Sunday, 19 July 2009

Shutting down for awhile


I'm going to have to shut this down for awhile. Things are deteriorating very quickly at work and I need to continue to pursue other methods of dealing with it.

I'll hide the blog for awhile until things chill out.


Monday, 13 July 2009

The Retired Nurse

I love this one.

Once upon a time I got an admission. This lady was technically elderly but was very youthful in looks and manner and as sharp as a knife. She is a nurse and worked on my ward about twenty something years ago as a staff nurse. I think she retired in the 80's. I think she was pretty old then.

"Over there in that side ward we had the cardiac arrest from Hades" "You see that closet over there, they used to have 2 patients in there and once we got stuck behind equipment".

This woman was great. We didn't want her to leave the place. She kept us laughing with her stories about things that happened years ago.

She seemed very concerned about Nurse Anne and her colleagues...

"Why are you not taking meal breaks, they used to prepare meals for the staff"

"Why do they not launder your uniforms or provide changing areas?"

"Where's the staff?"

"Why do they let the visitors interrupt and harass you so? Matron would have dragged them out of here by their shirt collars"

"Who is in charge? You cannot be the only nurse for that many patients and be 'in charge'!"

I couldn't answer her questions. Did they really provide all those things for nurses years ago?

One day she leaned in close to me. "There are 5 of you on duty right now. How many of you are nurses"

Hmm. I decided right then and there to be brutally honest with her. She isn't stupid. I wasn't in the mood to hold back. She was on her way home that afternoon anyway. And I trusted her.

"Two of us are actually nurses. I have been qualified for over a decade but am still technically a junior staff nurse because they won't promote and because of agenda for change re banded me downwards despite a pristine nursing record. I am the most senior nurse on duty so that makes me charge nurse as well as primary nurse for 12+ patients without the pay and official title. Susan is the only other nurse. She has been qualified for 6 months. She is the primary nurse for the other 12 patients. The other two members of staff are health care assistants. The third member of staff is a "kid" with even less training than the care assistants receive." That is all of us, for the whole ward, for 12 hours+.

My Nurse-patient took off her glasses and looked at the ground, rubbing her eyes. "They really are bastards you know. In the mid eighties, they started with this 'health care assistant idea'. We were very against it you know. Patients need trained, qualified staff. We were against all this, but they reassured us that the health care assistants would be used in addition to qualified nurses not instead of qualified nurses."

I would have liked to tell her that we are lucky if we get an experienced health care assistant these days. We are down 5 members of staff in total and if we are LUCKY we get 2 junior staff registered nurses and 2 or 3 untrained 16 year old "kids" for an entire shift. That is if we are lucky. These kids don't seem to hear call bells, nor can they feed patients without the patient aspirating, they don't seem to notice nil by mouth signs, nor do they understand about not sharing commodes between the MRSA patient and the surgical patient. They cannot seem to understand about intake and output charts. They leave side rails down. The next day they are sent to work on a different ward. And I will get a couple more who don't know their way around mine. The medics want the staff nurses to also function as a charge nurse/sister and have us at their beck and call following them on ward rounds for hours. This basically leaves the patients with nothing, NOTHING as far as nursing input.

We cannot watch these kids. They need babysitting and we can barely get the drugs out let alone watch Brittany and Brandon and stop them from fucking up. Tell them off and get stern and they call mummy and cry. It is dangerous. We need direct RN to patient ratios in line with the RCN recommendations that are dependent on adjusted for patient acuity. We need this right now.

The retired Nurse assure me that we were doing well considering what we were up against and said "God bless. I don't know how you do it. Thank you so much".

I hope she continues to recover and would like to see her kick Claire " I haven't nursed since Nixon went to China but I am convinced I have a clue" Raynor's behind. Ms. Raynor doesn't really understand what is happening on these wards. She thinks that an RN can go to work and spend all shift focused on basic care without killing someone and getting hung drawn and quartered. It ain't the nurses who made things this way darling. It's not the nurses who wanted this. They have this level of responsibility without being pretend doctors. It's not the nurses who decided that nursing needs to be a well educated profession. So who/what is the culprit? He goes by a few names: progress in medical care, increased knowledge, changes in health care delivery and economics.

Admissions and Transfers: NIGHTMARE

I wrote some bits and pieces about what happens when we get an admission and transfer in and old post.

Let me expand on that even more.

We are taking admissions and transfers when we already have way more patients than we can possibly get around too.

They are arriving on my ward when it is convenient for the sending ward to send them. I get a "ball park figure" for when my new patient(s) may arrive. He may come in 5 minutes or 5 hours. That is all I know. I don't know when they are coming. Therefore I cannot organise my time around my other patients to accommodate the new ones.

But that is a mute point. I cannot organise anything. I am trying to accomplish anything I can in the 30-90 second periods of time I have between interruptions. The entire shift is like this. We may be working our assess off, but we are only ever ever hitting on the very top priority things. We are getting the tip of the iceberg chipped away but nothing else.

The patients have this idea that if the nurse is not at their bedside as and when they want her, that she is not caring for them. They have no idea how much goes on behind the scenes, or behind the nurses station really, to keep their ass safe and alive throughout the duration of my shift.

Admissions are sent unexpectedly at mealtimes, during handover, change of shift, when my MI patient has another heart attack stopping me from getting to the cancer patient with the pain medication she has been crying for during the last hour. Unless you are retarded you will understand that the heart attack patient is first priority in this scenario with 02, ecg's, stat orders and organisation for possible transfer to the coronary care unit etc.

If I skim the surface with heart attack man and do the bare minimum to keep him (and my nursing registration) safe from harm then I can get to the cancer patient needing pain killers in 45 minutes. That is 45 minutes if I ignore the other patients crying out for me. IF I don't ignore them, it will be hours before I get to the cancer patient with her pain killers. Setting up her narcotics, checking them for safety and administering them between all the other interruptions takes another 15 minutes.

Where am I now? Oh yes, the admission. And the other patients crying for help and everything else. I go to the admission, walking past multiple voices begging me for help with everything from getting a drink to getting a commode . My new admission and his daughter look at me sharply. "We have been on this ward for nearly an hour and YOU have not bothered to come and check on my father". The other patients are still crying and I really need to check back on my cancer patient to make sure that she is tolerating the narcotics okay and still breathing. They may not be infusing properly because of a kink in the line and she may weep in agony until I get back to her. They might infuse to fast or be too much and she might die. And I will be blamed. Your grandma and ten other people's lovely grandma's are sat weeping in their own urine right now. Right. Back to my admission and his pissed off daughter.

The admission itself is a lot of work and that right there is the crux of this blog post. When these patients come to us they are a fucking mess secondary to a lovely stay on what I term "the sending ward". These wards are called acute medical admission units, short stay medical units, medical admission units, medical assessment units. It is all the same thing really. From here on in I will refer to these places as sending unit hell, or SUH.

They come to us filthy. They come to us in pain with no prescribed pain medication. They send them up with insulin infusing IV. It was ordered to stop 10 hours ago, 10 hours before they were sent to the ward. But it is still infusing without any dextrose etc. The patient has a BM of 1.5. They come up dehydrated with orders for IV fluids prescribed hours ago, yet not started. No venflon is in place. Half the paper work is missing. Trying to figure out what is going on with these people is a mission in itself which can take a lot of time. When these people come, and they come with no warning, I need to leave my other patients and do a bit of assessing and research. Otherwise all hell breaks loose. Most of them are elderly people, who need someone there at all times to ensure that they are clean, hydrated and that their dignity is maintained. If I spend any more than 30 seconds at a time with any one person then all hell will really break loose and I just won't get to see some people.

Sometimes SUH will handover that the patient had bloods done. They were not done. Or that sando k was started yesterday for a low potassium. It was never ordered or given. Last bloods were 36 hours ago and the potassium was 2.1. If I don't contact the medics and let them know that this stuff is going on then they cannot sort it out and treat the patient. It is the nurses legal responsibility to field this crap. SUH tell us that the patient is for an urgent OGD, and that the test was ordered. It was never ordered. Now I have to chase up a doctor to order this test. The patient has been sitting and waiting for this test, and has been starved. The test department doesn't even know he exists. The medic is overwhelmed and cannot get to the ward to order this test for awhile. But the patient again has a dropping HB. Not good. Lots of phone calls and paperwork to sort this nightmare out. And you can bet your ass that it is indeed my problem, with my ass on the line.

They send patients up with the wrong notes, without wristbands, and dump them in the middle of the ward. They send them up as they are taking their last breaths. They have sent septic patients with a low white cell count secondary to chemo without warning, and the porters have dumped him in a dirty bed that has only recently been vacated and not yet cleaned. They did this while I was down the hall in another patients room hanging blood. It was 10 minutes before I saw. I just had to hang that overdue blood then the hca was going to finish ups and our first mission after that was to clean that room. But they couldn't hold off for 10 minutes. They dumped him. Its not like we have any kind of domestic support.

They send them up with dressings and ulcers but no documentation as to how long they have been present and when the dressings were last changed. It is very doubtful that I will have the dressings I need in stock and pharmacy is closed. If this is a Friday it will be Monday before I get those dressings. They send them up without telling us that they are diabetic, or that they are allergic to wheat.

Why does this happen? The nurses in SUH don't have an easy time of it, by any means.. First of all, they have A&E on the phone every 5 seconds demanding that they move people out NOW. Secondly, there are twits with clipboards and magnets constantly up there ass screaming about targets and getting patients moved NOW. With all that going on, it is very doubtful that they ever see their patients for very long and get to sort things out before transfer to the wards. Targets Targets Targets.

They send up confused and wandering fall risk patients without warning, when I and the other staff are already outnumbered by confused, wandering fall risk patients who need one to one supervision. This is often happening while I am trying to help your gran with her tablets, which will then end up on the floor as I go running to hear what that "thump" was. It is the sound of a body hitting the floor. Third time this shift, same person, and a big fat piece of paperwork for me. Those have to be filled in whenever someone falls. No, I do not leave them unsupervised because I want them to fall. You are crazy for even suggesting that.

Then send up violent alcohol detox patients, before I even get the the falling and sick ones. The families come onto the wards with the new admissions and demand to speak to the receiving nurse the second the patient arrives onto the ward. But I am in the middle of a 100 things and people are dying and they are falling and they are shouting out. The family member makes a snotty comment about how "that nurse cannot be bothered speaking to us because gran is old, and they don't care about old people".

The powers that be tell the ward nurses to stop complaining about the screwed up transfers that we are getting. "They have done all the admissions work in SUH, you only need to settle the patients onto the ward".

Um Right.

Saturday, 11 July 2009

More fun during "protected mealtimes"

By 2PM I had discharged 3 of my patients and transferred two others to rehab and long term care facilities.

I had 5 empty beds! I made sure that the bed manager knew this. Our patients are always breaching the targets in a&e due to lack of beds. If she knows I have beds then she can get patients out of express admissions unit/medical holding and send them to me. Then she can get patients out of a&e and into medical holding.

I was left with a mere 10 patients (25 beds on ward total, and one other nurse). The healthcare assistant and I ran around making sure the beds were cleaned. I had to walk away from some important time sensitive things to help her do the beds quickly. Usually the discharged patients are not even out the door before the transporters are dumping another into that bed. What if the staff hasn't had time to clean the bed because the new patient is coming before the old one is out the door? Well then the porter will just dump the new patient into a dirty bed and go off on his merry way. He has other places he needs to be and it isn't his problem if the nurse gets an admission with no notice. It isn't his problem if she cannot sort the discharged patient's bed out right away because Gladys in the next bay collapsed onto the floor with a massive GI bleed. The buck always stops at the nurse and the numerous support staff goes on their merry fucking way and do as they please.

If the new patient complains about getting dumped into a dirty bed or gets ill as a result the ward nurses have to take all the blame. The porter can do as he pleases. Even if the patient has been on the ward less than 10 seconds anything that happens to that patient during that 10 second period is the responsibility of the RN. And they often send up admissions that I am not expecting and dump them and walk off while I am in another patient's room and don't see.

Sometime after I declare our number of planned discharges/empty beds to the bed manager the nurse from the "sending ward" calls me on the phone and tells me about the patient they are sending to me. This is called handover. After that happens the patient may arrive on the ward 3 minutes or 5 hours later or anywhere in between. They get sent to me at the convienance of the sending nurse's unit. I have no idea when they will show up on the ward. What I do know is that they like to send them all at once either at change of shift or mealtime. I don't know why it is that way. Either they are being twats or the situation on their unit is such that they have no choice.

Sometimes there is so much going on with the patients I already have that there is no fucking way I can nip down to see the new admission as soon as I want to and need to. I do not get given an exact time as to when they are coming so I cannot plan for it really.

I want to and very much need to go and see my new admission and give him a once over and a kind word of welcome as soon as he comes onto the ward. As a matter of fact I really fucking NEED to see him. But it isn't always going to happen right away. The ward receives admissions when it is convenient for those who are sending the admissions. That means admissions are arriving when I am up to my eyeballs in other things.

No thought whatsoever is given to what is happening on the receiving ward. That means that I am often getting new patients when it is unsafe. It means that I cannot always get to them straight away. Wanting to get to them straightaway and understanding that it is crucial for me to get them straight away is not enough to make it happen. This is the case even though I am an extremely hard worker and easily able to multitask.

If I had 5p for everytime a walking wounded transfer said "well I have been here 20 minutes and not one of the staff has seen to me yet" I would be rich. How I would love to say "well they sent your ass up here when I was smack in the middle of inserting an NG tube into someone with an obstruction.

As a matter of fact it is a crime for me to leave that very unwell patient at anytime for any reason EVER especially to be down here apologising and kissing your medically stable ass. But I took a risk to come down here because I care about your welfare too. Believe me, I took a massive risk when I left him and came to you. It's because I don't trust the ward who sent you or the transporters who dumped you here not to leave you in a bad way. Once upon a time the ward who sent you handed over that they were sending me a stable patient and when the man got here he was dying. It may have taken me 20 minutes to get here. But I got here as soon as I could. I did it in the only 30 second period I had to check on you and make sure that you are actually stable as they said you were. Your welfare is important to me, even if you are a complete twat. A word of thanks rather than a stupid smart ass comment about how long you had to wait would be more appreciated. Not one thing about this situation is created by the nurses. Nor can they control one bit of it.

Back to the point of this post. I had 5 empty beds at 2 PM and the bed manager knew this at 2:05 PM. She knew that those beds were coming up and already had transfers slated to come to us.

We got the beds ready right away because we know what happens. 3PM rolled around and I had not received a phonecall from a medical holding unit nurse to give me handover on a patient that she would be sending. By 4 PM I had received a call from the holding unit nurse. She handed over two patients. I told her to send them now, before mealtime.

By 5Pm nothing. At 5:50 they called and handedover 3 more patients. At 5:55 they sent all 5 of them up together. The porter left them in the middle of the ward and walked away. I found them all when I came out from a bay where I was pulling a central line.

3 of them were confused. None had wrist bands on to ID them. The one who was supposed to be treated for dehydration with an IVI and a had low potassium according to today's blood report had NO IV. No venflon. Nothing. Nothing prescribed for his K+ of 2.2. First priority above all else right there. Had to get a venflon and get something prescribed. He wasn't taking oral anything. The last note from a doc who saw him prior to his arrival on my ward said to hang IV N. Saline with 40 mmols of K+ and monitor fluid balance closely. Well duh. But he never prescribed it onto the medication chart. In the UK nurses are not allowed to transcribe orders from the doc's notes to the drug chart. The doc has to write it on the drug chart. Yeah. And for those of you who don't know, if your potassium is that low your heart will stop.

The one that had urinary retention (according to handover) and had not passed urine in 11 hours (bladder scan that was done in medical holding showed 800mls in bladder). The sending nurse handover to me that she was going to cath the patient. This was a few hours ago. He was supposed to have a catheter inserted. There wasn't one.

So all this was happening at the same time and there were 2 nurses and 2 HCA's. It was 5:55 PM. The supper trolley comes now, and we have 20 minutes to get all the food out and served and fed to all 25 patients (and 10 feeds). I also have an hours worth of a drug round due now and people need their pain killers. I can't even get to the new patients new and read up on them to see if there have been any changes since they were handed over. This is because the notes are on the desk and that is where the visitors are queing.

I go for the notes to read up on my patients and make sure there aren't any other life threatening "surprises" left over from the sending unit and the visitors of the other patients go for my jugular." Patients are crying for nurse and suffering and there is that nurse with her face in the notes" "Don't you know that grandma cannot feed herself cannot reach her drink? Don't you horrible people care?" It's not like I can through all the notes in a few seconds. Getting all the information that I need to takes time and concentration. But the families go nuts when they see me open a chart....then mistakes happen because the nurse does not have all the info she needs to be able to function.

The domestic was stood with the supper trolley hands folded staring at me menacingly while I was getting the venflon into the low K+ guy. The other nurse did the catheter. One HCA sorted the ID and wristband situation and tried to get the new people settled into their beds. They new admits got really pissy when she moved at the speed of light and wouldn't stay or organise their belongings in the cupboard. The reason she was moving so fast is because one HCA was now trying to serve and feed all the patients on the ward by herself. Impossible for speedy gonzalez let alone 50 year old Linda. We all needed to pitch in and help. Even with all 4 of us on deck it was never going to happen, let's be honest. It was 20 past 6 before I sorted out the man with the low potassium and by that point the fucking domestic was trying to collect all the dishes in so that she could get home on time.

Now it is 20 past 6. I was trying to keep an eye on my unstable patients, figure out who actually ate and who didn't...everyone was simultaneously shouting "nurse nurse nuuuuuursssse" as I walked by and the visitors who just arrived were queing up at the nurses station to bitch at me and tell me things I already know. My drug round still wasn't started. At this point I would be lucky if I finished it by 7:30 PM. That means it is going to be another hour before I get around to everyone in pain with their medicine. IF I stop at any point to talk to visitors or answer the cries of "nurse nurse nuuursssssse" it's going to take a lot longer.


Later on we again had two empty beds by 7PM. I told them so no later than 7:05PM. They handed over patients at half past 7 and then sent them both up together at 9PM. I am off duty at 9PM but the night nurse was going to struggle handling two new admits, her initial drug round, and all the problems that were happening. Really no choice but to stay late and unpaid and sort the new admissions. You would think that transfers from medical holding would be easy to deal with because the staff in medical holding due the initial admission and paperwork and "supposedly" get treatment started. When they are coming to us, they are merely transfers not proper admissions. Therefore it should be easy and straightforward. But it is not straightforward as that and I'll explain why later.

In the meantime if there are any medical express/holding/admissions nurses and bed managers around can fucking you tell me why the hell you send them up in clumps at mealtime and change of shift?

To be continued.

Thursday, 9 July 2009

Let's get something straight: The Chicken or the Egg.

All over the Internet I see posts that try and blame nurse education and nurse "snobbery" for the state of things on the wards. It's true that the wards are violently short staffed. It's true that many registered nurses are no longer ward based. The fact that many nurses are no longer ward based has nothing to do with the situation on the actual wards. Short staffed wards are that way as a result of business managers.

Let me tell you what I know after over 13 years of nursing in multiple countries and an obsession with issues surrounding nursing care.

We'll be real simplistic in case any daily mail readers are looking at this blog (doubt it but I'll endeavour to keep things on a year two reading level anyway, just in case).

The wards did not suddenly become short staffed overnight when health care delivery became more complex and the role of a ward nurse changed. Having a caring heart and a strong stomach are not enough to make a good staff nurse anymore. I often hear comments from people on seem to think that degree educated nurses do not want to be at the bedside. Complete rubbish.

They are educated to work at the bedside, they need years of bedside experience before they can change jobs into specialist roles. The abusive conditions at the bedside drive them away time and time again. These working conditions drove the 1972 grads with certificates away and it is driving degree/diploma grads from the class of 2009 away too. People who like to look down on nurses just cannot STAND the fact that nurses of the class of 2009 have more escape routes from this hell than the class of 1972 ever did. They want to keep it hellish for nurses and ensure that nurses have no escape routes. It allows them to put money towards things that give the illusion of decent patient care without ever really providing it.

The wards have always been pitifully staffed by greedy managers. This has always resulted in an abusive work environment for nurses. Their experiences were so harsh that they will never return. For these people, working a 40 hour work week with lunch breaks minus life and death responsibility is like a permanent vacation with a paycheck. Most escaping nurses do not go into practitioner jobs within health care. They go into everything from teaching to theology to working at GAP. And you wouldn't get them back into health care as a nurse if you offered them double the pay, so atrocious were their experiences.

Many people seem to think that if specialist and managerial nurses were forced back to the wards then we would magically have enough nurses to do the job. This is bullshit. Ward staffing by registered nurses does not follow the rules of normal supply and demand. "Supply and demand" of RN's is very tightly controlled by twats with a financial agenda which does not benefit nurses or patients. Do you know how many new grads are still looking for jobs, and feel that they have very little in the way of options?

Most of the time we only ever have 2 RN's per shift. This number seems to remain constant no matter how many new staff we hire, no matter how many leave, no matter how many are off sick, no matter how many want to work over time. If we have 3 + nurses for the shift, one gets sent away for the shift to staff another unit. If we only have 1 for a shift either she attempts to cope alone or they take from another unit to ensure that we have 2 RN's. 2 RN's for the whole ward seems to be the minimum number that management can get away with, without they themselves looking like the bad guys. The number 2 is the magic number and usually constant no matter what. We have 20 something beds. The medical ward downstairs has over 35. Neither ward ever really seems to have more than 2 RN's per shift even when they hire new people and have staff begging for overtime.

The ward budgets as designed by business managers do not allow for the wards to be staffed well with much needed RN's. They just don't allow for it. The specialist nurses and the managerial nurses will never be brought back to the ward for this reason. Ask any one of them, they would come back if they knew for certain that they would not get shafted i.e. have a manageable number of patients rather than ratios from hell. But even if they all came back, we would still be heaving with only 2 RN's per shift.

If we ever, god forbid, get 4 RN's for a shift, one gets sent to staff another ward and the other gets sent on a study day that she should have gone on two years ago (legal requirement) but could never go because the ward would be left too short. No matter what happens we always end up with 2 RN's per shift.

If all the nurse practitioners, nurse specialists, and practitioners came back and begged to be ward based we would still only have 2 RN's per shift.

IF every nurse who left health care came back, re-qualified, and begged for a job as a staff nurse on the wards as well...we would still only have 2 nurses per shift.

If every British nurse who left the UK for pastures anew came back to Blighty and begged and begged to be put to work in an NHS hospital as a staff nurse....we still would only have 2 RN's per shift.

And, if in addition to all that, every single dead nurse arose from their graves like something out of Thriller, and came along dancing with Michael Jackson towards the wards looking for jobs....we still would only have 2 RN's per shift most days.

Being only one of 2 RN's for a whole ward is hell on earth. This blog does not even begin to touch on how much a nurse in the position is crucified and made to suffer. When I was a kid I shoveled horse shit and worked as a sales assistant. When I was at Uni I worked in a bank and a museum. I know I take on more work and abuse in 5 minutes as a staff than I ever did in all of those jobs combined.

If you think that the normal rules of supply and demand apply to nursing then you are batshit fucking crazy.

The nurses who have long ago left the bedside know this. See, they know a lot more about the situation than the likes of NHS blog doctor. Doctors may be highly intelligent and brilliant at diagnosing an illness and prescribing a course of treatment. But they don't know shit about nursing. My 5 year old understands nursing and nursing issues better than any doctor ever could.

The AWOL nurses who left the bedside know that even if they come back, and all their friends who left came back and they all got jobs on the ward......the business managers would find ways of shedding other RN's through what they call "natural wastage".

All nurse managers and nurse practitioners know that if they come back, and everyone else comes back to the ward, that they will end up getting overloaded with too many patients. They know that they will be in the exact same position that Nurse Anne is in right now. They see us working 12 hour shifts without being able to eat drink and pee, getting crucified and screamed over things out of our control, slamming our heads into the wall with stress etc etc. If they all come back, the staffing numbers STILL would not change one fucking iota...and these returning nurses will be straight into our shoes.

It's a classic chicken and egg scenario with a bit of catch 22 thrown in for good measure to deflect blame from the real culprits who are responsible for shit nursing care. Did the wards become horrific and short staffed because of nurses being too snotty to work at the bedside, or did the nurses leave because the wards were horrific and short staffed? Make no mistake about the fact that the latter statement is correct while the former is complete and utter bullshit.

Never forget the golden rule of nursing. There is no shortage of RN's. There is merely a shortage of RN's willing to put up with appalling conditions. Appalling working conditions for nurses saves money....well that's how the business managers see it anyway. The reason that people cannot stand a well educated nurse is the fact that she has more options to escape than older nurses ever did. People resent that.

Tuesday, 7 July 2009


Had a great day at work. Yeah right. We were supposed to have three Registered nurses and a kid on duty for the shift. Not enough for a large medical ward. Not enough by any means. Every single patient is due medications at the same time, first thing in the morning.

If only one RN does a medication round it would take about 3 hours to get everyone their 8Am drugs. So we split the ward and each RN takes a side. It then takes about 1.5 hours for all the patients to get a quick initial assessment by an RN and hopefully they will get their 8AM drugs by 9:30 or 10:00. That sucks but it is better than sharing the ward and having one RN running around trying to do all the meds.

By the time you finish your drug round you are locked into your side for various reasons.

The third RN was going to do charge and work with the kid doing basic care. It would probably take them until noon or so to get everyone up and washed etc. The other 2 RN's who are locked into their sides get hammered with orders, phone calls, information overload, labs, treatments, assessments etc.

So it sucks but I was looking forward to having 3 RN's rather than just the usual 2 RN's and 2 kids/care assistants.

Then I got to work.

Another ward was short and we were ordered some non nursing manager to send our third RN to work there. Fuck. We cannot only have 2 RN's and 1 kid for the whole ward. Please don't do this I said. I had visions of listening to screaming relatives tell me things I already know for the next 8 hours. I had visions of not having any kind of support in an emergency.

"We need your RN to go to ward 1 as they only have one RN for the day. But, I will send you their care assistant, then you will have 4 of you. If you struggle make the housekeeper work as a nurse" says the manager. Keep in mind that this is a large acute medical ward of well over 20 beds. And we were getting 2 RN's and 2 untrained.

Having only 2 RN's and 2 untrained really blows for a large acute medical ward but this was the deal I was getting. I reluctantly agreed. Really I had no choice in the matter. My RN left to go upstairs and the other ward's care assistant came.

She did not speak a word of English. She had no experience nor training. She had been in the country two weeks (found that out later). She was only scheduled to work half a shift and she was getting passed off as a proper care assistant. Of course no one told me this. I found out a few hours later. I would ask her to do things and get the reply "Yes, Sister" and a lovely smile. She was lovely. But she had no idea what we were telling her to do. And she didn't communicate that with us either. We were under the impression that she was an experienced care assistant. When she first came on the ward I did ask her about her credentials and tell her to tell me if she needed help. I showed her around the ward and explained the routine. She smiled and nodded. I realised something was up after I realised she hadn't checked the blood sugars (hours after I realised they should have been checked, hours after I told her to do them). I won't tell you about the rest of the fuck ups........

Then she left. She was only scheduled half a shift. Neither her nor the manager who took away my RN and sent this girl bothered to mention that she was only on half a shift. That left us with 3 staff for 20 something patients. 2 RN's and a kid.

The kid is actually very good. But she is very limited in what she can do obviously. Really she can only do basic care. But most of patients need 2 staff to be moved in the bed, cleaned, turned, and Kid was basically fucked whilst the two RN's got slammed with admits, IV's, orders, phone calls from everyone and his brother etc.

Yes that is right. They took away my RN, sent me an untrained non English speaking non nurse person who was scheduled to leave in the middle of the shift, and then sent admissions.

And guess what. The patient's referred to the foreign woman as "that foreign nurse". Nurse.

And they complained about the fact that we didn't go around with a trolley hot drinks for everyone. If we have enough staff this is usually done by a care assistant or a free nurse at the end of the shift. The kid who was working with me had a choice between getting observations on all 20 something patients when they were due or handing out tea and coffee. There was no way she could do both. She made the right call. The other RN and I were on our knees with all the other things. And the patients complained about the Nurses being to miserable to hand out tea and coffee.

I cannot wait until the next time I see that fucking manager. He is going to wish he was never born. I really needed that 3rd RN as well as about 10 others. I cannot tell the complaining patients like it is so I am going to take it all out on the manager personally.

This is how they screw and screw medical/elderly wards and their staff day after day.


Personally I'd rather do facebook. But I think I'll leave that for now.

Anyway, give me a Tweet or whatever the heck it is.

Guest Post from an ICU Nurse

This is so well written. I really wish that I could write this well. I demand that this Nurse starts to blog!!

My name is not Catharine. My name is "Nurse!" Not "Nurse?" Or "Nurse." But "Nurse!" Sometimes "Nuuurrrrsssse!!!!" That is what I'm called by the patients (if they can talk), their families, the doctors, social workers, dietitians, respiratory therapists, chaplains, visitors, physical therapists, everybody calls me "Nurse!" I'd sooner be called c*nt, b*tch, f*ckface or wh*re because calling me "Nurse!" amounts to a Master calling a slave. And slave I am.
In my job I am not allowed to curse under my breath, disagree, look serious or speak my mind. I am not allowed to be anything less than warm, friendly and accommodating. Male nurses, of which there are many in critical care, are not held to the same standards. As long as they are knowledgeable and skillful, they are considered "good" nurses. Female nurses, no matter how knowledgeable and skillful, still have to do a lot of ass-kissing to be considered "good" nurses.

According to the hospital, nothing is more important than "customer service." Never mind that I am not selling anything, that I am working with patients, not "customers." I am servicing. Above all, I must service the whims and fancies of the patients (yes, people really do ask me to fluff their pillow), their families (an empty plastic pitcher is thrust in my face along with the command "ice!"), the doctors (no example needed), my manager, and to a lesser extent, my coworkers. In this age of consumer medicine, "servicing" has become more important than providing the actual nursing care for which I studied, was trained and practice according to the highest possible standards and latest research.

Despite the pretense of the "team" approach in our ICU, my opinion doesn't mean much. A few Attendings will ask if there are any "nursing issues," but not many. Nevertheless, because I want the best for my patients, I often "cover" for physicians. I say nothing when an intern presents my idea as his/her own during rounds. I order important labs and x-rays when the medical team "forgets." I spend an extraordinary amount of time explaining a patient's diagnosis, reviewing the plan of care and answering questions honestly and in a way that the family can understand, which often allows the time a physician spends with the family to be more efficient.

I have too many fingers to count the number of times in the last ten years a physician has thanked me for my efforts.

I had to laugh the day an intern was in the room with a patient who started to code (hadn't I been warning him for hours that this was going to happen?!) and the doctor desperately called out, "I need a nurse!" It wasn't about the tasks that needed to be done. This young fellow had no idea how to run a code. But that's how it is in a teaching hospital.

Nurses get no respect. It always hurts to see a patient's family, who has been rude and demanding and condescending to me for hours, bow and scrape and fall apart with gratitude when a doctor enters the room. Don't get me wrong. I have enormous respect for physicians. I am stunned by the intelligence, commitment, compassion and the huge amount of responsibility that doctors bring to the table. But a nurse is always, well, just a nurse. Somehow it is easy to forget that the person who keeps the patient clean, dry and comfortable, the person who makes sure that labs and other diagnostics are done, the person who administers the necessary medications and treatments, the person who manages the continuous dialysis, keeps an eye on the ventilator, collects and records the data, does the wound care, cleans up the shit, blood and vomit, educates and addresses the emotional needs of the patient/family, has the greatest risk of exposure, uses her knowledge and judgment to do exactly what needs to be done at exactly the right time, must stomp her feet in order to get the resident to listen when a problem is developing, in short, the person who keeps the patient alive minute by minute, is just a nurse. And when the time comes, it is the nurse who makes damn sure that the patient dies with as much comfort and dignity as possible.

Nursing is not highly valued as a profession. Nursing (especially critical care) demands a broad knowledge base, advanced technical skills and a great deal of judgment. It seems that we are suffering from a collective historical hangover from the days when nursing was unskilled "women's work." Plumbers make more money and nobody dies if they have a bad day. And I admit nurses are better off in the US than in most other countries. When my mother-in-law tells her friends in Serbia that I am a nurse, she might as well be telling them that I am a street sweeper. Let's face it: How many of you are hoping your kid will grow up to become a nurse?

In fact, with the exception of Halloween night in 1971, I never wanted to be a nurse. I was going to get my PhD in Philosophy. But then it hit me that I had a family to support and that changed everything.

As it turns out, becoming a nurse is one of the best decisions that I have ever made. I can't imagine any other job that would give me the same opportunity for meaningful, authentic human contact. I have provided comfort. I have eased suffering. I have protected the vulnerable. I have grieved with families. I have met needs that are real and immediate. I work tirelessly to keep people alive. I am a staunch patient advocate. I have seen many die but I have also saved a few lives. This work happens in a place much deeper than class, race, gender, sexuality, etc. Being a nurse has taught me more about being a human being than a PhD in Philosophy ever could.

So, yes, I am in many ways a slave. Many see nursing as nothing more than following physician orders (and be "caring" while you're at it!). I work in an ocean of blood, shit and tears that the average person just can't imagine. My work is hard (mentally, physically and emotionally) and in general, I do not recommend it. But at the end of my fourteen hour day, when I come home cursing and complaining, barely able to take another step, I know that I have done something meaningful, something real. And that, somehow, makes it worth it.

Sunday, 5 July 2009

Funny Complaints: The Nurses Cannot Win. EVER

So I am back. I think we finally have a fully functional PC now. Fingers crossed. We had built one recently and had problems with that so finally we bought one.

To be honest I have also been having a bit of blogger block. I think have about 30 half finished posts.

I don't have a lot of time today but I thought I would check in anyway. A couple of work related incidents have made me laugh out loud this week.

A large medical ward such as mine takes a large number of elderly patients at any give me time. This means that we often take patients who have hearing loss. It also means we have a large number of extremely grumpy and self centered people. I don't care if that last sentence sounds offensive. It's true. You and I will more than likely be self centered, miserable and easily stressed over nothing when we are elderly as well. Reality. Deal with it. I don't do politically correct on this blog. The fact of the matter is that old age sucks and that it will come to most of us someday.

Let's start with the hearing loss. We obviously have more than a few patients with some type of hearing impairment. Their hearing aids are usually lost somewhere between Casualty and the medical express units. By the time they get to the ward we have a serious barrier to communication. Whiteboards and notebooks don't always work out too well due to additional problems with eyesight, crippling arthritis etc. Most of these patients have only suffered from hearing loss recently and do not use sign language. If the hearing aid is awol we will try and get audiology to sort it out. If we are lucky they will come and the see the patient about 800 years after the initial referral. That's deemed quick.

So my patient cannot hear me. I am going a mile a minute and can usually only spend 10 seconds with any patient at any given time. This is bad. The patient has no understanding of what I have on my shoulders and thinks that I am running in and out of the room without taking the time to explain things because I am an inconsiderate bitch. Yes, we know that this is what you think. I do try to explain things in the few seconds I have between dealing with the transfusion reaction in bed 4 and the fall in bed 28. Sometimes I will fly into your room to give you a much needed pain killer when I am in the middle of an emergency elsewhere. I shouldn't leave the emergencies to give a pain killer. Not ever. But if I don't use the 2 seconds I have right now to do it, before the bleeder really starts to crash, then you may not see me again for 2 hours.

Multiply this situation by about 12. Realise that often the nurses are in this situation almost at all times. due to short staffing. Then you will see why we fly in and out of the rooms to fast. We are not trying to be rude or inconsiderate. If you think I can control how long I spend with a patient your are completely crazy.

Often we are trying to communicate with our hearing impaired patients by just talking loudly and trying to help them to lip read. Sometimes it works. Sometimes I just cannot work it all out due to time constraints. Most of the time the patients in near beds will complain about the nurses "talking to loudly and disturbing them". This is especially a problem at night.

Example: Patient with hearing impairment rings bell because they have started having pain. Nurse has to ask questions. If things like notebooks etc are out of the question ...then the nurse has to speak loudly and clearly. It's not a good solution but what else can your do at 3 AM if all other options are out of the question. The rest of the patients on the ward go ballistic and threaten to "strangle that deaf bitch and the nurse". We are often trying to communicate with patients who have difficulty hearing during the night. Unfortunately you are not all in private rooms. This is not a situation that was created by the Nurse so fuck off.

On the other hand, and often at the exact same time...we get complaints about the nursing staff from hearing impaired patients. The nurses offended them by "talking too softly and quickly when she knew I was deaf" and "not taking all the time that was needed etc". The former occurs because we have multiple other patients on the ward who complain about the lack of quiet on the wards. The latter occurs because we are always rushed due to factors out of our control.

Patients in general: We are not talking loudly to piss you off. Patients with hearing impairments: we know that there are mega barriers to communication and we are really doing the best we can with the resources and time that we have. We are not being "insensitive" the the fact that you have hearing loss. Nor are we insensitive to the fact that patients really need peace and quiet. We do get that. Yes, really.

But sometimes there is just going to be a lot of noise.

I'll never forget the night that my colleague found a young patient in full respiratory arrest (but with a pulse) during her rounds at about 2 AM. I was the only other nurse and was on the complete other side of the ward. ANNNNNNNNNNNE!!!!!! The way my junior colleague screamed my name made me go cold. It was an unexpected arrest and a young patient. Then there was the chaos of the cardiac arrest, the senior docs and ITU team shouting orders. The patient survived. The next day multiple other patients complained all day long to anyone who would listen about the horrendous noise they were subjected to at 2 AM. They complained about how much they suffered and how dreadful the nurses were for disturbing them like that.

Why is there always this bad attitude and towards the nurses? Why all the assumptions that all these bad things happen because the nurses are being cruel, insensitive, inconsiderate, thick etc. The answers to those questions can be found if one studies the history of the nursing profession and the subconscious images that people have of nurses. I'll get around to finishing that post.

My children were promised a day out today. I'll try and add to this in another post later.