Sunday, 27 December 2009

Who wants nurses away from bedside care?

Anytime there is a piece about nursing or care in our hospitals on the net there is always some shmuck posting his thoughts about what the problem is.

"Nurses don't want to work at the bedside" 

"Nurses want assistants to do all the real work"

"Nurses want degrees so they can be paid more and not get their hands dirty" 

People who say these things are Shmucks.

I even had one jerk telling me that the nurses themselves were behind the hospitals drive to hire care assistants instead of nurses because "nurses don't want to get their hands dirty".   Ha ha ha.  As if nurses could dictate to the hospital who they hire.

Nurses were forced away from the bedside.  They did not leave the bedside because they hate patient care.
I wrote another letter to a manager.  I tried to explain that we have more patients than we can handle etc etc etc.  That more care assistants than nurses  on the team means death and is not at all cost effective.

I actually got a response.  But all it does is show that he doesn't have a clue. Nor did he really read my letter.

"Nurses can either take a three year diploma or a four year degree course although there are moves to make all nurses take a degree, and I imagine part of the push behind that is to increase the starting salary. It will also probably mean more assistants on the ward, as the move to make nursing into a more clinical role will mean that the more hands on tasks will devolve to HCAs. This is a shift that has been happening for many years (alongside moving tasks from doctors to nurses) as it reduces costs at the same time as encouraging specialisation."

Fuckhead thinks that "dumbing down" reduces costs!  It doesn't. He wants me to "specialise" and play doctor while the HCA's screw up my patients' nursing care.  As a matter of fact I am sick and tired of having to play doctor and order diagnostic tests etc because it is taking us 10 hours to get a doctor to see our patients in hospital because there are so few doctors.  Example: If the nurses do not order the INR tests for warfarin control then they won't get done for a week. 

I have never seen anyone miss a point so massively.

It was NOT the nurses who did this people.  It's not about the nurses  "not wanting to get their hands dirty".

Edit 28/12.
Clueless management types have destroyed the level of care in our hospitals and driven nurses away.  I agree with the commentator who said that nurses need to be indpendent contractors...was it Suzanne Gordon who first said this?.  Nurses should be independent contractors and move away from this government run crap. It's worse than corporate run crap really.  Let's not be their scapegoats any longer. Let's no longer allow ourselves to be put in situations where we cannot do our jobs.

Saturday, 26 December 2009

Nice resource about RN staffing ratios

Remember two things:

1.  NHS nurses on general wards have anywhere from 10-30 patients.

2.  A health care assistant is not a nurse.  Whenever we are using the term nurse on this blog or in research like the following we/they are referring to RN's.  If you are not licensed to practice you are not a nurse, even if you are wonderful caring person who works in the hospital providing patient care.  You are not a nurse unless you are licensed.  And you are not licensed if you did not go to university.  Unless, of course, you are older than Methuselah .  But if you qualified as a nurse without university you are probably long dead or at the very least retired.

Nice one. And the conditions over here are triple brutal.

Hope everyone had  a nice Christmas.  I'm a bit busy but will be back to blogging and answering emails soon.

Saturday, 19 December 2009

Unsafe Staffing: Time to Jump Ship.

I have a meeting with our chief nurse next week.  Again.  Let's hope he shows up this time.  I am going to ensure that my words ruin his christmas.

I am sick of nurse leadership.  They don't have a clue.  They don't know what to do.

I'd like to organise something like this for as long as I stay here.

Recently worked a 12 hour shift.  There were two staff for over 20 beds.  That was it.  Twenty heavy medical patients that mostly required two to transfer, multiple IV's, patients with dementia constantly falling out of bed, 10 or 12 of them crying and screaming for a nurse all at once all shift.  WE couldn't even physically get to any of them 90% of the shift.The shift after us had one nurse.

Our sister ward had one member of staff.-an RN and that was it.  A 35 bed surgical-ortho ward had 1 nurse and 1 care assistant.  Express medical admissions had 2 people staffing it for 12 hours.  So basically I had it good.  My patients are a lot more stable and there were 2 RN's.  Horrendous but better than other wards.  I have never had so much back pain in my life.  I am in agony and can barely sit still while I type this.  Merry fucking Christmas.  Decent hospital management is supposed to invest in frontline staff and regular staff pools as well as on call staff.  They cannot invest enough in this kind of thing and it would save them money in the long run.  But instead they let everyone go, and try to band aid everything with agency care assistants (NOT NURSES).  Then they refuse to allow us to call agency anyway.

A couple of Patients were on the phone (mobiles) to their families about the lack of care.... who then got all upset and tried to ring the ward and speak to the "nurses" to find out what was going on.  The constant ringing phone just took us away from those patients even more.  They complained about us if we didn't answer the phone, but when we did leave the area where we could see the patients to answer the phone our patients got hurt.  Not one of those family members rang management to complain about staffing levels.  They just laid into the nurse who was trying to get away from the phone and get back to the patient area.

The site manager (nurse supervisor on duty) did what he could.  There was no staff anywhere in the hospital to pull from.  He tried to come to each ward for some minutes and take over to give each staff member a quick break. He did this all night.  No stopping for him.  Twelve hours is a long time to go without food and water and constant cognitive overload.

A teacher, office worker, etc would have lost their rag after 10 minutes. Imagine a teacher's reaction to having to work 12-14 hours non stop in an area of education that they were not used to teaching.  Then give them 30 kids they never met before. Then set it up in such a way that they are having to leave their classroom every 2 minutes to answer the phone and speak to families members of their pupils.  When I call my kids' school I leave a message for the teacher and she rings me back in the next day or two.  And it's not like she has life and death situations to walk away from in order to answer the phone!  Imagine if a classroom teacher had to run to the office and answer the phone every two minutes and imagine if this action could get one of her pupils killed.  Then imagine that her headteacher was threatening her with disciplinary action every time the phone didn't get answered while refusing to hire admin staff. Teachers would run a mile in this situation.  Run a mile.

My patient had a reaction to a drug.  Scared me enough to really make me tremble and get nauseous.  The drug I needed to stop the reaction was not on the ward.  Pharmacy was closed.  I had to leave him and my other patients and ring around until I found a ward that had the drug.  The only other member of staff had a bleeder and we were dealing with that as well.  Could not leave the ward. My patient was not crashing out but very unwell.  Believe me when I say we could not leave that ward. Add a dozen 90 year old patients to the mix screaming for their mamas over and over again and you can get a feel for the situation.

But then I had to ring around and find a ward that had the drug and enough staff on duty for one to leave and bring it to us.  Couldn't leave my ward with only one person.  God knows what the porter was doing.  He said he couldn't get the drug and bring it. I asked him what he was possibly doing that was more important!  They are fucking porters for christ sake not professionals with accountability.  Rather than waste time arguing I went back to ringing wards and found one with 3 people on duty and my drug.  They legged it up to me.  It took me way too much time on the phone to obtain this drug in an emergency situation. 

When the ringing relatives managed to get their call answered they pissed and moaned about the line being busy for so long, the phone not being answered right away....keeping me away from the patients even longer to give me an over the phone bollocking.  These people must have some level of mental retardation.  Morons probably think I was on the phone chatting to one of my boyfriends.  Remember that everything these idiots ever learned about Nursing comes from the Daily Fail and No Angels.

We are getting no help from the NMC, the unions etc.  

Make no mistake about it, nurses and senior nurses have been reporting these issues and believe me the NMC will to go after frontline staff.  If the NMC, the RCN, and Unison say that we haven't been whistleblowing  then they have confused me completely. Those in a position of power will not even acknowledge the staffing issues and the antiquated system/layouts/and ward set up nor will they acknowledge other management failures.  Our incident and grievance forms are probably being used to light some administrators oven.  Too many NHS nurses cannot function at all in their working conditions, not even the good ones.

They are only focused on going after individual nurses.And like the public they are blind to the real issues.  They just don't want to face it.  It's more fun to go after the frontline nurses who are trapped in a situation where they cannot function.

It's time to jump ship.  I have said this for a long time but have not been pro-active about it.  But the housing market is improving.  Had a long talk with the other half recently. He hasn't got a transfer back overseas yet that we have been waiting for.  We are not waiting any longer.  I hate to mess up his career in this economy but he is packing it in and we are getting out. It's a big thing to ask.  But he understands and is supportive.  At least someone (who is not a nurse) is understanding and supportive.  I am sure that somewhere in the NHS there are wards functioning well...but they probably won't be for long and I am not going to risk it.

Sunday, 13 December 2009

The Slovenian model of care

Wake up and smell the coffee with Ronald Reagan circa 1981.

Correct me if I am wrong here  (really I mean that) but isn't this model of care pretty much everywhere except western Europe.

Currently, the residential homes in the UK are  little victorian townhouses with lots of steps. The staff is comprised of care assistants.  Once those patients deteriorate and age enough to the point that they are confused and /or cannot mobilise they get sent into hospital and wait 8 weeks for a bed in a nursing home.  The minute a patient becomes confused suddenly or mobility deteriorates they are sent into hospital. 

The nursing homes here are wee little old victorian townhouses with lots of steps.  They have RN's on duty 24/7 as well as care assistants.  But, they do not take patients on IV fluids of any kind, they cannot give IV antibiotics and if a patient needs a chest xray they get sent into hospital. Many of them will not cannot take peg feeds etc. 

Is it really any goddamn wonder why are acute medical hospital floors in the NHS are 75% nursing home patients who are very demanding but not acutely ill?  Their relatives expect them to be cleaned and fed and entertained constantly.  They don't seem to realise that the hospital is only staffed with just enough nurses to barely keep on top of all the IV meds for the 25% acutely ill.  The hospital is the worst place for any medically stable but dependent elderly person to be. Duh.

Are they really just figuring out now that this set up is bad and that they need to "modernise"?

They should have figured it out in '81.  No excuses.  The NHS should have planned for his and implemented something before Reagan was shot and anyone ever even heard of Madonna.  Here we are in 2009 and suddenly they wake up?  Fucktards.  And nurses are taking the heat for the elderly getting poor care? Christ.

I worked in a "long term care" facility- in lets say- Maryland many many (more than 10) years ago.  It was set up very similiar to what is described in this article.

Ground floor was physio, OT, patient entertainment, restaurant etc.

Floor One: residential care with 60 beds.

Floor Two: EMI with  60 beds

Floor Three: nursing home with 60 beds

Floor Four. 30 beds. Skilled nursing unit for patients needing IV antibiotics, blood, IV fluids, Peg feeds, complex pressure ulcer management etc.  This was to keep extreme geriatric patients out of the hospital unless absolutely necessary.  Hospitals are the worst place for medically stable but extremely geriatric dependent patients.  The hospital staff cannot cope with acute patients and nursing home patients at the same time.  They are not staffed too cope.

Floor four had another 30 beds.  This was ultra skilled nursing care: long term patients on ventilators etc.

The local area was full of such homes.  They were known as nursing homes.

Sometimes patients needed to get sent to hospital.  But 24 hours a day we had a respiratory therapist on staff at the facility.  The GP's and specialist doctor surgeries  who were responsible for the patients did daily rounds and always had one on phone duty to give the nurses any orders required  We had a guy with a mobile x-ray machine and we could get one done 24 hours a day.  We had a phlebotomist who came in to get the bloods that needed to be taken every morning.  We had our own pharmacy.

If a patient became confused we checked their temperature and dipped their urine...maybe got the doc to order a chest x-ray from our in house chest x- ray guy.  When elderly people become confused it is sometimes due to an infection.  We could start IV antibiotics and fluids right then and there if that is what the doctor wanted. Other problems like extreme bradycardia and ecg changes would warrant a call to 911 and transfer to the local hospital a&e.   It was the doctors decision. But we even treated DVT's at the facility. he gave IV heparin infusions.  The skilled unit also functioned as a stepdown, rehab area for hospitals to discharge elderly patients too.   If they couldn't care for themselves at home once they recovered they stayed with us and moved downstairs. We took patients who paid privately and medicare, medicaid patients as well as insurance patients.

When a residential home patient became unwell but did not require hospitalization they were moved to the skilled nursing floor.  If their cognitive or mobility issues continued to deteriorate, which is what happens to most elderly people whether or not the decline is accelerated by a disease process, then they moved onto the nursing home floor at this same facility.

The NHS may be looking at this model of care but I doubt they will want to fund it and staff it properly.

At work in the NHS we get many many phone calls from angry family members of our patients.  "The residential home won't take 99 year old granny back because she can't walk now AND IT IS ALL YOUR FAULT BECAUSE YOU LET HER LAY IN BED."  Umm. Granny had a massive stroke.  Anyway Granny will wait 6-8 weeks for a nursing home and develop a pressure ulcer and hospital acquired chest infection.  Much of the time we are not staffed in away that allows us to bathe and feed granny at any point without killing KILLING our acute patients. Sorry.  We (frontline staff) did not create this situation nor can we control it. We aren't the ones who want it to be this way.  We want a controllable workload so we can do basic care for our dependent patients as well as deal with all the other things getting thrown our way.

We get patients from residential homes who are sent in due to confusion, diagnosed with a urine infection, given oral trimethoprim and stay in the hospital for 6 weeks because the residential home "cannot cope".  Yeah it does take this long to sort out another place for them to go on discharge.

Elderly people will deteriorate cognitively and physically. A disease process that you or I would get over quickly will accelerate this decline in elderly patients and most of the time they will not get their former level of function back.  The nurses did not do this to your gran. 

The current system in place for dealing with our elderly patients is a total fail and it cannot function in the 21st century as the geriatric population explodes dramatically.  We may be keeping people alive more now but not always at a level where they can function independently. Don't blame the hospitals and for god's sake please don't blame that lone RN running between 15 acutely ill patients and trying to care for  multiple elderly and dependent patients between giving IV drugs etc.

The system is not set up in a way that they can manage the rapidly growing aging population. 

Look at the system.

Is it any wonder why our elderly community is suffering?  Who still believes that their suffering and lack of care is down to uncaring nurses who require dignity lectures? Some people just need to be slapped and then thrown off a fucking cliff you know.   If only these older out of touch nurses would focus on the real problems rather than indulging in the nursing profession's greatest pastime-eating their young. If only....
Personally, I would love to turf the acute patients and drug users out of my face and sit with and nurse sweet granny all day.  But you would never know it when I am at work and running past these poor elderly patients at 10 miles an hour, ignoring their cries because my pregnant heroin user just shot up in the day room and collapsed on the floor at the same time that some one else has started with a lethal GI bleed.

Am I wrong?  Am I way off base about nursing and residential homes in England? Am I wrong about the ones overseas?  Let me know.  One can still be provincial even if  she has lived all over the world. Seriously.

Owned Part two

Read part 1 first.

So I arrive onto the clusterfuck "surgery suite" at 0800. There was a list on a table of patients due to arrive. Two were already there pissed off that there was not a member of staff there to greet them. The list had 11 people's names on it along with the names of each of their consultants.  Names I didn't recognize.  What the list did tell me was the general order that they would be going to theatre in and what they were having done.   There were 3 charts on the desk.  That means 8 charts are missing.  The charts provide me with names, dates of birth, hospital identity numbers, past medical history, whether they had pre op assessments etc etc.  These are all things that I need to get pre op bloods and all the paperwork done etc.  I was guessing about the pre-op bloods.  The two patients now there did not know if they had any done. Great.  Each patient all need 5 forms filling in for admissions, tpr forms, operation checklists, consent forms, care plans, make identity wrist bands out for each one etc etc.  All patients were told to come in by 9 AM.  The last person on the list was scheduled to go to theatre at 3 PM.

The list tells me that the first person on the list is the first person I need to get ready.  But you have to move fast because theatres change the order on the list without communicating that to the ward staff.   They might just show up at 9 AM to take the patient that is last on the list, and he better be ready.  So it is a situation where you move as fast as you can to get everyone in gowns, the admission and pre op paperwork which must be sorted before they can go the theatre, bloods for group and save etc.  Make sure that they are consented, venflon are in and any pre op medications are ordered and available to give.  Once the doctor has prescribed them you have to harass and chase pharmacy for the drugs.

But without charts it was impossilble.  The first thing I did was tell the patients to change into theatre gowns and sit down while I went to the phone and rang around to look for the notes.  No one had a clue so I had to leave the surgical suite and hunt them down from the wards that they were supposed to go to.  The "never worked in a hospital before" care assistant was useless.  She was offering patients cups of tea!!  They are all nil by mouth for their operations for christ sake!!  She couldn't even do pre op blood pressures.  The patients thought she was a "nurse" and of course laughed  at a typically stupid nurse who didn't know that they weren't allowed to eat.

By 09:30 they were all there and I had all 11 notes.  I was running my tits off trying to get everyone ready along with bloods paperwork and other problems that need sorting before theatre because any one of them could get called to go 1st thing. I started with the people who were scheduled to go first on the list and went from there.  Many of them hadn't been to pre assessment and hadn't been consented which means I had to figure out which docs to page, what there page numbers were and tell them that patients were not consented.  At our hospital they must be consented before theatre, and a senior doc has to do it.

By 10:00 I was getting there.  I had established a good rapport with the patients and my 1st one had got to theatre, everything done for his operation. Yay me.  I hadn't forgot as much as I thought about surgical.  I was having to move quickly though.

At about 10:15 a timid looking young woman walked into the surgical suite.  I asked her name.  She told me it was Miss Doe.  Her name was not on the list.  She was just an extra 12th patient that they sent to me with no warning.  She handed me a letter from the hospital that told her to arrive at 9 AM for her termination of pregnancy that was scheduled for today.  She apologised for being over an hour late. Poor thing.  No wonder she looked horrible.  I felt so bad for her. I had no notes for her.  And I had to spend 10 minutes finding them.

And as I explained in part one I have no idea at all about abortions or they do it by giving them a pill to induce miscarriage?  Do they operate?    Do they do it by sticking a coat hanger up their vagina?  Damned if I know.  I have not a clue.

If I had some warning the night before that I was going to be looking after gynae patients I would have been on google looking stuff up until 2 AM.  But there was no warning.  At 10:15  Miss Doe showed up, she was an hour late, I had no notes or drug chart for her and I know nothing about gynae.  Site manager confirmed that she was indeed going to be my patient and so were a few other gynae patients as the gynae ward was full.

Her notes had just arrived on the ward.  No pre-assessment.  No consent. No nothing and a blank drug chart to boot.  Shit.  I had just stepped over to the nurses station to ring the gynae ward and ask what I am supposed to do with this girl.  First I was going to ring the gynae team and see if they had any orders.   I got through to the gynae team secretary as the docs were not answering their bleeps.  The only thing she could tell me was that the gynae consultant knew this girl was coming to the makeshift surgery suite and was on her way down.

No shit, I couldn't believe my luck.  Having the gynae doc here so quick would give me the guidance I needed.  At 10:25 the gynae consultant walked onto my surgical suite.  The patient had been there 10 minutes.  The consultant immediately picked up the patients notes, glanced at the drug chart and threw it into a wall.  We had the following exchange in front of all the patients, including Miss Doe.  Consultant gynaecologist is in caps. because she was screaming like a banshee.


"Um. Her what?"  "She has only been here a few minutes and I don't have her...."




I couldn't really get a word in edge wise. She went on and on with the above type of stuff for about 10 minutes. I honestly do not know where all of that poison directed at me came from.

  But it did dawn on me that they must give termination of pregnancy patients some kind of vaginal pessary to make things easier.  It sounded like the things come frozen and need to thaw first.  It sounded like it needs to go in a few hours before the procedure to maximize the effect.   Doctors don't always remember to prescribe thing (happens with a lot of things) and depend on experienced nurses to know it needs to be prescribed.  They expect the nurse to know and call them and tell them that the patient is here and hasn't been ordered her whatsitcalled yet.  And we cannot obtain anything important like that without a prescription from the doctor written on the drug chart.

Now I didn't know anything about a pessary until the gynae consultant from hell started shooting her mouth off.   But had I had just a few more minutes with the patient I would have been able to get one prescribed by a doc and obtained from pharmacy.  The gynae ward nurses would have given me a heads up.  If only I had ever got a chance to phone them in the 10 minutes I was aware of Miss Doe's existance....well the 3 minutes out of 10 where I wasn't chasing after her notes as well as sorting my 11 other patients out.  We nurses help eachother out a lot via phone when one is floated to an unfamiliar area.  I had a gynae nurse on the phone to me once as her ward was taking medical patients and she didn't have a clue.  I clued her into many things that the doctors will not write or communicate with you but expect you to do.

The gynae consultant from hell had her gynae junior doctor with her.  Throughout the consultants tirade the junior doctor folded her arms across her chest and glared down at me, and every few seconds she added her two pence worth whilst nodding her head.  "yes what you have done is very bad, very bad indeed, very cruel towards the patient, very cruel indeed".  All within earshot of the patients of course.

Now I am perfectly capable of standing up for myself but really I couldn't get a word in edgewise AT ALL and I was not going to stoop to her level.  I had never seen, heard of, or worked with this doctor before.

We had 12 pairs of eyes, merely a few feet away focused on us. Those eyes belonged to my 11 patients and the 12th patient, Miss Doe who was listening intently.  Had they not been there I would have called that consultant a stupid bitch to her face, kicked her in the cunt and walked away.  But they were there.  I got the prescription, I got the pessary, I thawed it out and it was in the patient plenty of time before she went to theatre.  She was fine.  I managed to pull everyting together for everyone else as well.

But the rapport I had worked hard to establish with those patients that morning was ruined.  For the rest of the day they looked at me as if I was some incompetent bitch who wouldn't get them what they needed. 

Wow gynae doc, what a way to make sure that the blame for any fuck ups caused by the unorganised chaos in this hospital will not be attributed to you.  Kudos and applause, even if you are a total bitch.

When I blog on here I often changed details.  No details were changed here .    This happened just as I wrote it, it happened to me, it happens a lot to registered nurses and it is definitely militant medical nurse raw.

But at least it wasn't a fuck up in some area that was really critical and acute, as happens to many floating nurses when doctors don't bother to write out orders or strike out prescribed drugs that shouldn't be given .............drugs that are still prescribed on the drug chart to be given.  The nurses actually do get the heat for that you know.

This stuff happens all the time, and it is the reason registered nurses throw such temper tantrums when they are asked to float.

Nurse Anne Gets Owned by a Consultant PART 1: The Intro

Argghhh.  I hate it when we get moved off of our ward in order to staff one we are unfamiliar with. 

Yeah yeah I am fine. It's been a long time since I got verbally murdered by a doc.  I have been a nurse a long time, I know how to treat a doctor with the respect she deserves (at work anyway) and I know how to get things done  and done well in less than ideal conditions.  I never have any run ins with the physicians.  Of course all that applies to the specialty I work in currently and most of my career.  I am a general medical ward nurse.   I can handle general surgery basics as I spent a few years doing that.  But anything else and I am out of my scope of practice.

Nurses do not graduate from nursing school knowing how to work alone in every speciality.  That is impossible these days.  Impossible. If they  wanted to graduate nurses with that kind of knowledge they would have to keep them  in nursing school for ten years.

Definiting of Floating:  Floating is when a site manager has 3 nurses on one ward and 1 nurse on another equally large floor.  They will send one of the three nurses from the first ward to cover the second.  This is the case even if it is an area that she has no experience in.  They are covering their asses and putting the patients at risk and the nurse's license at risk when they do this.  The NMC tells us that if we are asked to do this and feel that it is unsafe we should refuse. The hospital bosses tell us to float or else.  They will not accept our explanations as to why it is unsafe.  They think nurses merely make beds and bedbath and feel that we should be able to do that anywhere.  Refuse to float and your job is on the line. Float and your license and your patients lives are on the line.

A medical nurse who has only every worked medicine would be like a fish out of water on a surgical ward.  A surgical nurse who gets sent to medicine for the day would be out of her depth.  Sending me to ITU would be like signing death warrants for those patients.  And when they send ITU nurses to general medicine they are in tears over trying to do a drug round for 20 people. In tears.  They cannot handle not be able to assess patients properly and dividing their attention between more than 2 patients.  An RMN cannot function on a general medical floor.  The powers that be tried to use an agency RMN to take a side alone on my floor once.  I would not know where to even begin on a psychiatric floor nor am I at all familiar with the drugs they use etc.

 In the USA they staff their maternity floors and psyche floors  with registered nurses rather than midwives or RMN's and have been known to float those people to work in charge on medical floors.  Not safe.  Those nurses may be registered nurses but if they are working in maternity and psyche they don't know dick about working on a medical floor and vice versa.  They are no longer familiar with those drugs, the diagnosis, the interventions that those patients need etc. It's a mess.  But floating is what hospitals do to try and cover up the fact that the staffing ratio matrix that they use is a joke and it is what they do to cover up the fact that their lack of investiment in hiring and retaining people on the frontlines is a total fail and it is murder.

I arrived to work one tuesday morning to find that there were three of us-registered nurses- to staff my large medical floor along with 3 care assistants. Not enough but better than the usual. 

Then the phone rang.  It was the site manager.  "One of the trained nurses has to staff a surgery suite for short stay and day surgery.  There are just not enough beds and many elderly medical patients who came in overnight ended up in beds on surgical wards.  Those beds were earmarked for incoming surgery patients.   We are putting the incoming surgical patients into this thing we opened up on the third floor and praying that some of the beds on wards are vacated by the time they come out of theatre."

Oh shit.  This sounds like a clusterfuck in the making. The other two Registered nurses I was on with (Julia and Kate)had both floated recently and it was my turn to go.  Yesterday Julia was sent to staff a bay for overflow a&e patients.  She started work at 0700.  She was due to finish at 3PM.  No relief showed up for her as the site manager had no one to send at 4PM..

 It is illegal for Julie or any registered nurse to leave until she could hand over to an incoming RN.  If there is no incoming RN you are legally mandated to stay even if your pissed off babysitter is about to walk out on your 2 year old because you are late.  If you don't stay it is patient abandonment and you will be struck off. She was there until past 7PM.  That is when they finally send her some relief.   She will remain unpaid completely for those extra hours. She was not keen to have another go at floating now that her childminder walked out on her for picking up her kids 4 hours late.  Julia may not have received payment for those hours she was legally mandated to cover unpaid.  But she still had to pay the childminder.

Kate had also recently floated.  She had been sent to colo-rectal surgery.  She had 12 patients there and failed them all because she didn't know that area of nursing nor did she know the floor.  She was just dumped down there with no support.  This is what happens to us when my ward sister staffs my ward with 3 registered nurses.  One usually gets sent away.

Nurse Anne on the other hand, hadn't floated in months.  So it was my turn to run up to and staff the clusterfuck hastily put together "surgical suite".

Oh shit.

Let's set the scene even more.  They hastily opened this place to take overflow surgery patients who were all scheduled to have their ops today.  The place wasn't prepared, there was no notes, I don't really know the routine with surgery any more or how to prep the patients excactly. I didn't know where anything was.  And I was alone up there with an agency HCA who never worked in a hospital before.

And I don't know a goddamn thing about gynaecology anything.  Not a goddamn thing.  Not at all.  I don't even think we ever really covered that in depth in nursing school.  I never worked in gynae in my life.  I have female bits and I know where they are.  That is the extant of my knowledge about gynae.  Just to reinterate, I do not know the first thing about gynae.

And this is where it all went to hell. 

But how badly can you screw up with a short stay gynae patient? It's not like it's coronary care right?

Will continue this later on.

Saturday, 5 December 2009

I am in the wrong job.

Read any of my posts on this blog about long shifts-no breaks- no help- multitasking-being held responsible for someone's death simply because you cannot be at once 10 places=constantly shifting between 12 hour days and 12 hour nights in the same week yada yada yada. Abuse Abuse Abuse.

That's what followed three years of hell at university that made my siblings' teaching and media degrees look like child's play. They'll tell you. Nursing school is something like DOUBLE the material to learn. Then you have to do thousands of hours of placements on top of that.

And I make less than a nanny, teachers, policemen-hell even cleaning ladies charge more per hour than what I earn. Now I learned about another occupation that out earns registered nurses...A DOG GROOMER.

Some Dog groomers can make in an hour what I make during 8 hours at work. For real.

£30-50 pounds for one medium sized dog (not mine) to have it's hair all trimmed, nothing fancy. it takes an hour. How many can they do a day? And they get to focus on one doggie at a time. Other groomers are quoting more money apparently.

Okay I worked 2 unpaid hours at the end of my shift the other day. No choice. Does anyone think that a doggie barber will cut my dog's hair for free since I don't always get paid for the work that I do?

Didn't think so. I still have to pay the childminder to look after my child for hours I didn't actually get paid for so....

God, you should see the look on the childminder's face when I pick my kid up 15 minutes late. She charges a pound a minute for lateness. She gives me a bitter lecture about how unfair it is that she has had to work an extra 15 minutes past her finishing time. My god. She was only looking after one child and she got £15.00 for working 15 minutes late. Twice that same week I had to stay over 2 unpaid hours past the end of my shift because patients went bad and there were no staff (luckily I was able to call Mr. Militant Medical Nurse and he was able to ditch out of work early and get our son-happens all the time-never marry a staff nurse). Staying over like this happens after many many hours of work looking after many difficult people with no break. And god forbid if I don't have a big smile on my face throughout that-the visitors make a bee-line to PALS to officially complain about the nurses looking like sour faced bitches.

Anyway I fired this childminder, but the rest of them are no better. Do people in other jobs really get to leave work on time and get paid for it when they don't? Brats. The childminder can even control how many children she looks after at one time. You won't see her forced to take on 20 of them and then accused of neglect and not caring when she cannot give one to one attention.

Can you imagine if registered nurses billed in the same way that these people do? Can you imagine if I charged £5-6 an hour per patient. I can have anywhere from 10-30 patients for 12 hours.

We should all become independent contractors and charge the hospitals for our services. At least then we could control our workload. I would never contract myself out to take more than 4 -6 patients at a time, at a cost of £5 an hour each. I'll charge so little for the important service I provide because I am nice and also want to be competitive. If the hospital or patient doesn't like me, they can sack me and find another. But really, how could I fail. I could do a hell of a good job as a nurse if I limited my patient load to 4 at a time. £5 an hour to keep your gran alive and care for her needs as well as managing and providing her doctors treatment plan. Even if I only charge what a childminder does I'll still be better off. Who can complain about a registered nurse wanting to earn like a childminder? I guess a lot of people would because if we billed as these people do and also controlled our workloads so that we can do a good job it would probably bring the whole health service down.

Anyway it's never going to happen so I am off to google "how to become a dog groomer?"

I guess I have a bit of attitude today. I think this is the first time I have posted bitching about pay. I usually try to avoid that subject. I have one more negative post coming after this and then a really positive one.

Feeling Sorry for the Kids.

I have done a lot of complaining about the kids. You remember the kids right? They are the untrained youngsters hired off the street, given nothing in the way of useful training and placed on the ward in pseudo nursing uniforms. They are told that they are on the ward to learn and can earn credits to go to university (either 3 year degree or diploma-the only way to earn the title Nurse). What really happens is they are used as cheap labour, they are hired instead of real nurses and no one has time to show them or teach them a goddamn thing. I am a nurse. If I am on a 25 bed ward with 4 other nurses then I have 5 patients. If I am on a 25 bed ward and those 4 other staff are kids rather than nurses, I then have 25 patients to keep track of, troubleshoot and medicate. The latter is how the wards are now run.

The kids work under the direction of a nurse who is "caring" for 20 patients. I put the word caring in quotes because you cannot care for anywhere from 10- 20 patients. That is such a high number of patients that the nurse can barely keep their names straight let alone nurse them properly. The nurse is so over her head with drugs, assessments, IV's, critical troubleshooting, labs, interventions, relatives, admits and discharges, j-tubes, chest drains, NG tubes, unstable patients, coordinating care between physio, OT, pharmacy, social workers and the medics that she cannot even see straight. I am not exaggerating when I say that I cannot go five minutes without having to answer a phone call. This is never ending, unrelenting, never stops for a moment. It's like getting hit on the head with a baseball bat over and over again. No we don't go for more than a couple of minutes without incoming calls from relatives- sometimes 10 separate calls from the same family because they won't talk to each other. They each want to hear it from the nurse- who probably has been on duty for 3 hours and not yet seen her patients.

The kid can not help the nurse with any of this. The nurse is on her own. That means the kid is on his own as well. He is the person most visible to the patients and also the person least likely to be able to help them. They want pain meds-the kid cannot even access the drugs cupboard as he is not an RN. Patients want information and questions answered-the kid has no training-he listens to the handover with the nurses but it all sounds like Greek to him. They want their dressings changed etc etc. He can't do that either. He is constantly getting orders barked at him by an overwhelmed nurse who is doing her best to triage her workload, do all the things that only a nurse can do and delegate anything else to James.

From the almost the very first day that a kid is at work he will find himself trying to deal with basic nursing care by himself for a large number of patients with no theory, no training. Nothing. The nurse he is working with cannot get away from the chaos for 2 minutes to even see her patients let alone supervise the kid. We hate this situation because even though it is 100% impossible for me to spend 30 seconds uninterrupted with a patient or watching and teaching the kid; I, as the nurse ,am still responsible for everything, especially any kid screw ups.

When I came on duty for the afternoon once I found 17 year old James crying in the utility room. This was awkward for two reasons. First of all the small, filthy utility room is the only place for staff to change on that particular ward and James was in there. Second of all, it's rare (for me as an older middle aged woman and a nurse) to have ever seen a young strapping lad reduced to tears at work. Of course I reduced tons of lads to tears in my young heart breaker days, and reduced many doctors to tears with my stupidity but that was a long time ago ; ) Yeah right.

James was pretty upset. He had been on the job a month-was thinking about attending nursing school or looking at some other area of health care at some point and needed a job. When the hospital advertised for paid cadets/apprenticeship he jumped at it.

He was dead keen and seemed like a real nice lad. We liked him from the get go but of course no one ever told him that because we are all so bogged down with negativity.

It's like this all the time: Oh no bed 1 -can't breathe, bed 2- has chest pain bed 3- has maleena bed 13's daughter is on the phone spitting mad and demands that I get my ass to the phone right now and speak to her or she is going to sue and bed 4 needs the commode.

James can only help me with the last thing on that list so it's constantly "James!!! so and so wants a commode".

No one talks to James or teaches him anything because they can't. It's just "James can you do this" or " James I am coming to help you clean up bed 8-oh wait bed 16 has just pulled her central line out of her neck and is spurting blood sorry have to deal with that you'll have to clean up bed 8 on your own or wait for me to stop the bleeding". or "James we really need to turn all 11 patients that need to be turned every two hours" and just as I get my gloves on the phone rings and it is the 3rd family member calling about bed 26 in the last half an hour. The caller is irate over hospital food and keeps me on the line for 20 minutes. "Sorry James-I will try and get down there and help you I swear..oh and bed 10 is crying for a commode".

How about "James, we have 10 feeds I will do these 5 and you do those 5, oh shit bed 11's surgeon is here and is snapping his fingers at me because he wants me to stand there while he sees his patient, and bed 17 is on the floor and bed 19 wants pain killers. Just feed as many as you can and I will try and get there after I sort all that out". Before I even get to sort the first thing out (that asshole surgeon who is actually standing there snapping his fingers to beckon me) one of bed 20's relatives are on the fucking phone again. The 3rd one in less than an hour. That goddamn fucking phone.

Why was 17 year old James crying and banging his head against a wall in the supply cupboard? Was it all this? Nah, he handled all of the abuse pretty well up until today. He did something today and a patient died from it. But let's back up a minute and take a look at James's short career in the NHS first.

From James's first week he found himself looking after 10-30 patients with only an RN to help. He didn't even know where to begin as far as location of supplies, how to bath an immobile but combative patient, the need to moniter intake and output, what hypoglycemia looks like etc etc but he was the one down there with the patients (and visitors)...and he was constantly getting orders barked at him by the stressed out nurse.

Patients would ask James for pain killers. James can't get them or give them and doesn't know clopidogral from zomorph. So he would tell the nurse that the man in bed 10 needs pain killers. She can't get to bed 10 with them because her other patient with cardiac problems has chest pain and shortness of breath and either there is no other nurse or the other nurse is even more tied up. No, you cannot leave a possible heart attack patient for 15 minutes to do everything you need to do to obtain and administer morphine for a stable patient.

James assures the patient that the nurse will bring the pain drug as soon as she can. Two minutes later the patient gets a visitor and they call James over "This is that lazy fucker nurse who hasn't brought me any painkillers even though I asked him over 10 minutes ago" says the patient to his visitor as he jabs his finger in James's stomach.

Patients and visitors are angry that dressings haven't been changed, IV fluids haven't been recommenced, that CT scan hasn't happened yet but they assume James is some kind of nurse and lay into him. He can't do anything but pass on their concerns to the nurse, and she probably can't do anything. It's a nightmare for him. The public sees him as a nurse who is passing the buck. But he is not a nurse. Well, his uniform is identical to mine.

Patients scream at him and blame him for their wet beds when he was singlehandely trying to toilet 5 heavy patients at once, they go mad when their food goes cold but don't realise that James is trying to get 5 people fed while answering call bells and dealing with the alzheimers patient on the floor. The nurse at this point still cannot get away from the chest pain patient or the constant incoming phone calls. She gets it in the neck even more from patients and relatives. Constantly.

They throw water at him, slam tables into him, pinch, bite, kick, (and these are the ones without dementia). The only rock and support he has is the registered nurse who runs past him at the speed of light shouting " Hey you James that your name....will you bring a commode to bed 4 -my epileptic patient is having a seizure and needs drugs to stop it so that is where I will be. After that I will come and help you". But she rarely does come. She rarely can. She is fighting her own battles.

This describes most shifts from week one onwards for untrained but lovely and keen to nurse teenager James.

James held onto his stiff upper lip and did real well until today when I found him crying. A new patient came to the ward that lunchtime. He seemed very alert. The porters dumped him there without letting the nurse know he arrived onto her ward. The nurse was in sideroom 4 and didn't see her patient arrive. The nurse knew that the patient she was expecting anytime could not swallow but she didn't know when he was coming.

She had only received the notice that he was coming and the information about him five minutes before the patient was dumped on the ward. Once you get told you are getting a patient they will show up either in 5 minutes or 5 hours or anywhere in between. Relatives with questions and patient problems were interrupting her every move as she tried to find James to tell him that the new patient coming any time could not swallow and could not stand. This patient would, however, tell anyone that he could do these things and then demand food he could not safely swallow. It was mealtime, and James gave the patient dinner. He didn't cough and splutter right away but instead appeared like he was swallowing. James realised something was wrong after a few minutes and got the nurse. Bad outcome.

Rule number 1: Never ever trust a patient when they assure you that they can safely swallow and eat, even if they walked onto the ward and look healthier than the staff.

Rule number 2: Never ever ever give a patient diet or fluids until you have spoken to the nurse. If the nurse cannot speak to you because she is tied up elsewhere, then you have to deny the patient food and fluids until she can and shoulder all their nasty comments accusing you have being too lazy to get them a glass of water.

I have known these rules for well over 10 years but James of course, did not..or he was under pressure and he forgot. Most kids his age cannot handle running the grill at Burger King very well.

Who is in trouble here? The nurse is in trouble because she is the one responsible for everything everyone does. The fact that the phone was ringing off the hook and nothing is done to protect us from these constant never ending interruptions, drugs were due, and patients were unwell at the other side of the ward, that the porters dunped the new patient without telling her, and that she well and truly meant to tell James that the patient could not swallow as soon as she could mean nothing. The fact that management put staff in these situations and then won't communicate with them mean nothing. The fact that management allow these stressed out and heartbroken visitors to come in and stop these nurses mid step and demand instant service in the time frame they want means nothing. There should be a system in place to communicate with the relatives effectively. The fact that we have to field constant phone calls by ourselves and that patient area is away from the phone mean nothing. And believe me when I tell you that the nurse cannot walk down that ward when visitors are around. You cannot move ahead two feet without "Nurse can I have a word". Tell them you can't (and you really can't stop even for one minute because you are on your way to bed 6 with a drug that is overdue and takes ages to bolus) and many of them go fucking ballistic. They are stressed and scared too.

It's not good for James either. The poor boy is a goddman wreck. He feels totally responsible and ended up leaving his notice via phone message, never coming back. I have seen him in town. Being the cheeky bitch I am I asked him if he was still thinking about nursing school. "Hell no, I am going back to college to study restaurant and hotel management". It's a shame because when he first started he was dead keen and was thinking very seriously about becoming a nurse. I think he could have been good and told him so.

Another new recruit getting a taste of reality, realising it ain't all Holby city, and running like hell.

99% of the time we do a great job when you take into consideration our working conditions. We actually do quite well on my ward. But when the ball gets dropped, holy shit it really drops.

* So much information has been changed in this post to protect the people involved that this post in no way resembles what actually happened that day and confidentiality has not been breached. It is an utter figmant of my imagination but you all get the gist. Lots of people choke on medical wards all the time, including rushed staff nurses (oh yes I did). The situation described in this post did not happen to anyone you know.

Saturday, 28 November 2009

Why has Nursing care changed?

Why aren't the nurses as visible? Why does no one answer my call bell? Why is so little getting done in the way of basic care? Why are so many nurses leaving? Why isn't the care the same that it was in 1980? Were the nurses themselves better back in those days?

Somebody actually decided to do a little research into these issues and determine just what exactly is going on.

You won't find any "too posh to wash" "too clever to care" "needs matron to knock them into line" and "it all went downhill when they started training at university" comments here. Not by a long shot. Not by a long shot. The person who wrote this article knows her stuff and did her research.

I won't post the whole article here (edited to add, I should really as this got way longer than expected) but please, please, check it out. So much is similar to what is going on in the UK.

Here are some excerpts in no particular order. These are just paragraphs here and there that I copied and pasted for those who don't click on the article. My comments in blue. I'd do more but I am getting kicked off the pc by the warcraft brigade.

*The burden of care for nurses, patients, and families has demonstrably increased since 1990.

*This situation has three fundamental causes. The first cause is a profound change in the nature of hospitalization, the kinds of illnesses and conditions of patients treated, and the level of care required. The second is the reorganization of hospitals, which has led to a reduction in the amount of time nurses spend in direct care of patients. The third is the lack of broadly accepted expectations about the caregiving responsibilities that family, friends, and patients themselves ought to assume, both in the hospital and at home, about how this care should be coordinated with the work of professional nurses and other nursing personnel, and about the appropriate ratio of direct-care nurses to patients. This report deals with each of these causes in detail.

*Pressures on families are particularly severe when a patient has been sent home from the hospital after a shortened stay or has received outpatient care for problems that were formerly dealt with in hospitals.

*Nurses report increasing dissatisfaction with their work in hospitals that have cut staff, that require frequent overtime, and that have replaced nurses with assistive personnel. Research has shown that these phenomena are related to adverse nurse and patient outcomes.

*This situation has three fundamental causes.

*The first cause is a profound change in the nature of hospitalization, the kinds of illnesses and conditions of patients treated, and the level of care required.

*The second is the reorganization of hospitals, which has led to a reduction in the amount of time nurses spend in direct care of patients. The third is the lack of broadly accepted expectations about the caregiving responsibilities that family, friends, and patients themselves ought to assume, both in the hospital and at home, about how this care should be coordinated with the work of professional nurses and other nursing personnel, and about the appropriate ratio of direct-care nurses to patients. This report deals with each of these causes in detail.

*Hospitals and hospital nursing have changed dramatically since 1990. Changes in reimbursement and demography have, in turn, added to the pressures on hospital systems, on patients, and on caregivers. Inpatient lengths of stay have declined dramatically (by 40 percent between 1980 and 1995) (Reinhardt 1996), and the average acuity of patients is higher in any given unit. Therefore, every patient assigned to an RN requires relatively intensive monitoring and care—a situation that is complicated by the fact that increased demands for documentation mean that caregivers can devote fewer hours to direct care and monitoring.
Try telling any of this to these old bats who trained in 1960 and haven't been back since 1962. One stupid bitch said that the problems were down to university educated nurses, and everyone else just repeated that statement like a robot.

*Advances in knowledge and medical and nursing expertise have enabled a greater number of seriously ill patients to survive. The shortened length of hospital stays, resulting from pressure from insurers (Or nu-labour targets), means that more severely ill patients are being discharged sooner to nursing homes, rehabilitation facilities, or their own homes. Moreover, the way hospitalization is financed and the growing number of chronically ill people and the aging of the population in general are also affecting hospitals' inpatient mission.

*Nurses, physicians, patients, and families have formed their expectations about care over many decades. Personal experiences, fictional depictions, and anecdotes from family and friends shape notions about care. The concepts care and nurse are both freighted with complex historical and emotional content. Seldom verbalized, this social legacy contributes to the public's expectations about caregiving. That the nature of hospitalization has changed, that demographic changes have brought different emphases to the health care system, that financial pressures have led to restructured and reorganized systems, and that hospitals have had to alter their mission to suit these financial and demographic shifts—all these developments have been received with gloom and anxiety by patients and potential patients and with concern by nurses and physicians.
Well it seems that everyone just blames the nurses for being lazy. Problem solved eh.

*Recent changes in what people can expect from nursing and hospital care have not been widely discussed with the public. Nor have changes been discussed with nurses very often.

**. Nurses represent the primary surveillance system in hospitals 24 hours a day. An adequate surveillance system provides enough nurses to observe patients directly so that they can recognize an impending or actual problem. These nurses are the first to mobilize an intervention that often requires the coordination of the activities of others, including physicians, to save a patient's life. Silber finds nurse staffing even more important than the board certification of physicians, since physicians are usually the second to know about a complication.

*****Consulting firms brought in to help hospitals reengineer their services and achieve cost reductions usually target labor costs. But nurses and physicians often complain that consultants do not seem to understand the complexities of delivering care or to grasp the complex role that nurses play in observing, monitoring, and assessing patients' needs. All too often, cutting professional nursing staff—and replacing nurses with nurses' aides or other assistants—serve as an easy solution to budgetary problems. This is exactly what is happening in the NHS.

*I once had a chance conversation with a man who, I learned, had in the past worked for one of the major consulting companies and had been deeply involved in the restructuring of a number of hospitals. Learning that I was a nurse, he said, somewhat sheepishly, "I'm one of the bad guys." He told me about what he described as his "naive and dangerous period" and was filled with guilt over the restructuring recommendations he had made in his former job. His awakening, he said, had come when his wife had had a baby who required intensive, long-term neonatal care. During the hours and days the couple spent at the hospital visiting their critically vulnerable infant, they had a chance to see nurses at work expertly caring for—and ultimately saving—their child. In the process, he came to understand what nurses do and how important their job is. Well well well. NHS hospitals have been bringing these same kinds of management consultants in for years. Doubt they are remorseful though. They are just out of control. Prejudice against Nurses leads to managers listening to these clueless dipshit management consultants rather than frontline staff who know the score. It's the same everywhere, doesn't matter what country you are in...

*The word care has a variety of meanings, and is used to describe both personal and professional activities. But the professional care that nurses are trained to give is in many respects quite different from the personal sorts of caring that characterize relationships between spouses, parents and children, family members, and friends. Professional caregivers are independent decision-makers, whose autonomy of action is legally defined, and they are highly educated specialists who act in accordance with expert knowledge and in ways appropriate to their responsibilities.

*When a person's daily life is seriously impaired by illness, age, or disability, he or she may require the assistance of nurses—whether in a hospital, a nursing home, or at home. Unfortunately, many ambulatory settings are poorly suited for nursing activity, a situation that calls for an even higher level of professional knowledge and judgment.
In other words, care—the kind of care that nurses render, sometimes under difficult circumstances—consists of much more than giving patients confidence, assurance, and comforting words. Nurses base their practice on exacting professional standards.

*The complexity of the care given by professional nurses, however, is only poorly understood by the public at large. . Because "caring" is such a ubiquitous concept, and because the word is used so loosely, nursing care is often seen as intellectually undemanding, a "soft" profession. And this perception has been bolstered by the fact that historically, and in many nations, young men have been forbidden or discouraged from entering nursing, leading people to see nursing as "women's work" and a second-class kind of career. That nursing has been so demeaned has led men and women both to discount it, rejecting careers in professional caring for more powerful, economically rewarding roles.

**Chief nursing officers told Gordon that nurses' greater workloads occurred mainly because patients were in and out of the hospital so quickly. Administrators said the same thing, but their agreement did not seem to translate into support for bedside nurses. Staff nurses complained of a lack of support from nursing administrators and said they felt they were reliving failed nursing delivery models of the past, such as less expensive substitutes and team nursing.(Oh Nurse Anne could tell you all about that) They said administrators blamed them for being inefficient, dismissed them as complainers when they reported problems in patient care, and constantly challenged data culled from their daily experience in providing patient care

*In addition, Sovie's study reported a declining number of RNs involved in direct patient care and a growing number of UAPs participating in patient care. (The study also showed that UAPs are being assigned an expanded role in providing patient care.) Although reductions in the number of RNs were intended to reduce costs, Sovie's findings showed that costs per day/discharge were influenced by hours worked per patient day (HWPPD) and paid full-time equivalents (FTE). Thus FTEs and HWPPD were the expense drivers, not the percentage of RNs. In many instances, as RN percentage went down, both FTEs and HWPPD rose since, with fewer RNs and more unlicensed personnel on staff, it took more people more hours to deliver care.

*The majority of these changes were cost driven; however, costs per day/discharge decreased as the percentage of RNs increased. That reengineering does not necessarily improve performance but can in fact be detrimental to it was also found in a study that examined cost per patient day at 2,306 urban medical/surgical hospitals with 100 or more beds (Walston 1998).

*It is difficult to ascertain the overall skill level of nursing staff at restructured hospitals. The American Hospital Association stopped collecting data on aides in 1993—just as hospitals had begun substituting aides for registered nurses—because, it said, hospitals balked at completing the survey (Aiken 1999). The AHA still collects data on RNs and LPNs, but, as aides are melded with other hospital personnel, it is no longer possible to calculate the nursing-skill mix.

*The training of the aides who are replacing RNs is not regulated by state licensing boards. There are no minimum requirements governing the amount of training aides or "cross-trained" workers must have before they can be redeployed (at least part of the time) to do nursing work. Training periods can range from a few hours to perhaps as long as six weeks. Ninety-nine percent of the hospitals in California reported fewer than 120 hours of on-the-job training for newly hired ancillary nursing personnel. Only 20 percent of those hospitals required such aides to have a high school diploma. The majority of hospitals (59 percent) provided fewer than 20 hours of classroom instruction, and 88 percent provided 40 or fewer hours of instruction time (Institute of Medicine 1996).

*In April 1999, nurses at several New York hospitals went on strike to protest patient loads and work hours that they deemed dangerous. In a complaint to the National Labor Relations Board, the New York State Nurses Association reported that nurses were sometimes working 20 hours out of 24 and caring for as many as 18 patients (New York State Nurses Association 1999). Many other reports tell similar stories: of nurses dealing with ratios of 1 RN to 10 patients on the day shift and 1 to 15 or even 1 to 20 on some shifts (well that sounds almost as bad as what is normal in the UK, those are our regular numbers), of nurses being expected to work double shifts, and of a growing demand that nurses work mandatory overtime.

*Anecdotal reports from nurses, doctors, patients, and families suggest a dramatic decline in the availability of professional nurses to care for acutely ill patients while hospitalized and during the immediate post-discharge period. Most of these anecdotes contain bitter complaints about the lack of nurses to meet the increasingly complex needs of patients and express genuine concern (often outrage) about the decline in the quality of care provided to vulnerable patients.
Mostly this outrage is directed straight at nurses who are caring for way too many patients at one time. Nurses are told that the failures in care are down to their laziness, their stupidity, their uncaring slovenly attitude.

* Nurses, physicians, and chief nursing officers all agreed that they could no longer provide the level of care given in the recent past. Both nurses and physicians reported that heavy workloads caused nurses to postpone or miss tasks, and nurses described a troubling erosion of their capacity for empathy because of the difficulty they had finding time to provide even basic physical care. The combination of crowded schedules and inadequate staffing permitted little or no time for education or mentoring of neophyte nurses.

*The experts did, however, make the following positive recommendations for action by public-sector regulators:

Establish standards for safe patient care, while acknowledging the extraordinary difficulty of doing so.

Establish training standards and competency (certification) exams for previously licensed personnel, through both national and hospital-based strategies.

Find new ways to regulate the sites in which nurses practice. Such regulations might include requirements that address the issues discussed in this report (for example, closing beds when RN staff is reduced below a particular level and adding clinical nurse specialists to units).

Require that clinical assignments be given only to persons qualified to perform them.

Require that all staff performing clinical tasks be properly identified.

Encourage state legislatures to establish commissions on nursing to address issues of regulation as well as the adequacy of the supply of nurses, as has occurred, for example, in Maryland and California.

Create a nursing assignment registry that provides information about training and background in ways that earn the respect of members of the profession and others.

Establish licensing requirements that reflect the different capabilities of nurses with different educational credentials, in response to employers of nurses redesigning jobs and rewards that reflect differences in education.

*The experts offered the following recommendations to address the issues:

Adopt the ANA Principles of Nurse Staffing, either as an industry standard or by regulation.

Require hospitals to report nurse-to-patient ratios publicly on a regular schedule. (Note: This is not a recommendation of required nurse-to-patient ratios.)

Establish protocols to prevent the circumvention of technologies designed to prevent medical errors (for example, turning off alarms that would alert staff to problems).

Establish a more effective standard hierarchy of expertise in nursing service; in particular, establish as a norm the strong presence of persons with substantial recent clinical experience at the highest levels of management as well as in team leadership in patient care areas.

Provide opportunities for education and career progression for all hospital positions. Encourage hospitals to improve working conditions in order to be eligible for Magnet Hospital Recognition, awarded by the American Nurses' Credentialing Center.

The experts recommended that policymakers in government, provider associations, and nursing should:

Improve working conditions, compensation, and benefit packages for nurses to encourage long-term institutional employment, so that nursing can compete more effectively with other professions.

Tie repayment and forgiveness of educational loans and grants to the recipient remaining in nursing, in hospitals and other health care agencies, for periods of time related to the extent of support granted.

Make nursing education more efficient by reducing the number of nursing schools in hospitals and community colleges and increasing capacity in baccalaureate and graduate degree programs. See my posts on patients of degree educated bedside nurses having highter survival rates.

It's an excellent article. It's not that long. You can read it in 5 minutes. Check it out of you get a chance. I am so sick that the changes in nursing care in hospital being blamed on uncaring, overeducated, lazy nurses. Nurses are just a soft target eh? Why is that? Why is it so easy to target Nurses? That answer can easily be found in the history of Nursing. That's a blog post I am still working on.

Thursday, 26 November 2009

Nice Headline about Nurses Daily Mail

No doubt whatsoever that there were issues with Nursing care at Basildon.

With the kind of trained nurse to patient ratios that British nurses are working with I am not surprised. I wouldn't expect a nurse with superpowers to do any better. I have worked in 3 countries as a nurse over a period of 13 years. Let me remind you of something. Nurses in the UK are working with trained nurse to patient ratios that wouldn't be legal in a 3rd world hellhole like Haiti. Not only that, but they have a lot less back up than say a nurse in Canada or Australia would have.

I once asked asked a super american nurse friend of mine if she would take on 15 acute patients. She is a bedside nurse, very well respected and has won multiple awards. She would tell you no way would she take on more than 6 acute patients with no back up because it would be nothing but a total fail, no matter how hard she worked. She would refuse to work in a hospital like mine that can assign a nurse anywhere from 10 to 30 and upwards patients. This statement came from a nurse friend of mine in the North East USA who won an award for most compassionate nurse at her Magnet Hospital. Google Magnet.

No one in their right mind would expect a nurse to be able to function in the conditions that NHS nurses are working in right now. Whether they are angels or devils, they are going to fall flat on their faces and fail. Therefore we can conclude, once again, that most commentators on the daily mail are lunatics.

I'll let my readers take this apart in the comments section. I don't have the energy right now.

What have I learned from this article? Journalists still don't understand that most of these "nurses" are not actually nurses.

The daily mail is such an extreme example of Yellow Journalism that it would even shock William Randolph Hearst with it's vileness.

I also take offense to the fact that they are depicting nurses as lazy. If you are an RN in acute care you WILL be working many 12-14 + hour shifts without taking any kind of a break. The health care assistants and clinical support people running around in their nurses uniforms don't go through this but Nurses often do.

12-14 hours without a break or a drink, on your feet while the support assistants stop for tea. It's not like they can help you keep up with the nurse stuff anyway. Remember that most of the readers commenting on this daily fail article probably work 8-9 hour days and get an hour lunch break. Now that is lazy.

Dear Daily Fail,

Interesting piece. I will never so much as have a minute free in shift to screw around with mattresses. If the hospital will provide more staff nurses on shift with me to handle all the drugs, treatments, assessments, orders and accountability then I will happily clean the mattresses. Happily. God I would love a shift spent cleaning and I am very much a degree nurse.

There is a massive difference between a nurse not cleaning a mattress because she is alone and cannot drop the ball on the drugs and the treatments for 30 seconds and a nurse that just doesn't want to do it. The former is a lot more likely and the latter is rare. Cleaning mattresses rather than being the only RN for multiple acutely ill patients sounds rather pleasant to 99.9% of us. You see, we would consider an 8 hour workday without life and death responsibility a vacation day with a paycheck. Especially if it was an 8 hour workday without life and death responsibility and a lunch break. Even if it was only a 10 minute lunch break.

This is what we think of people who work outside of health care and un-registered people who work in health care. You are all having permanent vacation days with paychecks. A nurse I used to work with who left health care to work as a teaching assistant explained it to me that way and so have many others.

An RN can be working at a pace you cannot begin to imagine sometimes for 14 hours straight with no break and still only get through the top 1% of what needs to be done that shift. That means that even if he is working at that kind of pace most of his patients will languish and not get fed or basic care simply down to the fact that the nurse is so outnumbered by people who need help.

I am starting to realise that it won't actually matter if I stop for 5 minutes to get a drink during my 12 hour shift. It won't change a goddamn thing.
Patients are going to suffer whether I do or don't.
Get a safe trained nurse to patient ratio campaign going on or shut the fuck up.

Sincerely Yours,

PS- no one believes that you care about patients. A sustained media campaign to expose the reality of the situation and staff our hospitals with trained nurses would result in a level of care that would have made the idea of starving neglected patients on filthy wards a distant memory. It would also be cost effective to increase your ratios of trained nurses. But that wouldn't give you sensationalist yellow journalism headlines now would it?

By the way does anyone know of a casualty unit anywhere in the NHS where the actual nurses could afford to be lazy for even 10 seconds and then get out of there without being blamed for someone's death?

Tuesday, 24 November 2009

Last post on Nurse Degrees....for awhile anyway

We're all sick of arguing with nutters like Iain Dale and others who worked in a hospital they say...... and weren't even bright enough to realise that they weren't actually any thing like a Nurse.

But I am posting this next piece because I think the author sums it all up quite nicely. This was written by a colleague of mine.


I'm about a week behind the curve on this one, but I've been browsing through all the blog reactions to the news that all nurses will study for a degree from 2013, and alternately laughing and crying.

This is a desperately unfashionable thing to say, but I actually think it's a good thing. I trained in Wales, where nurse training is already all-degree. The news is only bringing England into line with Scotland and Wales. Contrary to what a lot of commentators are suggesting, doing a degree doesn't mean you spend less time on the wards while studying - whether you do a degree or a diploma, a student nurse has to spend over 2500 hours out on clinical placements before they can qualify.

Here's what Iain Dale (described as "insightful, informative and entertaining" by the Observer) has to say about it, in his insightful and informative way.

I once spent a year working as a nurse. There, that surprised you didn't it? Admittedly it was in Germany and was in a private clinic specialising in spinal injuries, but it was still nursing. I had no qualifications, no training and certainly no degree (it was my gap year).

So, Iain, you weren't a nurse at all. You were a care assistant. Don't get me wrong, I'm not knocking care assistants; many of them are brilliant, but they're not staff nurses.

So when I heard this morning that the NHS was now going to insist on a degree before nurses could train, I was dumbfounded. Not all nurses are academically gifted and would want to do a degree. Does a degree in astronomy make a nurse better able to do his or job, than four years hands on training?
Nooo, Iain, they have to do a degree in nursing, not astronomy!

Then there's this guy, who despite being a doctor, still doesn't seem to understand how nurse training works.

The same is the case for nursing training, the ward hours and apprenticeship has been lost at the expense of satisfying politically correct mumbo jumbo spewed forth by educationalists.

But the ward hours and apprenticeship haven't been lost. I'm a degree-educated nurse, and I still had to do my 2500 hours on placements before I could qualify. I spent a hell of a lot of time running around wards doing hands-on nursing to get my degree.

Then I read Melanie Phillips article in the Spectator. Yadda yadda nurses don't want to nurse yadda yadda Florence Nightingale yadda yadda nursing is a vocation not a profession yadda yadda ...then I had to stop before my brain exploded onto my PC monitor. Though I understand this is a fairly usual reaction to reading a Mel Phillips article.

Right now there are many problems with providing nursing care, just to list a few:

- criminally low ratios of nurses to patients on NHS wards. I've heard of some wards where 2 nurses and 2 healthcare assistants were left looking after 35 seriously ill patients.

- more form-filling being forced on nurses in an increasingly lawsuit-happy culture - see also teachers, police officers and social workers

- advances in medicine making the job more technical. Florence Nightingale wasn't running around dealing with IVs, catheters, tracheostomies, all the while mixing potentially lethal medications

- an ageing population making the patients on the wards older and sicker, thus needing more care to keep them alive.

But what is not the problem is that nurses are getting too uppity because they've got degrees. All this is inverse intellectual snobbery that says that clever people can't be good nurses. My experience is that clever people often make for outstanding nurses. They think on their feet, they can problem-solve, they look at new ways to do this, they keep their knowledge and skills updated. All of these things are good qualities in a nurse.

As for the media stereotype of nurses who are too busy daydreaming about their next sociology paper to notice the patient's call bell ringing....they may well exist, but I haven't met any of them. What I have met repeatedly though is nurses who were rubbish at their job because they were ignorant, unimaginative and thick as a plank.



Melanie Phillips article here. Melanie, your ignorance is shocking. That goes for you too Iain Dale.

Monday, 23 November 2009

Minette Marrin revisited: She's still doesn't have a clue.

Minette just wrote an article for The Times. Check it out. I do not believe that she did one iota of research. She doesn't seem interested in getting the facts across. She seems more interested in getting a reaction. Okay I'll feed the troll. I am starting to believe that The Times is a worse example of journalism than the daily mail. Neither the times or the daily fail will acknowledge any letters or offers to write from Nurses who actually understand the situation. If they do, they get a nurse who retired 19 years ago which is pointless really because they don't have a clue. The only one that comes close to trying to present both sides is The Guardian. And believe me, it is tough for me to throw a compliment out towards a liberal anything. I wrote this in 5 minutes as that is all I had to get it in on time and felt I could have done better but I appreciated the fact that they published it.

We first met Minette here. Let's take her latest on nursing apart. It's so vile that I am typing with gloves on. The blue text is mine. The rest is toxic waste.

One of the government’s sillier initiatives was its announcement last week that in future all NHS nurses must have a university degree. From 2013, all would-be nurses will have to have taken a three- or four-year university course to enter the profession. The disastrous consequences of this ought to be obvious to the meanest Whitehall intelligence.

No change there then. You see Minette, for a person to become a legally obtain the title of Nurse and work as a Nurse....they already have to have 3 to 4 years of Uni under their belt either diploma or Degree program. And they have to put in thousands of clinical placement hours doing basic care and much more in order to earn their degree or diploma. Nursing care on the wards has gone south when management decided to replaced real live nurses with health care assistants. Health care assistants have no training, no education. They are not nurses in anyway shape or form. Just because someone works on a ward providing care and wearing a uniform does not mean that they are anything AT ALL like a nurse. Ian Dale and that dude who writes for Devil's Kitchen both say they worked as care assistants. They tell people that they were "nurses" once and are deluded into thinking that they have some kind of insight.

All sorts of people who might make excellent nurses will be put off, and lost to nursing: anyone who is not particularly academic; anyone who — frankly — is not particularly bright; anyone who has a vocation to care for patients without wishing for the most high-tech training; anyone who is unable to take on a mass of student debt on a nurse’s poor pay; any late entrants — and this at a time when the NHS is desperately short of nurses.

Minette. If they are not particularly bright they are not coming anywhere near me as my registered nurse when I am a patient on multiple infusions etc. I have seen too many deaths as a result of stupid mistakes by RN's. Hospitals don't want to hire registered nurses anyway. All they want to do is hire care assistants. Care assistants require no education or training, take no responsibility and are in a position to do more in the way of hands on care. And they get to wear a nurse's uniform. As a matter of fact if you want to care for patients without having to get an education or deal with anything technical then a career as a health care assistant is for you. A health care assistant also has a much better chance of obtaining employment on the wards.

Rare though it is for me to agree with any trade union, I believe the nursing unions Unison and Unite are right when they say that there is no “compelling evidence” that degrees for nurses would improve patient treatment.

Yes there is much compelling evidence. Do your research. Here and scroll down. Since when did Unison or Unite say anything intelligent anyway? Seriously. What the fuck do they know about any of this?

I have come across a great deal of anecdotal evidence quite the other way: that nursing degrees on a university campus with too little practical hospital experience have recently been producing graduates who are all too often, in the words of one consultant, “a liability on the wards” — not necessarily “too posh to wash” but often not much good at it, or at the important clinical observations that go with it.

Degree nursing programs are 50% practical hands on experience on the wards and 50% theory. They have to do thousands and thousands of hours of hands on practicals to earn their degrees. Otherwise they fail and do not graduate. Remember that nursing students at university spend much more time in class and on coursework than their non nursing fellow students. This is the case whether you are a diploma student or a degree student...the only two ways to actually become a Nurse.

And on top of that they have to do something like nearly 3000 hours of clinical placements. Any nurse taking 10, 15,20 patients is going to fail miserably. She can't read the charts, she is being constantly interrupted, she has to accomplish any task that comes her way in the 30 seconds she has between interruptions. Your dumbass consultant friend doesn't have a clue either. He is thinking back to the good old days where ever shift had a nurse in charge with a team of staff nurses providing care and he is comparing today's nurses (who are working alone often in horrid conditions, and sicker patients in a more chaotic environment )with his memories.

To say this is not to dismiss the value of demanding degree courses for any would-be nurse who is suited to intense academic and technical study. Such nurses should be able to take degrees and already can, though one might argue about the nature of the present courses: more than 25% of nurses already hold a degree.

Minette. Anyone who obtains the legal title of Nurse is going to be left alone with too many patients making critical life and death decisions. He is going to have to think fast, and think on his feet. He is going to have to have a hell of a lot more knowledge to do his job than a teacher, PC etc. That is why nurses in other first world countries are paid much more than teachers, policemen and social workers. Oh yes they are. A real nurse working in acute care will have to multi task and prioritise in a way that you are incapable of understanding. You do not fuck around with people's lives.

You seem to think that every person working on the wards providing care is actually a nurse. I think that you are assuming that all the health care assistants are some kind of junior nursing division. You are wrong wrong wrong. Anyone who earns the legal title of nurse will find themselves virtually alone on a large ward with only untrained care assistants who cannot do much. This is what you have to remember.

If I am a nurse on a 36 bed ward with 5 other nurses on duty then I have 6 patients to assess, medicate, take off orders, and care for myself. If I am a nurse on a 36 ward and my 5 colleagues are care assistants rather than nurses, then I have 36 patients to assess, medicate, take off orders, and care for myself. Have you ever tried to even keep the names of 36 people, their medical history, their diagnosis, lab tests due, and drugs straight for 36 people? Impossible. But this is the staffing matrix that management insists on. This is the current situation. This is the shit storm any newly qualified nurse is walking into.

I don't see you or the public up in arms about this. If you want nurses to provide care then why aren't you demanding that your hospitals staff the wards with nurses? You are the service users. So am I. That is why I am fighting.

However, not all would-be nurses are suited to a university degree; just as people vary hugely, so do nurses, so do the nursing roles they are fitted for and so does the training that suits them best. Plenty of the best bedside nurses are not academic, and much essential nursing work does not depend on the dizziest heights of training. There is more than one way to be a “supernurse”, and a degree is not enough.

Are you talking about health care assistants again? No, they don't need a degree and never will. They are the only people that the hospital wards will hire thanks to tight managers. But they cannot do the job of a nurse, so the few nurses left are just covering a larger number of patients who are sicker than ever. A caring, empathetic but thick person would be a disaster as a bedside nurse, but okay as a health care assistant. Remember that anyone who earns the title nurse will be left on their own making critical decisions that require a high level of knowledge. That is what being a bedside nurse is all about these days thanks to disgustingly poor understaffing and increasingly acute patients.

As the nursing unions said last week, “The emphasis should be on competence, not on unfounded notions about academic ability.”

The person who said that is brain dead. He/she does not understand what bedside nursing actually is, and probably confuses bedside nurses with health care assistants. Again.

The health minister, Ann Keen, has been making predictable noises about providing higher-quality healthcare, but the real motivation beneath all this, quite explicitly, is the desire of the Royal College of Nursing and the nursing establishment to raise the status of nursing, and to end the stigma of the “doctor’s handmaiden”.

No what we want is safe nurse patient ratios. I want a small enough number of patients to each Nurse. That will allow her to get the difficult stuff out of the way and do basic care herself rather than have to delegate to health care assistants because she has over 50 IV drugs and to give, a bleeder, and no one to help. The health care assistants cannot help me with drugs, bleed outs etc. I am managing that on my own for 36 people and the doctor on call is ignoring my bleeps. Guess who takes the fall when it all goes wrong. Me.

Nurses — or rather those who claim to represent them — want to have the status of professionals, on a level with doctors, and part of being a professional is having a degree. So nurses must have degrees. All of them.

All real Nurses needed to go through a hellish training at university already and it is very academic. Nurses are going to be working in chaotic situation that teachers and social workers cannot even begin to fathom. People die if nurse screws up. To call themselves nurses they must be registered with a professional body, the NMC, act like professionals and follow professional guidelines. They are accountable to society, their patients, their colleagues, and their professional body. They will be prosecuted in a court of law for a math error that harms a patient. And you don't want to call these people professionals?

So nurses must have degrees. All of them.

All of them indeed. For god's sake love. Your average 35 bed ward is only be staffed with one or two nurses anyway. The other 3 or 4 staff will be health care assistants. That means that even if all nurses have degrees most ward staff providing care will NOT have degrees. Let's see..what do we often have on the ward per shift as far as staffing... one nurse (either degree or diploma) on the ward and 3 care assistants....that would mean that only 1 out of four members of staff are actually trained and educated, even if all nurses have degrees.

They are saying that all nurses will have degrees, not all ward staff caring for patients. The term nurse is not a word that you hand out to anyone who takes care of people, unless you think it is still the year 1846. Nurse is a legally earned title. You are giving people the idea that all ward staff providing care are called nurses and will be degree educated. Not by a long shot love. A few weeks ago a patient of mine asked the health care assistant a question. She did not know the answer. "Damn nurses with their damn university training don't know a damn thing" said the patient. I jumped right in there and pointed out that the young lady was not at all a nurse and has had no training. Then I answered his question. Management brought the health care assistants in. Management did it. The nurses fought this tooth and nail. We lost the fight.

What’s particularly depressing is that this obsession with status is not unique to the nursing establishment; it has become a national obsession, of which this is just one expression.

It’s what explains the feeling that everyone must go to university now and the government’s determination to turn 50% of all school-leavers into undergraduates, regardless of the consequences. (There have been some suggestions that the government welcomes the idea of sending all nurses to university because it will effortlessly bump up the student numbers closer to the promised 50%.) When I was a child only very few people, and only those of supposedly high learning and intelligence, called themselves professionals and had concomitantly high social standing. Now, increasingly, everyone is described as a professional, even journalists occasionally.

No journalists are not professionals. You have to have some kind of moral code and be held accountable for unethical conduct to be considered a professional in my book.

If you want to read any more of Minette's rubbish
here you go. Don't forget to check out the comments section. We are going to have a militant medical nurse competition. Post the dumbest comment that you can find from Time's readers and will can post them here and vote.