Thursday, 23 April 2009

More fun with the kids Part 1

The patients and visitors think that anyone walking around the ward in uniform is a "nurse". How wrong they are.

A nurse in the UK trains for about 3-4 years at uni. I think I doctor is 5-6 years initially. Untrained cadets and carers have zero years of training. Some have NVQ's. I did 4 years at university and then took a licensing exam to qualify as a nurse. I was taught about how to nurse a patient with diseases and treatment plans diagnosed and ordered by doctors. I took microbiology, anatomy and physiology etc to help me understand what I need to know. I have a professional registration and accountability.

First of all, the cadets are not allowed to do the majority of things that need to be done during the course of a shift. They do not have a professional license and cannot be held responsible for any errors. Everything they do is on the registration of the RN that they are working with that day.

They do not have knowledge behind patient conditions, treatments, drugs, doctors orders etc. On my general ward, and many general medical wards throughout the country (hell the world even), the majority of staff on duty are indeed kid types rather than actual nurses. The actual nurses cannot even remember the names of all their patients because they are so overloaded. This is not an NHS only phenomenon.

The kids can do a few things. They can bedbath a patient. They do this as quick as they can. The do not notice changes in condition or plan nursing care around the patients needs.

"Ah", says Nurse Anne as she is bathing a patient "His mobility is impaired, his skin integrity is at risk he needs to be repositioned frequently. His sacrum is breaking down already. He needs an airmattress. Oh look, His left side is showing a dense weakness and there was no weakness yesterday, no history if a stroke. The doctors have been treating him something else entirely.
The doctors might want to know about this now instead of 2 days from now when they do rounds. Can he swallow without choking? I need to make sure he eats safe foods and that he can swallow safely first! He doesn't need aspiration pneumonia on top of everything. He is due to have medications this morning and damn is he tachycardic. O2 sats and temperature are fine. Hmm. He just failed the safe swallow test I gave him using a teaspoon of water. Really fucking failed it, but he is alert. Left side of his face is droopy. He is hypertensive and tachy and cannot swallow his little digoxin pill, or any other meds. He might need a cannula to have his meds/fluids IV since he cannot swallow so I will get that sorted as I call the medic etc etc etc". Shit, I better put a Nil by Mouth sign above his bed so that the tea lady doesn't give him any. He'll fucking inhale that stuff right into his lungs. I could go on for 3 pages about that guy alone. There are many nursing care tangents that I could branch out onto about this fictional patient of mine. It's not my job to diagnose what has happened to this guy, even though it is pretty obvious. I am here to notice changes in condition, make medics aware of changes in condition, and plan nursing care around all that.

But when kids bath all the patients they just do it quickly and run to the next patient. They don't pick up on this stuff. They would bathe a patient as I described above and then throw sandwiches that are hard to chew and swallow at him for lunch and run to the next patient. I am so tied up with all the constant bullshit that I have no choice but to delegate basic care to kids. It fucking sucks. It is like working blind when I don't provide basic care to my own patients. I cannot relay to you here how scary this is for me.

I spend the whole morning with drugs and ward rounds, and phone calls from relatives and at about 12:30 a medic comes across one of my patients with a one sided weakness, facial droop, no history of stroke and a plate of hard sandwiches and half drunk cuppa on the table at the far side of the bed. He sounds chesty too. "When did he get like this?" says the medic. Damned if I know says Anne. I had so many meds to give this morning (took 2 hours), so many rounds (1 hour), discharges (very complicated, angry screaming daughter who wanted her dad out now so the whole thing took forever), constant phone calls from relatives, social workers etc etc (every 10 minutes for 4 hours) and one emergency over the last 4 hours that the kids bathed the patient. The cadets and I walked onto the ward at 0800 into all this plus 15 patients who needed full assistance with morning hygiene and each one takes 10-25 minutes each to do the bare minimum. The morning hygiene and 10 bed baths were the only thing the kids could help me with. Now Anne looks like a tit.

The kids can fill in intake and output charts. If someone has a cup of tea then you record the amount on the intake section. If they pee, you record the amount on the output section. It ain't rocket science and it sounds lame but it is extremely important. People are on fluid restrictions because their NA level is fucked. They may be in heart failure. They may be going into pre renal failure due to dehydration. I need to know their Intake and output and more importantly, the doctors need to know.

But try getting a kid to remember to fill in these charts after they have handed out drinks or taken a bedpan away. It's like pulling fucking teeth.They are in such a rush to get onto the next patient (and avoid complaints from prima donnas who take it as a personal insult when they are made to wait) that they do not document the one thing that they are allowed to document. I want to do it all myself. I do not have eyes on the back of my head. If I did all the care myself I would know if someone has passed urine etc. But I cannot be there every time someone needs to pass urine. It's physically impossible. The kids can be there, it is one of the only things they are allowed to do. But they don't really understand why we are measuring and recording, so it's not all that important in their minds.

I am tied up with too many IV drugs that need to be mixed and given, 3 angry relatives on the phone, a new admission who says she cannot breathe and a patient discharge as well. The kids cannot help me with any of that. But the weights need to be done now. That is something that they can do. They can weigh a patient and write down the number. I have asked them to do it. It's important. They are not going to do it. They don't seem to understand why weighing patients is important. Heart failure patients are weighed. It is always the last thing on the cadet's short list of jobs. Granted that the kids have many call bells ringing all the time, the nurse is tied up with bullshit and the cadets don't want to get bitchslapped by patients who think that they are being made to wait on purpose.

Here comes a consultant showing up on the ward round, seeing the incomplete charts and asking the registered nurse if she is to stupid to fill in a fluid balance chart or a weight chart. "Are these nurses to retarded to document whether or not someone has a wee" he whispers to his junior medic in a gentle yet astonished tone with a posh accent. We heard him. LOL.

Some kids can take blood pressure, heart rates and temperature (obs). They have been asked by me to check obs on all 15 of my patients please. They did 8 of them only. I didn't find out that they only took obs on 8 patients until hours later. They didn't tell me about the pyrexia in bed 31.

"Why did you not take obs on all the patients" says Nurse Anne. "Well the other patients were already done on the last obs round 4 hours ago so we skipped them". Nurse Anne slams her head into a wall. The obs are done every 4 hours to look for changes in condition!!!!

Why didn't I do my obs myself? I wanted too. Again, it is a chance at assessment missed and I feel blind. If I stop at the end of a bed to look at the obs chart all the other patients in the bay start shouting "nuuurse". I need to rely on shitty obs being flagged up for me sometimes. I don't have a fucking choice. At the time that this set of observations were due I was knee deep in bringing a rare surgical patient back from theatre (rare because we don't get a lot of surgical patients), arranging pain meds for a dying cancer patient, taking an admission, and was outnumbered by angry relatives wanting to speak to a nurse. The surgical patient was so hypotensive that I cannot believe they let him out of recovery.... and this is with IVF running fast, and that was taking my time and causing the hospice patient to wait and wait and wait for her next prn dose of pain killers. The kids couldn't help me with anything that was happening during that moment in time....except for that set of observations, bedpans and intake and output charts.

Enter Tara. She's the new kid in town and she is about 17. She is my latest ward kid and she really really doesn't want to be here. Most of the kids work hard and try hard even if they fuck up occasionally. Tara refuses to do things because "it is too disgusting". Tara has no interest in going to nursing school. Maybe she did when she first started, but once she got on the ward and reality set in she changed her mind. But she won't quit. She stands in the middle of the ward and refuses to do anything. We had to get management to get rid and get rid they did (they do come through for us sometimes). But there were a few weeks when things were rough. I was on shift with Tara many times with a full on load of 10-15 patients and only little Tara and maybe another cadet or HCA to help. .

I need to go now. I'll put part one in the title and finish the story about Tara later. I don't know how these get so long.


Anonymous said...

I have a daughter who is recently qualified and working on a ward with staffing problems though not as badly staffed as yours - she happily does bed baths and other basic care despite being told you don't have to do that, but so she can see skin condition etc. Not very long ago, while covering for a much more senior (in years)colleague she looked after a patient whose heels were black - NOT with dirt. Said colleague had been heard to insist very loudly the day before that she could "guarantee that patient's skin is like baby's". The patient was terminal, very poorly - and a query had been made why she wasn't on an air mattress. We never knew that gangrene could appear overnight. It's not just the kids who miss such things - but they sure don't help the situation.

Nurse Anne said...

Hi There,

I think the truth is that we all miss things down to the fact that we are rushing through the baths etc like we are on an assembly line.

I doubt those heals went black overnight. But they can go black quick. Sounds like they were forgetting to look at heals.

Brian said...
This comment has been removed by the author.
Ulrike said...

I am sorry to hear that you have had that many bad experiences with HCA's. But I am a bit annoyed that you seem to tar us all with the same brush...
I have been a HCA for about five years now, with a brief pause in which I worked as an Occupational Therapy Assistant. And I have come across so many caring and lovely Assistants that it really feels like a kick in the gut to read things like this. I initially found your blog when I was looking up articles on nursing stress, because believe it or not, HCA's experience it, too. We are regularly finishing shifts late or start early because we are needed, without pay, out of sheer goodwill - just like you. To say that HCA's all try and wash people as quick as possible and then rush off to the next patient is not true. There might be black sheep among us but that is the same for Nurses. On the Elderly ward I work at, 70 percent of the time it is HCA's who draw the Nurses' attention to changes in the condition of the patient. If they feel clammy. If they are developing sores. If their mobility seems to have gone worse all of a sudden. If they have difficulties swallowing. If their cough has gotten worse and they start coughing up things. Usually we ask the Nurses to have a quick look, but then proceed to collect and send samples off to Microbiology ourselves. If it is minor dressings, we put them on. We do bloodsugars. We try very hard and actually care about our job being well done. And it really hurts sometimes when you read stuff like this.
I have been in situations where at the end of the shift, just before Handover, the Nurse came over to ask us how the patients had been during the day and if there is anything to report - because she herself had only seen them when doing Obs and handing out medications, the rest of the day being taken up by arranging discharges and chasing social workers. So if we are pretty much the eyes and ears of the qualified staff, but yet get told that we are not to write in the patients notes about things we have noticed, then what are we to do? Often you do not get to speak to the Nurses all day. If you take a typical Monday, 30 patients, four carers, alot of them needing assistance of 2, the Nurses tied up first with medications and then with the ward round, later completing paperwork, doing obs, then IV's, then talking to relatives all the time...
If things do not get handed over from HCA's to Nurses, imho it is not necessarily because the HCA does not understand the importance, because they lack the opportunity. We work bloody hard and have had our fair share of shifts without breaks, too, because we were so busy washing, toileting, and helping to feed patients plus cleaning beds doing the menus for the next day doing the tea round doing the weights etc. and at the same time try to spare ten minutes to sit with a patient who is dying but has no relatives in sight.
I understand that a Nurses job is very demanding, but please dont make it sound like HCAs have it easy. It really isnt like we rush to wash patients, just so we can have an extra cup of tea and sit around having a chat.
If I ever tried to do this, it was due to the stress put on us: You will get a telling off from the dinner lady if you are late to serve lunch (because you did your bed baths right) then get told off if you hold her up for too long (because you took your time helping patients eat) you get told off if the bed is not chlor cleaned within an hour of the discharge of a patient, because the Acute Medical Unit wants to send someone up as A&E is about to burst, Nightstaff tell you off if you have not totalled up the menus for the next day even if it was because you were having very poorly patients that took up your time...
Maybe I should stop ranting, as I know that if someone has made up their mind there is no changing it, but one can hope that you will stop making these generalisations. After all, you say you were a HCA once - what were you like?

Amanda said...

I live in the US, and work as an RN in an acute care in-patient rehab facility focusing mainly on hips, knees and strokes(with everything else thrown in to boot).

We have some really great Patient Care Techs(That'd be the HCA's) who are wonderful, but just as overwhelmed as the RNs. Everyone is overwhelmed, with no less than 9 patients at any time, usually 12-14 for the PCTs and 12 for the RNs.

The PCTs who care are good, and I love all of them a lot. The ones who don't, I'd like to shove out a window. Even when they are good, though, things can be missed, because we're all too busy. A lot of things are missed, even by nurses who are acting as PCTs because there weren't enough PCTs that night.

A good PCT makes a nurse's job somewhat bareable, a bad PCT makes a nurse's life hell.

Anonymous said...

I work as an RN in the ED in Canada. I know how frustrating it is to work with staffing problems. We are a 32 bed ED and most often have 85-90 patients at one time in our department, with about 20-25 of our beds being used for admitted patients. We try not to miss things, but when you have one RN for 16 admitted patients, chances are that in a 12 hour shift, something will get missed. We often depend on our senior assists to help us, often times just to help us turn our patients every 2 hours. I find them to be helpful, observant, and aware of the importance of notifying the RN of changes, no matter how subtle. In all honesty, our larger struggle is with the ward nurses who feel that 25 admitted patients in an ED hallway is more acceptable than opening a closed bed on their unit in order to accommodate an admission. I hope you are able to convince your senior managers that patient health and safety is a reason to improve your budget for better staffing and if you do succeed, please give your formula to those of us who are also struggling with adequate staffing issues.

UCL Med Student said...

Wow, just reading that I got stressed.
I know necropost but ouchie.

Sounds crazy.

Anonymous said...

I've met some brilliant HCA's, mind, in my 3 years as a student. Many of them were more helpful than some of my RN mentors at teaching me basic skills, what to look out for and where to record information. My mentors were up to their necks in discharge forms and family complaints and interrupted drug rounds!

Anonymous said...

Yes there are some wonderful conscientious, hard working HCA's who actually care about their patients which is why it is a shame that the antics of a few 'black sheep' spoil things. Like the HCA who used to pull up a chair and sit on the ward, alongside the visitors, night after night when they were attempting to have some precious private time with their husbands, wives, or parents. She would brag about how she loved being "a nurse" adding "it is all I ever wanted to do". The visitors, who were very polite, simply smiled tolerantly. They would not have smiled had they known that when their precious relatives were frantically pressing their buzzers for drinks or bedpans this HCA wasn't on the ward then (where she should have been, monitoring, observing and responding to patients' needs) but taking numerous unofficial breaks in the ward kitchen, drinking tea, gossiping and reading Chat magazine because the professional nurses were so frantically busy that they didn't notice she was missing. Oh yes, and foolishly they trusted her.

Anonymous said...

I have been nursing now for 3months as a newly qualified nurse on an acute medical unit. I have developed a permanent left twitching eye due to stress and survive on 4 - 5 hours sleep a night due to my mind racing as soon as my head hits the pillow. I regulary work at least 1 hour over my shift every day just to catch up with the endless paperchase of careplans, risk assessments, etc.. I have one drug error on my file already due to a doctor writing a medication on a kardex which looked like a totally different med to the one prescribed. Today I had a patient sent to me from A&E with a temperature of 33.4C and scoring 6 on a Mews. I spent the next half hour frantically phoning around A&E, ITU, equipment pool, co-ordinator, bed manager and ward managers for a bear hugger (which I never got). Bleeped SHO, HO,and finally got my patient seen by the consultant who was carrying out a ward round. My patient died 2hours after being admitted to my care. I finished my shift at 16.30 instead of 14.45. I did my best for my patient but i feel I let her down. I go home most shifts feeling like this. My other patients in the bay were upset and distressed. One was crying, not because my patient had died but because she had been waiting for an hour for my assistance to help her to get on her bed. Not wanting to risk a complaint from a relative I strained my own back trying to get her onto her bed alone. I then had to listen to her complain about staff ignoring her requests. I profusely appologised to her to for leaving her sat in her chair. Inside I was shouting [YOU WANTING TO LIE ON YOUR BED DOES NOT RATE HIGH ON MY LIST OF PRIORITIES AT THIS MOMENT IN TIME]!

Anonymous said...

Most HCA's are very kind and caring people who do the job to the best of their ability but through no fault of their own there are times when they lack vital knowledge. Here is a simple example. An HCA was sitting in a chair next to a patient's bed, giving one-to-one care. She was watching the television, which was blasting out at full volume only a few feet from his face, the screen flashing in his eyes even though he had severe brain damage. She just shrugged her shoulders and accepted it when he declined her offer of a drink by mumbling incoherently and pushing the cup away. She didn't realise that the very low volume of urine in the patient's catheter signified that there was a problem i.e. he was becoming dangerously dehydrated, so naturally she didn't feel the need to inform someone immediately.

Anonymous said...

Managing a group of patients. Next job give a particular patient enteral feed after which I need to confirm that the patient's sacral area remains intact. Go into room and find first-year student,(who had been allocated to the team working on the other half of the ward that day)about to commence feeding my patient. Surprised I tell her I need to do this particular task and ask why she suddenly decided to have a go. "Oh the healthcare assistant ordered me to do it" she replies. Irritated, I remind her that I am in charge and the healthcare assistant is supposed to take orders, not give them. Unfortunatgely some HCAs are so used to being given a free rein and the freedom to 'do their own thing' that they forget that they are support staff who are obliged to work within clear boundaries.

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Charlotte Edwards- Medical HCA said...

I'm one of those 'kids' you talk about, a HCA on an elderly medical ward. Thank you for your support and appreciation for all the hard work we do- it really means a lot.

Maybe you have worked with a few HCAs who are lazy and incompetent but, as you know, the majority are not. Our job is thankless enough already without you telling the world how useless you think we are.

'The kids can do a few things. They can bedbath a patient' you say. Are you purposely omitting the majority of our workload? I find that as offensive as you find your uncle telling you you're a saint for cleaning up poo all day (as said in an earlier post).

On my ward, the HCAs are responsible for all the basic patient care: bathing, feeding, 2 hourly turns, making them comfortable, minor dressings, fetching commodes/ bed pans,making beds, cleaning, obs, bms, fluid balances, stool charts, dealing with various bodily fluids, taking samples and dip sticks etc, and generally keeping an eye on patients. We, just like you, do all this whilst stopping patients pulling out cannulas and catheters, escalating when there's a change in a patient's condition, putting out crash calls, preventing falls, and performing first aid when this fails, calming down the ones who scream or get aggressive, and quite often failing and getting hit, scratched, sworn at- for trying to help, as well as running to other wards for you to fetch bags of saline or extra care plans, calling doctors and bed manager and clinical support for you, linnen runs, pharmacy runs, path lab runs, finding the folders and other bits and bobs you loose ten times a day. We try our very best to get all of this done and we care a great deal about the quality of the care we deliver but, just like you, we sometimes won't get everything done. There simply isn't always enough time in the day to do all this, multiple times a shift, for upwards of 20 patients. Here's a question you should ask yourself when next you feel like calling us lazy: When was the last time you saw a HCA sat down?

Our job may be less skilled than yours, but it is by no means easier and without us, you would be lost. Could you imagine trying to do all that and still keep up with your nursing duties? I thought not. And may I add that we do this, over long hours, often coming in early and leaving late, doing extra shifts with less than an hours notice because of how ridiculously short staffed we all are, for little more than minimum wage?

Also, just because we do not have a degree, does not mean that we are completely uneducated.We all went to school and I guess the majority went to college also. I have a multitude of GCSEs and A levels behind me which do help with some aspects of my job, but are not necessarily needed because, as you say, I am not a nurse. However, we do note the patient's skin condition and general wellness as we are doing our rounds. It doesn't take a degree to see when a patient's sacral sore is worsening or to know how to prevent this, we can tell if a patient is getting sob or they're having difficulty swallowing or their general condition in worse than it was last time we saw them. It's our job to look for these signs and let you know so you can do something about it, but we're not allowed to document it anywhere official because we are not qualified to do so (so please, start bloody listening to us instead of relying on the notes). If it wasn't for us, you wouldn't notice half the time because as a nurse you get wrapped up in more important things due to your ever expanding workload.

We understand how demanding your job is and we appreciate you greatly. It really is disheartening to read that you do not feel the same about us. We may be 'just' healthcare assistants, but our role is vital. We deserve the same level of appreciation and thanks as you do, but we receive that even less often than you do: as is evident from this post, we don't even get it from the very staff we are working so hard to assist.

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