Thursday 21 May 2009

Why does caring burn us out?

Found this over at Nurse Ratched's Place.

"Before I sign off, one of my readers asked me to help him out. Edward J Gordon, RN is doing some research for a book and he wants to hear from you. The book is about burnout. I’m sure most of you know what that is. Here’s what Edward said:

I sure would like to understand what’s at the heart of burnout. What is it that kills us about nursing? What is it that makes us so unhappy? Almost everyone I work with is either trying to get into NP school, or CRNA school, or is already taking classes-as if there were some unlimited amount of jobs away from the bedside. I think if I were younger and wanted to leave the bedside, I’d leave nursing altogether, become an IRS agent or something (I like numbers.). It seems like caring kills. It kills us personally to care for others. It turns us into something we are not. But is that a bad thing or a good thing? And is it this kind-of spiritual suicide that’s at the heart of burnout? I’m just wondering.

Please send Edward an email at if you can help him out."

Nurse Anne decided to email Ed. I basically summed up the reason for this blog and made my usual amount of typos due to the fact that I am always in a rush. I know I simply told him things that he already knows, and I doubt that my email is really what he is looking for, but I sent the email anyway.

It went something like this:

Dear Ed,

Why do nurses burn out?

Nurses are expected to take on a ridiculous number of patients. At the same time they are expected to treat each and every patient as if they are the only patient on the floor. It is an impossible task and that is what burns nurses out.

We get the most wicked abuse when we are unable to provide this level of care from patients, families, our managers, the media etc. Here in the UK they will staff a 25- 35 acute medical ward that has a significantly high number of elderly, dependent patients with dementia with 2 RN's only. If we are lucky we may get 2 or 3 care assistants to help. We don't even get a ward clerk to answer the phones anymore as management does not want to pay for it. This is getting normal for general medical surgical floors in the NHS. It is definitely the norm for wards that have a high number of elderly patients.

I cannot remember the last time we had more than 2 RN's on duty for the whole floor.

If you open the newspapers here in England you will read countless articles about the suffering of patients in hospital. They claim that the nurses are uncaring and lazy and that this the whole cause of the problem. They claim that the whole problem is that nurses are better educated these days, and that we think we are above mopping the floors and caring for patient's basic needs. They claim that this is the reason MRSA and cdiff are rampant. This is what people think.

We are often left with critically ill patients during mealtime and 2 nurses and 2 care assistants to feed 18 people. We get a 20 minute window at mealtime to get all the food out and feed the patients. The critically ill patients do not go away at this time. What to do? What to do?

The press and various patient rights groups are claiming that nurses these days think that they are "too clever to do something so menial as feed patients" and say that this is the reason that patients are starving. They hit us up with these insane patient loads and then they say that if we are not sitting at bedsides mopping brows and holding hands it is because we are all cruel. We often work 14 hour days without a break and without stopping and still cannot get anything done. let alone done well.

People do not realise that nurses have life and death responsibility on their shoulders and that every second counts. They place unrealistic and unfair demands on the nurses, and then they lauch direct attacks towards the nurses when their unrealistic demands are not met. This is why "caring" burns us all out. This is why our nurses are running away from the bedside.

I blog about this if you ever want to have a read. I'll just warn you about my language. I do tend to swear like a sailor at times. I don't swear normally, bad language just seems to rear it's ugly head when I blog.


Saturday 16 May 2009

Coloured Coded Uniforms? They won't change a thing.

The BBC came out with this little article recently.

"Colour-coded nurses' uniforms to help patients in Wales recognise who is in charge on hospital wards are being unveiled.
The assembly government said the new unisex scrubs would clear up confusion about who does what.
Ward sisters will wear navy blue, clinical specialist nurses royal blue, staff nurses sky blue and healthcare support workers will wear green."

It's a waste of time. Patients and visitors think that anyone walking around the ward in uniform is some kind of nurse. The fact is that the nurse is massively outnumbered by untrained staff and those who are at a level above staff nurse do not come near the wards. Our uniforms are currently colour coded with a different coloured stripe designating our rank so to speak. I do believe that we need better uniforms and laundry facilities and changing rooms. But I do not have any confidence in the fact that the public understands what a nurse is or understands the difference between a nurse and a care assistant.

When patients need a bedpan or a drink they think the ask for the "Nurse". I would like to be doing those things for people, as I know that they appreciate it and are grateful for any help. But the fact is that if I am in the middle of the drug round, ward rounds, emergencies and I am the only nurse with a few care assistants then I HAVE to delegate these things to the care assistants.

The 3 hour drug round to get everyone their 8 AM medications will turn into a 6 hour drug round if I do not delegate all the simultaneous requests for the commode that I get while focusing on the drugs etc to the care assistants. It's not like the care assistants can carry on with my work while I stop to help with toileting. The vast majority of errors etc that I have seen during the course of my career occurred because of nurses being interrupted for these kinds of things. I am already going to be getting interrupted constantly for things like phone calls, visitors, doctors orders, admissions etc anyway. The care assistants cannot help me with that either.

This leads to patients saying things like "That nurse (the care assistant) was kind enough to stop and help me wash my back but that mean nurse (the lone RN doing the drug round for 15 people while managing someone who needs constant monitoring) couldn't be bothered.

Even if the patients can differentiate between a nurse and the care assistants they are still going to ask for the "nurse" when they want something relatively minor. The nurse is usually up to her eyeballs with constant problems and cannot always get that commode. Nurses have to make quick decisions as to where they can go and when.

Janelle was a colleague of mine who got written up over something like this. She was a lone nurse for the ward with only care assistants to help. It was 7PM and she was still doing the drugs that should have been out at 5PM. She was running between a GI bleed and a COPD (infected excab) patient who was really kicking off as well, very short of breath and looking septic too. She had visitors of other patients up her backside wanting immediate answers. Sitting down with them and giving them those answers would have taken her away from the GI bleed and the COPD patient for too long. She was the nurse and had to deal with it all alone. The care assistants cannot help with things like this.

At one point she was drawing up some antibiotics and getting IV fluids reading for the COPD patient when the care assistant burst into the treatment room. "The woman in bed 3 says she must have a nurse right away. I told her that I am a care assistant and I can help but she says she wanted a nurse straight away". The patient in question often gets chest pain and Janelle thought that this must be why she wanted a nurse. So she legged it to bed 3. "I want a commode, that is why I demanded a nurse" says the woman in bed 3. "I am going to let Lena the care assistant to help with you with that right now because I have a situation with another patient who needs some medications" says Janelle. Cue the patient getting pissed off and complaining as a result of not understanding the situation. Cue Janelle being stupid and getting her a commode to appease her. Cue the medic showing up and pitching a fit because the IV antibiotics and IV fluids were not yet started on the copd patient and Janelle, the only RN, was handing out a commode while the care assistants twiddled their thumbs.. Janelle was complained about by both the patient asking for the commode and the medic of the poorly patient.

Nurses do not mind giving out commodes, cups of tea etc. But we are rarely in the position to do so. We did not create this situation, it is out of our hands. There is a lot of work that can only be done by a nurse and we are severely outnumbered by untrained staff who can really only help with basic care.

Colour coded uniforms are not going to change much. Nurses who are trying to concentrate and focus and get from one sick patient to another with drugs and treatments are still going to get interrupted constantly and asked to deal with things that the care assistants could handle. And we will continue to have mistakes and omissions as a result. I have seen severe mistakes occur because of it.

We are taught to prioritize but we have all walked away from things that we should NEVER have walked away from in order to prove that we are not "to posh to wash". And problems have occurred. I have seen patients harmed because their nurse was off helping other patients to get commodes. They are sensitive to the fact that people are accussing them of being "to clever to care" and then they do something stupid. I have seen more patients hurt by this rather than harmed by uncaring nurses.

Please realise that the nurses are professionals who are overwhelmed with their workload and understand that horrendous consequences can occur if they are not allow to focus and delegate. Please realise this rather than accusing them of being shirkers who are trying to get out of getting their hands dirty.

Thursday 14 May 2009

The Surgeon Who Screamed At Me.

Once I was working on a medical ward that started taking surgical patients when the surgical ward was closed for refurbishment. When we were first told about this we celebrated.

We assumed that the nurses from the closed surgical ward would come to us along with their patients. They were short staffed on their 20 bed ward and we were short staffed on our 25 bed ward. Their ward was closing. We assumed we would get them as well as their patients.

Wrong wrong wrong.

Management sent most of them to staff other parts of the hospital.

One morning I came into work and was handed 5 care of elderly demented patients. They were climbing all over the side rails, falling out of bed and spreading porridge in their hair as well as eating their own faeces. Constantly. Old age and dementia will come to many of us. Looking after a patient such as this is tougher than managing a group of hyperactive toddlers. One patient with dementia was having a blood transfusion and she bit through the tubing and was spraying the walls with it. In addition to that I had 5 medical patients including an alcohol detoxer who was licking the floors and very disoriented. You cannot control and or rationalise with people like this. Not at all. They need someone there at all times or all hell breaks loose.

I also had 5 surgical patients. 3 of the surgical patients were given the go ahead to be discharged at 11AM. Discharges are often multi faceted and time consuming. The patients who are being discharged think that they are the most important people in the world and don't seem to get that the nurse is running between and managing dying patients while she is also organising their free discharge drugs to take home, follow up appointments and discharge letters etc.

The two other surgical patients were for theatre in the afternoon and somehow I managed to get them ready for it, spending about 10 seconds with each one and barking orders about gowns. I wanted to be a good nurse for them but I had to move fast.. Just doing that little bit and taking the time to rush through the discharges caused my elderly patients to be on the floor 3 more times. Those discharges were done in a half ass manner as I was rushing, but it was still enough to cause neglect to my elderly patients. The site manager was up my ass because they had more patients than beds as usual and demanded that I needed to sort the discharges. I know I know, the site managers are getting shat on from a great height. I did ask her for help but she said that there was no one to send.

Before the 3 discharges were out the door the 3 new surgical cases for the afternoon were on the ward. The beds needed to be cleaned and the new surg patients needed to be admitted (time consuming) and prepared for theater (time consuming). They also had a million questions (time consuming). My 5 acute medicals and my 5 elderly dementia patients were still there, doing the same things that they were doing this morning. That won't ever change. The alcohol detoxer was still licking the floor, refusing meds and throwing things at other patients. You cannot sedate people like this. You will hurt them more. Haloperidol is a joke and benzodiazapines are out of the question for this patient.

I do not have the right to get an additional nurse to help me while I am in the middle of this kind of situation. I do not have that right. But the hospital management has every right to dump more patients on me in this kind of situation. I did not create this situation. But I am responsible for any problems and bad outcomes.

Jesus christ it has been a long time since I looked after surgical patients? Am I doing everything right? I never worked with their surgeon before and do not know his ways. All doctors have different ways that they like things done but they won't communicate this. The nurses who work with them regularly just know.

I couldn't focus on the discharges very well because I also had someone with pancreatitis who was going downhill. I did get "forced" to get the discharges done and that is when my pancreatitis patient really went south. The pancreatitis person was critically ill. There was only one other nurse on the ward with me that day. She ditched her patient to give me a hand. It took two of us to monitor and implement orders for this man, that is how bad it was. We couldn't leave his bedside. The three care assistants we had carried on with bathing and toileting. They cannot admit patients, help with discharges or deal with the acutely ill in any way. They were going to make my surgical beds up , get the new patients in them and gown them and get basic observations but the elderly patients were constantly falling. Constantly. The phone was constantly ringing.

At this point the new admit surgical patients were filtering in and the beds were not cleaned. It was only 5 minutes since the discharged patients left. I'll be damned if I am going to leave a dying patient to clean a bed and kiss arse and admit a minor hernia patient for the PM theatre list. "Welcome to Nut ward, You are my only patient and I am here to gently guide you through the journey of having your minor hernia repaired and answer all your questions and bring you tea. Can I shove my nose a little further up your ass please?" Yeah right. I am surprised that management hasn't scripted that one yet.

At this very moment the surgical doctor came onto the ward. He saw that his new admission patients for the afternoon lost were not yet in beds, admitted, or ready for theatre.

So he tries to pull me away from the pancreatitis guy (the patient of another doctor) to scream and scream and scream at in the face, eyes bulging, on his tippy toes...


This is in front of the patients. 3 of them are already pissed off because they have taken time off of work and shown up onto the ward for a long awaited operation and the beds are not ready for them. The first one is first on the afternoon list and he isn't even in a bed or admitted or anything. The afternoon list starts in 20 minutes. There is not yet a bed in ITU for my critically ill patient. What about my other acute medical patients? What about my elderly patients who haven't been given a drink all day? The blood transfusion had yet to be restarted on the woman who bit right threw her first unit of blood. When was that? Over 4 hours ago? HB of 6 by the way. Oh Shit. Getting more blood and restarting that transfusion could have easily taken me away from the others for a long time. Very long time. And she will bite through the next transfusion as well because she has dementia and I will be back with the pancreatitis patient, or the other medical patients, or the surgical patients, rather than in her room.

It is not an exaggeration . It is a normal day.

Where are all these managers and highly paid matrons? Just like ghosts. We know they are there, we just don't see them.

Where are all these supposed "new nurses"? The government is telling people that there are more than ever now.

Why was I put into this position as a former e grade now band fucking 5 medical ward staff nurse?

What kind of a stupid fucktard thinks that a nurse should walk away from critically ill patients, acute patients, and at risk elderly patients to discharge and admit stable minor short stay surgical patients?

How does a fucktard such as this actually get into medical school?

Why didn't management let us have the surgical nurses if we were getting their patients? We would have had to additional RN's on the ward that day.

Why are they so against staffing these wards?

Who was in charge of the ward that day? Me. The only other RN that day has less seniority but we both had heavy and large patient assignments. I had to take the official role as charge even though I was a very overwhelmed primary nurse to a group of patients.

When is this going to end?

It did have a good ending. Kind of. At least we were entertained. I blanked the surgeon. He went even more apeshit at me. This caused the medic of the pancreatitis patient to go apeshit at the surgeon. We damn near almost had a doc fist fight. Those are the best. You have got to get your kicks somehow.

Sunday 10 May 2009

The Uppity Bitch from the DoH. (Northern Doc reminded me all about her)

I read this on Northern Doc and it reminded me of a little story. It happened on an evening shift preceding my night shift.

Once we had some bint from the DoH show up in the middle of a shift. There were 2 nurses and maybe 2 carers to a full fucking medical ward of patients, with all the things that I describe in other posts happening all at once. There are not enough hand washing facilities and they are in very bad locations. The domestics are around for several hours in the morning and on the evening and they have to serve hot drinks and prepare meal trolleys and dish up food plus do all the washing up in a short amount of time. They also have to manage hospital laundry from the ward. Ten bags can pile up in an hour and the domestics have to pack it up and get it to where ever it needs to go.

All the DoH trollop did was constantly interrupt the nurse while she was pushing IV drugs to say things like "You must clean the commodes every hour and fill out this form and that form and put this coloured sticker on that and this coloured sticker on this. Every hour, no ifs ands or butts."

She pulled the nurse off of her 5th attempt to start the drug round "You must wash this every hour, and fill in this form and that form, then fill in this sticker and put it on to show you have cleaned. This colour for Mondays, this colour for Tuesdays etc etc"

She stopped the nurse in the middle of mealtime to ask her to inspect trolleys and trays for cleanliness. Mealtime is when the nurse is still trying to start her delayed medicine round as well as monitor 15 patients and feed 5 of them. And the phone is ringing constantly. And she is trying to answer call bells. The two care assistants were feeding 2 of the 10 feeds on the ward. The nurse was supposed to pick up 5 of them. The other nurse was staying put with a dying patient and his heartbroken family with no back up.

The nurse responded with talking about the things that I talk about on this blog. Nurse patient ratios that are unsafe (triple what is recommended by the International council of nurses, the RCN, and AMA etc) constant interruptions, poor facilities, untrained support staff, lack of management etc.

The bint responded with "It's not really about lack of staff and facilities is it? It's about dirty nurses not wanting to take pride in their work". She cocked her head in a funny manner as she said it, and actually smirked. She said it with a mock syrupy sweet voice. It was sick. One of our care assistants is a hell of a mimic and she repeated it perfectly for me, when I came in for the night shift that night. The very proud hands on nurse was just weeping at this point, as she handed over to me.

This nurse was left speechless by this DoH fucktard. She had just put in a 12 hour day without a meal and she was treading water trying to manage multiple patient problems that were occurring at that time. There was a lot more going on than the meals and the medications. She still had 2 hours to go on her 14 hour shift and would not even consider feeding herself. This nurse has a degree in biology as well as nursing and she has been nursing for over a decade. She is very proud hands on nurse. She is older but she pushes herself every day to do her job and do it well. She thought that she was career changing into nursing to "help people" and that she would be respected for it.

One of the care assistants piped in to the DoH twit. "We are struggling to care for the patients in any capacity and although we don't mind cleaning, we are going to take care of the patients first. Often we work double shifts without breaks etc and we still don't get most things done. Everything is a rush job. Cleaning every hour and filling in five forms and coordinating them with coloured stickers without additional staff will deny the patients any kind of nursing care at all".

DoH whore smirked again. "I suspect that is a bit of an exaggeration. You don't look busy". Again, it was done it a sickly sweet patronising voice.

It's a damn good thing Nurse Anne was not there. I would have gone crazy and I would have gone medieval and nutted her right there, in the middle of the ward, and I would not be blogging about this or nursing ever again because I would be in prison for assault. I would have gone apeshit. I am always professional and gentle at work. Always. No matter how bad I feel inside. But this would have sent me over the edge. At work, I look like a nice little white girl with a smile on my face and a gentle manner. But I could have easily gone jerry springer guest on her.

When the nurse went to see why a patient was collapsed in her chair and diaphoretic, the DoH slut was right behind her, lecturing her about hand washing. And when the nurse ran to the next patient because the care assistant reported that he had a pulse of 35, the DoH cow was right behind her, trying to pull her aside to talk about coloured stickers for commodes and drip stands. And when the nurse sorted that out and headed back to her drug round over an hour late, the DoH skank was right behind her, wanting to observe her washing a bed pan out, to see that she was doing it correctly.

This is what we are dealing with folks. This is how they think they are going to prevent MRSA and CDiff. Leave one nurse to 14 patients and constant interruptions and expect her to clean commodes and drip stands and document it in different places every time.

The tramp from the DoH was NOT interested in the fact that:

Nurse patient ratios are crucial in fighting hospital acquired infections.

Poor hand washing facilities leads to poor hand washing when nurses are trying to literally do 15 things at once.

100% bed occupancy and beds to close together lead to cross infection.

There are too few domestics who have too much to do in a short period of time.

The managers are racing patients up from a&e the minute they find out we have a discharge planned. The porters are in a hurry too, and they just dump the new patient into the old patient's bed. It will only have been cleaned if I had 30 seconds of free time to clean it while I am stuck with someone with chest pain and someone who needs oxygen. We have had to walk away from really sick people to clean a bed because a&e is sending up a neutropenic patient 2 minutes after another patient was discharged. If I don't stop what I am doing to clean that bed the porters will dump the new patient in a dirty bed. Everyone is busy. Targets Targets Targets. As a ward nurse you get admissions when it is convenient for a&e, not when you are in a position to actually care for a new patient. I have begged the manager to hold off on sending admissions for 15 minutes when we are trying to feed patients, or give drugs. It never works. Targets.

We have two working blood pressure/temp/pulse machines for the whole ward which includes people with cdiff and mrsa.

No, the bitch from the DoH wasn't interested in any of this.

But she definitely got a lot of pleasure out of smirking the line "dirty nurses".

I think would have bitch slapped her about 180 times, and then happily trotted off to jail.

I see things like this, and it scares me.

Look, I believe in handwashing and hygiene but let me tell you something. Cdiff and Mrsa and a whole lot of other superbugs are every where. Everywhere. Waitrose, your child's school, colonised on the lady sitting next to you on the train. Stickers and handwashing posters are not going to do a lot about this. Deal with it.

Nurse Interruptions/Staffing Numbers: The number 1 cause of patient neglect

Reading through some comments on Nellie's Shift .

Do people really think that if the workload triples on a shift that I/we get extra nurses? Do they think that if we go from having 3 patients who need to be fed to 15 patients that need to be fed that we get extra staff? Nope. But we may end up with less staff.

If we have all stable patients we have two staff nurses. Those patients go home and we take unstable admits....and we still have 2 staff nurses. One staff nurse pulls her back out during this shift and can't move....she goes home. Now we are down to one. Finding another nurse in the middle of a shift is impossible.

If we did get another nurse in the middle of a hectic shift how the hell would I escape from the mayhem to spend an hour telling her all the information she needs to know about the patients. If she hasn't had report then she cannot function. Who would carry on with all the late medications etc while I stopped to give report to this nurse?

Now we have sicker patients than we did in the morning and only one staff nurse and a few care assistants.

That same staff nurse is automatically in charge during a situation like that, even if she is newly qualified. She is the RN. It's not like years ago where every shift had a sister in charge, a handful of RN's as well as EN's and care assistants. My hospital recently left a brand new grad as the only RN on a large med-surg ward with only 3 useless care assistants. So the new grad was in charge, and she had to do all the patient care that can only be done by a nurse. The care assistants went about their merry way toileting, bathing, and making beds. What else can they do?

So in addition to being the only one who can administer medications, assess, do dressings, nasogastric tubes, trach care, monitor patients, trouble shoot, admit, discharge, do ward rounds, hang iv's and deal with emergencies the lone nurse for a group of patients also has to:

1. Field every phone call. The care assistants don't usually answer the phone, and if they do they just have to go and get the nurse anyway. It's not like the care assistants can take handovers. answer relatives questions, take critical lab results from the lab, talk to pharmacy, talk to social services etc etc.

2. She has to field the visitors questions. I may be the only one to do the drug round for my 14 patients but I am also the only person that the care assistants can direct relatives with questions to. So between phone calls and visitors I am interrupted ever 2-10 minutes on average, all day long.

I am often stopped 30 or 40 times during drug rounds to answer relative queries either in person or by phone. It's not like we have a nurse in charge without an assignment who can deal with all this. All these constant interruptions lead to a whole lot of patient neglect and errors. Nurse Anne is not kidding. I am dead serious.

But every single person who walks onto that ward thinks that it is their god given right to stop a nurse with no consideration for what she is in the middle of....and expect her to drop what she is doing to deal with their problem. Ever wonder why your dad always gets his insulin so late? No, it's not because "the nurse is too stupid to know that insulin must be given on time". It's because she was stopped 9 times between grabbing his drug chart and going to the med room to get his insulin and a further 7 times between drawing up and checking his insulin before she gets to his bedside.

3. She has to make phone calls to try and cover the next shift if that shift is short. If she leaves it and does nothing, things will be no better for the patients on the next shift, possibly worse. The patients will suffer.

4.Supervise the care assistants. How? The nurse is literally legging it to the phone every 5-10 minutes and getting stopped by visitors in between. As a matter of fact I never get down the ward for more than 5 -10 minutes without having the leg it back to the phone. The nurse's station is a long walk from the bays.

On the rare occasion that they allow us to have a "ward clerk" she answers the phone. She finds out who the caller is and goes to get the nurse. The ward clerk cannot tell callers about the patients because she doesn't know. She drags the nurse off of her drug rounds to take the call and then goes back to facebook. I cannot even get one pill out of a pack, or one IV med bolused without Fiona the ward clerk shouting "Anne,so and so's daughter is on the phone and wants to ask about 10 questions". WTF? I haven't even laid eyes on the caller's father due to the constant phone calls and interruptions. Constant. When do these relatives think that we are going to get some uninterrupted time to take care of patients if they call all day long? Why do they think that there is someone with all the up to date information about the patients somewhere near the phone at all times? Not on a large general medical ward baby. Places like CCU and ITU are better equipped to deal with it all because they are smaller units with a better lay out.

IT'S FUCKING ILLEGAL FOR nurses to be giving information on the phone anyway. I can get away with it if I know for sure that I am talking to the patient's designated next of kin. Genetics doesn't matter. The name under "next of kin" listed on their hospital admission form matters. Really it is a big no no and we will be fired if caught. Immediately. This has nothing to do with the trust wanting to "hide things" from the relatives and everything to do with patient confidentiality laws. NHS bosses did not invent patient confidentiality laws and neither did nurses and doctors. But man oh man, do we get BUSTED if we break them. Many hospitals have had million dollar lawsuits because Nurse Susie gave information to the caller who passed herself off as Mrs. Doe's sister.

These interruptions are constant. This goes on all day long. I am telling you this as someone who panics and wants to run to the phone when one of my loved ones goes into hospital. I want to but I call the next of kin instead. If my dad, as the next of kin for my gran, wants me to talk to the hospital then I make an appointment. My dad, has to give permission for the hospital to talk to me about gran or it doesn't happen.

All I want is some uninterrupted time to see to the patients. I walk down to my first patient and get halfway through her meds and assessing her, and the phone rings. Back up the ward. Answer the call. Before I get back to her the phone rings again. I finally finish with the first patient and go to the second patient. The phone rings again. This goes on and on and 2 hours later I still haven't got to my third patient out of fifteen. And it never stops. In between walking up and down to the phone patients are shouting for commodes and visitors are stopping me with questions. This leads to a whole lot of patient neglect. Actually, in my 13 years experience as a nurse I would say that interruptions and staffing is the number one reason for patient neglect rather than uncaring nurses. I am not kidding about the sheer number of phone calls that are coming through either.

I am trying to do everything that I need to do in the minutes I have between interruptions. We cannot escape them. I will not have a 10 minute block of time uninterrupted in a n 8-14 hour shift. Ever. Every single thing I do is done as a rush job because I don't know if the next uinterruption is coming in 30 seconds or 4 minutes. The care assistants, the physios, the ward clerk, they dump every query back onto the nurse and go on their merry way. What else can they do? They don't have the information that the relatives, social services, and pharmacy want. Only the RN does, but just barely. How can I look at the patients, and look at the doctors treatment plans in the notes with all this going on?

We complained to management about this. They know that if the nurses are constantly interrupted that it will lead to patient neglect and missed assessments that blow up into massive lawsuits. So they worked with us on solving the problem.

They haven't staffed the wards well enough yet to allow for one nurse to be in charge, fielding the queries etc while the other 2 nurses carry on with the patients. They tell me they are trying and I have seen evidence to back that up this month. Even then, I would have to be constantly stopping to update the charge nurse as to what was happening with my patients so that she could answer the questions. Lots of information gets thrown your way very fast. It all moves very quickly and is constant. Keeping up with it all is like chasing a race car. We need lots more nurses each with small groups of patients.

But management did do something. They have visitor cards with information about the ward etc and on the card they printed a nice reminder that goes something like this:

We understand that this is a difficult and uncertain time and that you are concerned for you loved one. If you can, please ring once a day. Only the patient's designated next of kin should ring. The next of kin should then disseminate all information about the patient to concerned loved ones.

Nurse Anne would have added "if your fucked up family dynamics do not allow for this because you all fell out and you aren't on speaking terms that is not the hospital's problem. Grow up. One caller once a day. Full stop. Nurses cannot answer 12 queries an hour from 12 different members of the same family who are not on speaking terms. Duh. This is especially true if the patient is stable and never ever has any change in condition.

If people actually followed this request nicely spelled out by management it would cut down on the vast majority of interruptions and promote patient safety.

But the public is as resistant (and paranoid) as all hell. I'll give you some examples in the next post.

Wednesday 6 May 2009

Kind Man

I was walking through the Town Centre walking past some tables in an outdoor cafe this week when I heard someone shouting my name. He was the elderly husband of a patient of mine. I said hello to him and he took my arm and took me over the the table he was sharing with his wife and friends.

He introduced me to them by saying that I was the nicest nurse in the world who had saved the life of his dear wife.

Ermm. I didn't save her life. She had a seizure and I stayed with her, administered 02, put her in recovery, gave IV diazamole etc etc. But okay. This is rare so I'll glow a bit.

He went onto say that the nurses on my ward are so hardworking and outstanding and etc etc etc until I was red in the face. Okay. Cool. He then said " I don't know how you girls do it every day". I didn't know what to say other than thank you and we always try to do our best. Nurses don't take compliments well.

Some people are so kind. It's good to know that someone felt that they were taken care of properly.

Sometimes I find positive feedback hard to take because I can always think of a millions things I could have done better if I had the time and the resources. You get a complaint and your feel guilty, someone says you have done well and you feel guilty too. Weird.

But I'm not complaining.

Tuesday 5 May 2009

Ginny did not get her pain medication on time. Why?

"The night nurses managed to give the morphine on time. The day nurses managed it. But that horrible, evil little shit of a late shift nurses did not. What a fucking bitch. They should get rid of that horrible Amy, the late shift nurse"

More dumbass comments from people who don't have a fucking clue.

Amy is just as good as the nurses who preceded her but she ended up in a hell of a situation on that Tuesday afternoon.

See, the night shift from Monday into Tuesday had 2 staff nurses and had an extra in the form of a student nurse. It was relatively quiet. Most of the patients were stable and waiting for discharge on Tuesday. The nurses could cope. There were two staff nurses on the ward which actually enabled the nurses to access the controlled drugs that were due every 4 hours at least for the the cancer patient, Ginny.

Fast forward to Tuesday morning. The day shift comes on. They are so lucky today. They have mostly stable patients waiting for discharge and there are 2 staff nurses and 3 care assistants. 2 and 3. Not great staffing numbers but survivable. You need at least 5 staff nurses on a day shift easily for 30 beds but we never ever get that. At least with 2 they can access the controlled drugs. Two nurses and mostly stable patients for the morning.

Here comes the late shift. Amy starts her late shift at 1PM. The medically stable discharges are going home and before the nurses have a chance to clean the beds, new patients come.

These new ones are unstable acutely ill patients with pages of orders, IV drugs, etc and they are coming through the door a couple at a time. They were rushed up here and they are in mess. The nurse who was looking after them down on medical A&E hold didn't have time to sort a thing so the ward nurse has to pick it up. These patients need almost one to one support. It is not safe to leave them for any length of time.

There were 9 discharges and there are 9 of new admits in total and they all arrive in groups of 2-3 between 1PM and 1:30 Pm. Amy is just getting out of report at 1:30 where she listened to overwhelming amounts of info about the other 15 patients she is caring for on this late shift.. A&E is desperate to meet their targets and these new patients are being brought up in a group . They were getting into the lift before the 9 discharges were even out the door.

There is another twist. Amy will be working as the only staff nurse this afternoon. Usually we have 2. The other nurse who was supposed to be working with her is upstairs on another ward with endocarditis and management hasn't allowed anyone to replace her on this shift. They don't want to pay for bank or agency or pool nurses. Amy has to carry this alone. The day shift nurses cannot stay on. They have stayed onto extra hell shifts before, only to end up in the shit basically. Our husbands are all threatening to leave us for staying onto extra shifts, unpaid, causing husband to have to walk out of work early to pick up the children from the childminders. My husband used to have to do this twice a week when our kids were little. It's amazing that he did not get fired. I was always having to stay onto unplanned additional and unpaid hours after the end of my regularly scheduled shifts due to unforseen circumstances on the ward. He hasn't dumped me or got the sack yet, but it has affected his career. These goddamn fucking childminders sure as hell won't work before 0830 or after 6Pm, or weekends and holidays. And they charge you for picking your kids up late.

"Never ever marry a staff nurse unless you can afford built in childcare in your house 24/7" says Mr. Militant Medical Nurse as he stands here reading over my shoulder.

So here we have one nurse and some very acutely ill patients plus many other dependent patients for the late shift. The number of sick patients increases and the number of nurses decrease. Happens all the fucking time. As there is no way to control the number of patients coming into the hospital, there is no way to plan staffing. A childminder knows exactly how many babies she will be looking after. Nobody suddenly doubles her number of charges without any warning, and takes her help away. This is normal every day stuff on medical wards.

Night shift came onto relieve Amy at 9PM. So we were back to two nurses again. Finally, Ginny could get her controlled drugs without Amy having to wait for a nurse from another ward be able to leave her patients and leg it to our ward. Amy had to stay on for 2 hours unpaid to finish her documentation.

Amy didn't have a chance in hell of being able to get those controlled drugs out to the cancer patient in time. But the nurses in the preceding and the succeeding shifts absolutely did. They got it done, and Amy didn't. And after that hellish shift she got slammed as the "bad one".

If we have 10 feeds on the ward we get 2 nurses and 3 care assistants maximum.

If we have 2 feeds the staffing numbers don't change. If it suddenly increases to 18 feeds on the ward, the staffing numbers do not change. We do not have the right to additional help. We are just responsible for any bad outcomes.

If we have all healthy easy patients we get 2 staff nurses and 3 care assistants maximum. If all 30 are crashing out and trying to die we still only get 2 staff nurses and 3 care assistants maximum, maybe less.

Say we have all healthy, mobile patients on one shift, and then on another shift we have all very sick ones . The staffing numbers do not alter, except to reduce.

We can have any kind of random set up: Lots of sick patients and our maximumn of 2 and 3 for one shift. Another shift has very little in the way of really sick patients but we have 3 and 3. The next shift has the sickest patients they have seen all week yet that shift only has 2 and 1. The next shift is so so and they have 2 and 2. Or maybe we get all easy patients and we luck out with 3 and 3 and two students. Maybe we only have 2 and 1 but we have easy patients so we cope and the families think that we are so much nicer than those horrible nurses last week. Um. We are the same nurses who were here last week and we were on our knees. But thanks for the attempt at a compliment. It's in god's hands it seems. And we all know that God hates nurses.

The workload can reduce or triple in an instant with no warning, yet the staffing numbers never really change.


Why can't management always give us great staffing numbers? That way when the shit hits the fan we would be able to cope.

I'll tell you why.

They are so afraid that on those rare, easy days, when we have all stable easy patients, that some nurse, somewhere, might actually have time to sit and hold a dying man's hand because she has nothing else to do. They fear idleness. If a nurse has time to help a patient then she must be idle. And if a nurse has time to sit and hold someone's hand that means that there are too many nurses on the ward and that staff needs to go. This is how hospital managers think. This is not just a problem in the NHS. I have worked outside of the NHS. The staffing levels are worse in the NHS but the general attitudes and incompetence of those who manage hospitals are a massive problem everywhere.

Monday 4 May 2009

Why don't nurses smile?

I smile a lot during the beginning of my shift before the hunger, and the sheer terror of the reality of what I am faced with really starts to kick in. Admittedly it is forced. I care very deeply about my patients, and I don't wish to make them think that I don't want to look after them. But the pressure I am under makes me want to run away screaming. I was less scared on that flight to St. Louis where the 02 masks dropped and we had to make an emergency landing and go down the chutes, than I am at work. Thank god this blog is anonymous because in real life I would never, ever admit that I am more scared at work than I was that day in Missouri. I felt more in control in that situation than I ever do at work. Admittedly, I was probably in a bit of shock on that plane, and no, we didn't crash.

Buy the time I reach hour 10 without anything to eat my human side takes over and I can no longer smile. I am always so scared that I will hurt or kill someone because I cannot be ten places at once. Would I simply lose my job and my registration? Or would it go to a criminal court as well? There is no back up and no support. The relatives troop in ready to have a go at me for anything they can find wrong. Grandpa hasn't been shaved, grandma doesn't have her slippers. And I can't even get past them to get to my septic patient with her IV antibiotics, and IV fluids. Her BP is bottoming out and she is becoming vacant and unresponsive. As I try to get past them they imply that I am being rude to them.

After that I need to get back to check on the previously hypoglycemic patient who seemed better last time I checked him. How long ago was that? He has been having these hypo episodes, not due to the usual cause and no one knows what is going on with him yet. After I clear that I can get to the controlled drugs for the cancer patient. IF I get all that accomplished then I can get to all the drugs that were due over an hour ago, and if I can get through that then I can try and conquer some basic care. It has been like this all day with no let up. Never has there been more than 90 seconds where I could carry on uninterrupted. Never. Never. Everything I have to do has to be accomplished in 90 second blocks of time in between interruptions, sometimes less. I've just had 10 hours of that.

I lose the ability to smile at this point. I just want all my patients to be safe. I am so scared that tiredness and hunger are going to cause me to lose my concentration and I am going to fuck something up. Focus focus focus. Push yourself and keep going. Now someone needs a heparin drip immediately. Septic patient first. Can I organise Mr. Smith's heparin drip and all the ins and out of that at the same time that I make up the syringe driver for Mrs. Jane? Can I do both those things while I turn Mrs. Peel? She has grade 3 pressure sores and hasn't been turned in hours.

Damn. I have to prioritise the heparin infusion first. Got to get the right heparin, syringes, tubing and pump, set it up, cannulate the patient which on it's own takes forever, organise blood draws etc. If I keep getting interrupted through that, the patient waits longer and longer to have his infusion.

Then I have to fight my way through hordes of visitors and call bells to get to Mrs. Jane's syringe driver for pain control She has already been waiting for hours. Then after I clear that I can turn Mrs. Peel. By the time I finish sorting out the heparin infusion and get to Mrs. Jane she will have been waiting in pain way too long. Mrs. Peel's pressure sores and the fact that she has been on her back for hours and hours is also weighing on my mind. If I run past the call bells and people shouting for help I can get to the hep infusion up and running, 30 minutes later get to the syringe driver and 20 minutes after that get to Mrs Peel. I usually have 15 patients. So multiply this scenario by 5 all day long. Then factor in the fact that the nurse never goes more than 90 seconds without an interruption, and someone who doesn't understand the situation trying to steer her into another direction.

OMG the hypoglycemia patient!!!! Oh fuck!!!!

Drop the heparin infusion and leg it back down the ward past the call bells, the crying, the begging for help. The hypo patient is again very hypo, pale, sweaty and vacant but I can get sugar gel into his mouth safely,still will need an IV. I need more supplies. Back down the ward I leg it still past all the crying and begging patients and hordes of visitors waiting to pounce. Up and down the ward 3 times, past all these really pissed off people to get every supply I need. The ward lay out is terrible.

I start to think about what would have happened if I had stopped to answer the myriad of requests for the commode and pain killers that were communicated to me in between drawing up that heparin infusion and realising that it had been to long since I checked back on the hypo man. I may have found a body in that bed. And then I would have had to call his family. My blood runs cold, my stomach goes into knots and I feel a bit sick myself.

The septic patient hasn't gone anywhere and I haven't been back to him since I hung those antibiotics and IV fluids. Let's hope he didn't have any kind of allergic reaction. Let's hope he is still alive. He never should have been left in the first place. Still there was the heparin infusion, the pain meds for Mrs Jane. The hypo patient. Back down the wards, past the bays of really pissed off patients ringing their call bells, shouting for help and hordes of visitors ready to pounce.

I don't think that there are a lot of people who can smile and look happy in this scenario. Why are nurses expected to?

Are we supposed to be superhuman? They don't even pay us for all the hours we work for christ's sake.

Just look at some of those comments!

And yes. Academic degree educated nurses are taught about basic care. Very much so. My first semester of nursing school was anatomy and physiology , nutrition, and pharmacology lectures in the morning and 5 hour lectures of NURSING 101: BASIC FUCKING CARE in the afternoon. Bed making. Bed bathing. Hygiene. Skin care. Pressure area care, etc ,etc, etc,etc,etc,etc,etc. The next day was a 10 hour placement on a ward. Fuck up a bed bath or on bedpan duty and Mrs. Lewis, the nursing 101 instructor would have you for her lunch, in front of everyone. And the next day was lectures again. The day after that was wards again and so on and so forth.

We did this for months. That was first semester only. 10 hour days, baby. It got harder later on. Especially when they threw chemistry and microbiology on top of advanced medical surgical nursing lectures and constant ward placements in second semester. The microbiology, anatomy and physiology and chemistry etc were taken with other university students who also needed to take those courses, not just other nursing students.

We were taught nursing on our nursing courses. Not medicine. Not how to pretend to be a doctors. It was nursing that we were taught. God forbid if we tried to put a medical diagnosis on our care plans and schematics rather than a nursing diagnosis. Our nursing professors would have had their rulers up our backsides, flinging us out of school. This was 1994. All right all right I didn't train in this part of the world but still.

The new graduated nurses that I am working with now here in the UK have a very good handle on basic care. The kids and the carers do silly things sometimes. But the newly qualified nurses that we have had are pretty damn good. The vast majority of new nurses and nursing students were Health Care Assistants for years (decades even) prior to attending nursing school. How could they not know how to bath a patient or make a bed?

*Patient names in this post were invented by me and are not based on real people.

Friday 1 May 2009

Nellie's Shift

Nellie volunteered herself to do an extra shift on her day off.

There was only one nurse for the ward that day and that is dire. Beth was to be that nurse and she was freaking out about it. Nellie said that she would come in and work the day shift.

It was chaos. Thank god Nellie came in. A childminder may be able to set a limit on the number of people she looks after but a nurse cannot. A childminder cannot have additional children dumped on her with no warning, on top of her other charges. But we do this to nurses and expect them to function every day. Otherwise, they would have to close much needed beds.

Nellie and Beth had a crap day. Half the patients were acute medicals with massive amounts of stuff going on. The workload was unreal. The other half of the patients were 100% dependent elderly patients.

I would feel safer leaving my 9 year old unattended on a ward than my 98 year old grandmother. My 9 year old can follow directions, ensure his own safe environment to a point, ask questions, communicate, remember instructions etc. He will not throw himself on the floor, or try and eat his own faeces. He will not forget that he has a broken leg and try and walk to the toilet. I am not being disrespectful to people with dementia. I am explaining to you the facts of their condition and why they need so much care, rather than an overwhelmed nurse who cannot be there.

Your average person will go on and on about how they cannot help grandma in hospital. But if it was his or her 9 year old child, their arse would be parked on that ward 24/7. Visiting hours. On my ward we will let you stay as long as you behave. But no one wants to stay with grandma. They don't have the time. If it was their 9 year old child hospitalised they would find the time and not leave his side. Yes but it is the nurses who do not care. Right.

Nellie and Beth had a patient go into cardiac arrest mid morning before they even finished the 0800 tablets. It was a bad one. I am so glad I wasn't there. I would have freaked the fuck out. Cardiac arrests are the norm on medical wards. But when it catches you unexpected its like someone sticking their fist into your stomach and pulling all over your guts out and stamping on them. I cannot describe how I feel in those situations any better than that.

At 11:00 hours Beth needed to go in and talk with the now dead patient's family. This left Nellie on the ward. Alone. By 11:30 she had got through 5 of the 13 patients that still needed their 0800 meds. She was focused. She was rushing and nearly made a massive medication error but luckily she re-checked and she caught it. She became even more focused. Medication errors kill thousands of people in hospitals every year. Many (some say most) of these errors are caused due to the nurse being interrupted and or overloaded. It's a big problem.

There are mountains and mountains of individual drug charts each with many different medications prescribed on them and every single thing on those charts needs intense scrutiny. It took her until after lunch but she sorted the mess out. And it was a big mess. There was a lot of other things going on as well that only a nurse could deal with. She could hear the weeping and wailing from the family room, and knew that Beth wasn't having a good morning either. Only 3 HCA's were trying to hold down the fort basic care wise. They managed to bedbath and wash every patient who needed it. There were 15 patients such as this who need at least 15-20 minutes each if you are going to do a half ass job. Before they moved onto their next patient the previous ones were crying out again. That it. Two nurses (one with a grieving family) and 3 care assistants with a whole entire ward of patients who are more dangerous on their own than a young child.

A few weeks later our manager received a complaint to respond to. The reason for the complaint occurred on the day and the time of Nellie's extra shift. It went like this.

"I visited your ward on such and such a date around 11:30. I was appalled to see the condition of the patients. Call lights were not being answered. There was a lady who did not have any shoes on and she was sitting out in her chair. Her bed was unmade. Nursing care has really gone downhill. The nurse was in the middle of the ward staring at a trolley, oblivious as to what was going on and did not appear to care anyway. Her name was Nellie Doe. I looked at her name tag. I believe that if matrons came back to hospitals nurses like this would be dealt with."

True story. It's really not funny. This is getting beyond a fucking joke.

Thanks for coming in on your day off and working your tits off Nellie. I doubt you'll be suckered into it ever again.

Fact is, this is the kind of bullshit that the complaints department has to wade through on a daily basis.

I have a friend who works on a medical telemetry floor. The nurse's station is in the middle of the ward and their are monitors all over this station, displaying patient cardiac rhythms. That is telemetry. The patient wears a device that sends a reading to these monitors at the nurse's station. These monitors need constant monitoring. Sometimes you have a few patients to on telemetry and a staff member to just sit and watch the monitors. Some times most patients are on telemetry and you have no one to watch the monitors. Leads need to be printed etc. A missed assessment will kill on there.

My friend who works in telemetry reported that they are always getting complaints from visitors about "the nurse's sitting at the station watching TV's. Why do the nurses need those TV's? Why can't they look after the patients instead?"

Documentation and Computerised charting is essential, ESSENTIAL to patient safety whether we like it or not and there is a hell of a lot if it that needs to be dealt with for all your patients, during the course of the shift.

"Why are all the nurses playing on the computer rather than looking after the patients".

Yes, this is the kind of bullshit that the complaints department has to deal with. No wonder the real complaints don't get deal with properly.

So who thinks we will talk Nellie into taking on another extra shift?

Doom Doom Doom. Not. Doom Doom Doom. Not.

I am not going to blog about this. Okay, except for this little post.

I may start to care if the unlikely scenario of swine flu turning into a pandemic along the lines of "I am Legend" "The Stand" or "8 Days Later" occurs and sparks my interest. Otherwise I don't really give a toss. All good films by the way.

Life could get pretty interesting if they start forcing us into quarantine at gunpoint.

My Zombie Plan is ready for action. I might get a valid reason to shoot a hospital manager 50 times and then cut his head off when he keeps coming after me! You do know that I am kidding right?

You have seen Shawn of the Dead right?

The american government seems to have a little too much planned about how to deal with all this, especially considering that it started on one of their pig farms in mexico. I am always open to the possibility that they just know more than they are saying. If you really want to have a laugh read some of the comments below that article from armed yanks. And I guess Swine flu is easily classified as a novel virus.

Since it is such a novel (new) virus, there is no real "herd immunity" so the rate of infection could be very high. Just a thought.

But in the meantime I am just going to assume that this will go the same way as SARS,anthrax and everything else that the media tries to scare us shitless over. What the heck happened with SARS anyway?