 or 3 of us to do all these feeds. if we don't send an escort, they won't do the life saving diagnostic test. Now there are 2- 3 of us.

At 6:15 my cancer patient who is dying rings to say that the pain meds she has had isn't helping and you can tell by looking at her that the poor women is in excrutiating pain. It is safe for her to have some oramorph now. I will get it for her simultaneously with sorting the blood for the other woman.  But what about the trays going cold?

The oramorph is a controlled drug. Two nurses have to go through a long and time consuming process in order to be able to access that medicine and give it to her. I will not make her wait. Fuck you for asking me too. I had to pull the other RN away from feeding a patient in order to access the oramorph (morphine). There is no way to access it without 2 registered nurses. Now one care assistant is trying to do all the feeds, the food is going cold and the domestic collects them back in.

But what is the most fucked up part about mealtime? Is it the fact that the domestics are on a tight time scale and will run down the ward collecting all the meals back at 6:30 whether they have been eaten or not? Is it the fact that the relatives will show up at 6:30 with venom shooting out of every pore of their being screaming at me wanting to know why grandpa has a cold, untouched tray in front of him?

No the most fucked up thing at meal time is the goddamn doctors. I look after 14 patients with 8 different doctors and they LOVE to show up at mealtime to do a ward round and demand that the nurse drop what she is doing and follow them around for a half an hour. The bastards do it every fucking mealtime. I hate them. When the nurses asked for protected meal times we begged the docs to try and do their rounds outside of mealtime. The response was that their ward round will get done when it is convienant for them, not the nurses. They also laughed right out loud at us for asking. And you can bet your ass that on every single mealtime we are sure to have 2 or 3 consultant doctors show up to do rounds. Remember that best case scenario I wrote about above? The one where we can at least get 6 people fed in 40 minutes if all hands are on deck. You can fucking forget it thanks to the docs. I can refuse to attend their ward round and keep on feeding. But it means getting screamed at in front of all the patients and a complaint about me going into management.

Whether we have 6 people who need to be fed or 16, the number of staff DOES NOT alter. We get 2 nurses and 2 healthcare assistants no matter what. If I get a contracter into my house to do some work, and it looks like the job is bigger than he anticipated he gets more staff. If a nursery takes more children than the normal numbers on any given day they get more staff. A hair salon has more staff in on their busiest days. This does not happen in nursing.

So I open the newspaper and I see comments galore accusing the nurses of not caring about feeding patients. They suggest coloured trays to identify vulnerable if we are too stupid to know. They all look the other way when the hospitals get rid of nurses and refuse to hire nurses. The coloured trays don't do shit. They don't help at all. You can take your coloured trays and shove them you your asses. Please help us instead of making things worse.

So we begged management for protected mealtimes. We begged them to help us tell the public not to ring at this time. We begged the docs to not do ward rounds at this time if they can help it. We asked a higher power to not allow anyone to crash or become extremely unwell, especially during meal times. We begged management to allow us to increase our numbers. We begged the domestics to not collect the damn meals in so quickly when we haven't had a chance to feed.

Their collective response has all pretty much been : Fuck you Nurse. Fuck you.

Thanks a lot for your fucking support.

The nurses will keep on trucking but if they only bit of help we get is a goddamn coloured tray...then I just don't see things improving.