Sunday 28 February 2010

What actually happens when we are shortstaffed?

You should know what it means, since we are like this all the time.
First of all it means that during my shift I am responsible for so many patients that I can not keep all of the pertinent information about them that I need to know straight.  And I'm pretty good.

If I have 4 patients I can get through their notes and information pretty quickly.  I can catch onto new orders from the doctors quickly and plan nursing care around this. I can see the whole picture regarding the patient and communicate effectively with the family. I can do this and still have time for nursing care.  I can do my initial assessements of the patient and make sure that they are clean, dry, have a drink pretty quickly at the beginning of my shift. Then I have 10 minutes to get through those charts and answer phone calls before I go back to those patients.

If I have 20 patients I will never get through more than three charts at a time, without being interrupted.  By the end of my 12 hour shift it is very unlikely that I have been able to read any notes.  Every attempt I make to read those notes means that I am leaving people who need a nurse at their side.  It would take me hours and hours to do my initial checks on my patients.  Having the phone calls of 21 relatives to take means that I am being interrupted constantly.  It means that during my shift I am having to leave the patients and run to the phone every 5 minutes.  Once I finish one phone call and start to head back towards the patients, another call comes in.

If I have 4 patients, and all their relatives are phoning the ward all day I can handle those phone calls without neglecting my patients too badly.   With 20 patients the phone calls are never ending.  They never stop.  I am constantly having to leave the patients to answer the phone.  I am getting asked questions that I cannot answer because I do not know what is happening with my patients.  There is too much information for me to wade through and too many people wailing for help to allow me to do it.

If I have 20 patients it takes me from 8 AM until 11:30 to get everyone their first lot of medications that are due at 8AM. Unacceptable that half of those meds are hours late but it is the best I can do.  And  I will only do that well if I ignore the phone calls, abandon the idea of looking through the notes to get that information about you that I so desperately need, ignore everyone requesting a commode and ignore the wet beds throughout that drug round.  I must also abandon the idea of staying with patients and helping them to take their tablets.  I must move fast and keep my eyes down and remain focused.   I have to mentally block out everything else that is going on around me and focus. If I didn't do it that way, it would take until 3 PM before your mother got that pain killer that she was due at  8AM.    I really have to be strong and limit the amount of time I spend with each patient to ensure that I get to all of them fast enough.  If I am not firm about this and drag myself away from people who need me then patients will wait 7 hours rather than 3.

Shortstaffing means that if I take all the time that Mrs. Smith needs to get washed and go to the toilet, take her meds and eat and drink that it is done to the exclusion of all the other patient care for all other patients.  I could hand pick 4 of them and take care of them really well by ignoring the others.  Or I can do little bits and pieces very quickly to ensure that I can get around to all of them.

 In those 30 minutes that it takes to help a confused and reluctant Mrs. Smith take her tablets your mother is at the other end of the ward, falling out of bed.  If I rush and push Mrs. Smith and do it in 20 minutes than it is 20 minutes before I get to your father who has been ringing his bell,  waiting for his bedpan.  He gets out of bed and pees on the floor, slips and falls.  If I really push Mrs. Smith to the point of causing her great distress than I can get her tablets into her in 10 minutes.  That allows me to appear caring to your loved ones but I will appear uncaring to Mrs. Smith's loved ones.  If your Uncle Peter has stopped breathing at this time I will get to him too late because I spent 10 minutes in that attempt to get Mrs. Smith to take her tablets. I have 20 Mrs. Smith's to medicate at 8AM.  If I am going to do this right it is done to the exclusion of multiple other things that are happening on the ward for hours and hours.

I cannot do one thing right by one patient without causing harm to all the others.

Mrs. Jones is immobile and unable to use a call bell. She has had a bowel movement and it is smeared from her head to her toes.  I immediately stop what I am doing and clean her up, taking the time to reassure her and coax her into taking a drink while I am there.  Doing all that efficiently takes about 40 minutes.  Sounds good but there is one problem.  Your mother has cancer pain and she is in agony.  Two minutes after I commenced cleaning up Mrs. Jones your mother cried out, begging and sobbing for her pain killers. 

It will take me 10 minutes to hunt down her pain killers and 10 minutes to track down another staff nurse to check them out.  If I finish cleaning up Mrs. Jones first your mother is left in agony for an hour rather than 20 minutes.  If I immediately abandon Mrs. Jones to help your mother then I am leaving Mrs Jones in a bed smeared with shit for an additional 20 minutes.  And it is only 20 minutes if I ignore the other requests for drugs and commodes that are being shouted out to me as I run past beds.  If I stop for them, it takes longer to get back to Mrs. Jones.   Visitors will jump in front of me during this, angry and demanding that I speak to them about their Aunt Joan's care. They won't take "No I can't stop right now" for an answer so I get real stern and push past them.  As I am running back to Mrs. Jones'  bed I avert my eyes to ensure that I don't make eye contact with the other patients or that I don't get dragged into any other jobs, as they will only delay my attendence to Mrs. Jones even further.

Your son has just arrived back on the ward from surgery and post operative patients can deteriorate very quickly.  Patients with his issues are known to crash more quickly and dramatically than the usual post surgery patient. If that redivac starts to fill up and his blood pressure starts dropping and I don't see it your had better start planning your son's funeral.  Get the baby pictures and your black suit out.

Post operative patients like him get sent back to the ward too quickly from recovery, so that more people can get operated on.  If you have a post op patient like your son arriving back onto the ward you must immediately do a series of checks and jobs to ensure that he is okay and does not need to be rushed back into surgery.  If you do not document every single action that you do for this patient as you are doing it then you DIDN'T DO IT.  If you didn't document his observations, respiratory rate or document that you checked his morphine drip and redivac bottle then YOU DIDN'T DO IT.  And it doesn't matter if you have a thousand witnesses declaring to a court of law that you did do it but were too busy to document it on the paperwork.  Write it down as it is happening or they will say that you didn't bother to check that redivac and that is why this man bled to death.

I did good by your son.  I went to him as soon as he arrived back onto the ward.  I know how patients like him can crash.  I did all of the necessary checks and stayed with him to do look for an emerging pattern with his observations.  And there was a pattern.  His blood pressure was going down, his pulse was going up.  His redivac which looked good at first check 15 minutes ago is filling with blood. He is less alert than he was when he arrived back on the ward 20 minutes ago. I look at what I wrote and saw 20 minutes ago and compared it to what I am seeing now.  Oh shit. But we caught it and the doctors swung into action when I phoned them and implemented the necessary steps to sort him out.  He went home.  Had I delayed my checks on him I would have found a corpse in that bed.

Sounds like I did real good with your son but there is a problem.  At the time that the theatre staff were dumping your son back onto the ward I was at the bedside of  Mary.......  a lovely 50 something woman who is full of cancer.  She is going to die anytime and she knows it.  There is nothing that the medics can do and she has requested a DNAR.  Her pain is under control and up to this hour in time she has been smiling, strong and stoic.  She is completely aware. But in the last hour she has been scared, trembling and clingy.  All nurses know that patients know when they are going to go.  Mary has an inkling that today is it, and now she is terrified.  I was at her bedside when your son was dumped back onto the ward by theatre action that they could not delay to allow me to stay with Mary.  Her fingers were clamped around my arm "please don't leave me, please don't leave me".  I had to pry those fingers off of my arm and run out of the room to check on your son and nurse him properly.  Had I not, your would be dealing with the funeral home now.   As they were taking your son back to theatre the first thing I did was run back to Mary.  I ignored call bells, patients shouting for commodes, family member phone enquiries and averted my eyes to the visitors and patients in order to get back to Mary.  She had died while I was with your son.  I can't even feel good about the fact that we helped him because I feel so bad that Mary died alone and scared.

Do you see how the nurse can be at the bedside of one person, oblivious to her surroundings and focused on filling in documentation whilst another dies alone?  There will always be an observer (a visitor) watching this situation with an untrained eye.  And he will say "look at that nurse messing about with the notes of that young lad whilst other patients shout out for help".

What if I had stayed with Mary?  What if I delayed my checks on your son to go to the nurse's station and call Mary's family? There are visitors at the nurses station and once they saw me that would be it...I would never have got to your son on time. What if I cleaned every bed that was wet at that time and picked up every confused and elderly patient off of the floor or coaxed them into eating rather than doing that series of observations on your son?  It's all happening once and this is during mealtime. What if I hadn't bothered to document his initial assessment and change in condition so that I could sit with Mary instead?  Well, I can tell you now that he would not have received the help he needed.

It's mealtime and if I take all the time I need to feed one person it means that I will not see any others until long after the domestics have collected the trays in.  So I try to do a spoonful each.

If I go around with a cup of tea for everyone it would take so long that it would be to the complete and utter exclusion of all drugs and treatments that were also do at that time, and all day long.

If I go to the nursing station to answer your phone call about your loved one I am having to leave people who need help to do it.

If I am ringing your about a change in your grandmother's condition I am having to leave a confused patient who is climbing over the siderails to do it. I can spend an hour with her, repeatedly stopping her from falling out of bed.  The minute I leave to finally ring you about your mum's condition she will be on the floor.

If I am helping one patient with toileting and hygeine properly, than I am leaving 19 other patients without for as long as it take to help that one.  If I do a half ass sloppy job for each person and limit myself to 3 minutes each I might get to see all of my patients and catch and deteriorations in condition.

I am responsible for an elderly lady with dementia called Jane.  Jane cannot walk but forgets this.  She frequently tries to stand up and falls.  Even if I am there, kneeling in front of her and talking to her she still screams "Help me" and stands up and nearly falls.  I show her how to use the call light and she tries to eat it.  I give her food and she spits it out.  I could spend hours with her, reassuring her and making sure that she has all she needs to the exclusion of all other patients on the ward. I could spend those hours toileting her and cleaning her and stopping her from falling.  I could sit with her for 6 hours and do that.  Five minutes after I walk away she will be lying on the floor with a broken hip, lying in a puddle of piss.

And I cannot pick her up off of the floor  and clean her up without ignoring your father's cries for help, or delaying the treatment he needs for that massive allergic reaction he is having to those IV antibiotics he was just given.  His face is swelling up and his lips are blistering right in front of our eyes and his breathing is sounding wheezy.  Do I leave Jane on the floor to help your dad?  What do I do about the other patients who are making requests for care while this is going on?

Let me tell you.  The situation on the wards is crisis management. Everything is happening at once.  As a nurse you must look at what is highest priority and what can be left undone without killing someone (i.e. toileting). 1.  Life threatening problems and related paperwork, 2. pain control, 3. doctors orders, 4.monitoring for changes in condtion,5. medications, 6. treatments, 7.basic care (care assistants can help you with number 7), 8.discharge planning, 9.stupid  paperwork.

And when we are short staffed we are never getting past number 5.  Sometimes we cannot get past number 2.  Unless you want to cause harm you can never tackle number 7, not even for a moment, if numbers 1-6 for all 20 patients are not sorted out first.  You may not like the idea of leaving basic care undone while you do a never ending drug round.  But the facts are this: if you tackle basic care before ensuring that the higher priority stuff is dealt with you will almost certainly cause great harm to someone.

If I had only 4 patients I would get from numbers 1-7 and get it all done well before half past 10 in the morning.  With 20 patients It takes the first 5 hours of my shift to get to number  5 (if I take shortcuts that cause observers to view me as callous and uncaring, otherwise it takes longer) and after that I will only hit on various fragmented parts of numbers 6,7,8, and 9.

So this is what happens when we are short staffed.

Saturday 27 February 2010

Mental Nurse Blog: Staffordshire's "Uncaring" Nurses

This post is Out-fucking-standing.

Unison's new campaign "HCA's are Nurses too"

Apparantly Unison has been handing out badges for  health care assistants to wear that say "HCA's are nurses too".

I have now had 2 separate people contact me and inform me of the fact and would like to hear from others who may have seen this.  I need a little more conformation before I really show you why I termed myself a militant.

If it is true it is criminal ,and I cannot believe that an organisation like Unison would be so stupid and reckless.  I already knew that they were absolutely useless and in business to promote themselves rather than workers.  But hearing about this has made me realise that they are actually quite dangerous.

The lack of real nurses on our wards is a public health crisis that maims and kills.  I do not care how nice an HCA is.  I do not care how hard working she is.  I do not care how good she is at doing a bedbath.  The fact is that 1000 HCA's cannot replace one Nurse.  Nor can more nurses make up for a lack of doctors. 

I have well over 5 years of university under my belt and I cannulate.  So where is my "Nurses are Doctors too" badge.  Yeah right. I'd throw something like that in the goddamn bin.  And that is what any conscientious HCA should do with her Unison badge.

I was an HCA once, breaking my back to do bedbaths and getting in a huff about being ordered about by Nurses who seemed every so distant to their patient's basic needs. I drew blood as an HCA.  I performed ECG's.  I was a senior nursing student at the time and the Nurses allowed me to hang drip bags (under direct supervision), suction, and apply 02.  I worked as an HCA to pay my nursing school tuition.   I took observations. I made minor assessments of patient conditions and reported them the Nurse.  99% of the time my observations were wrong because my level of knowledge was not fully developed.  But I tried.  I, too, thought that I was "just like a nurse".

Of course I was not allowed to legally call myself a Nurse until I graduated from University and two months later sat and passed the licensing exam for nurses.  Then I was legally allowed to apply for a job as a Nurse.  And this I did.  It took a week to get a job.  During that week I was still an HCA at my old hospital.  They offered me an RN position but the hospital down the road paid more.

The first thing that struck me when I qualified was just how every different (and more demanding) it was to actually be a Nurse.  It was like getting hit by a lorry. 

It was like my eyes suddenly opened to what was really happening on the ward and why. I suddenly felt bad and ashamed for my previous frustration with the Nurses I worked with as an HCA.  I felt mortified for thinking that handling basic care , taking a few blood pressures, and doing bedbaths on my own for a large group of patients was stressful, or anything like being a Nurse.  My god, there is no similiarity whatsoever. 

We know that a lack of real nurses on the wards is killing patients.,  We know that an increase in care assistants staffing the wards compared to Nurses leads to poor care, tragic outcomes and death.  We know that a lack of Nurses in favour of health care assistants actually leads to increased costs.  We know that hospital chiefs do not want to hire nurses for the wards and that they are not trying to hire real nurses.  We know that I am going to be on my knees as one Nurse to 15 patients and that this is the case whether I have 2 or 10 care assistants on duty with me.  To be honest, 10 care assistants would be worse than 2.  They don't know what they don't know and they interfere and they need to have an eye kept on them.  I pity any doctor who has to cover a large group of patients with only noctors to assist rather than other doctors for this very same reason.

When organisations like Unison run around handing out badges to HCA's that label them as Nurses it completely undermines the claims we make for more real Nurses on the wards.  It adds to the confusion of patients and visitors. Yesterday I was the only RN on the shift with 3 care assistants.  The visitors informed me that they thought I was the "Sister" and the care assistants were my " junior nurses".  I corrected them, but the fact is that public doesn't have a clue.  They didn't really understand what I was telling them about the care assistants not being nurses.  They couldn't understand why the fact that I was in an emergency stopped me from bringing their dad his PRN pain killers at that moment.  "Well matron, if you are tied up in an emergency can't one of your junior nurses bring the morphine to dad?" they said.

Sometimes I will see a group of visitors stare down at a 19 year old care assistant who looks decidedly unprofessional and I hear them say "These new university trained nurses look like slobs".  Ha.  If only the girl you were staring at was actually a Nurse, or had ever been to university I might see your point.  This may sound cheeky but more often than not, the real nurses do look very professional whilst the carers (who have no professional standards)  do not. Enough said about that.

If we are going to fix the problems with Nursing care in our hospitals we need to fight every attempt to undermine RN's and replace them with care assistants.  I love the care assistants I work with, I do.  But depicting them as Nurses is unfair to them, the real Nurses, and the patients.

I can cannulate, interpret ECG's and bloodwork, draw blood and listen to lung and heart sounds.  But I am nothing like a doctor.  I can do certain physical tasks but I cannot pull the whole picture together in the way that a doctor can.  And an HCA cannot pull the whole picture together the way a nurse can.

I am going to look into this further, and then notify the NMC and I hope they deal with it.  I know I would be prosecuted for impersonating a cop or a doctor.  Why should anyone be able to call themselves a Nurse?  It is not legal and this needs to be enforced.

Doctors, I suggest you get on board with this.  Do you really want to see band 5 staff nurses running around  wearing "I can prescribe just like a real doctor" badges?  Didn't think so.  It sounds pretty far fetched but the current efforts to dumb done medicine and nursing appear to know no limits.

It's not going to be long now before we have one real nurse covering every ward in the hospital.  The ward staff will consist of health care assistants who will throw everything back onto the nurse's plate.

Wednesday 24 February 2010

Nursing Advocacy and Minnette Marrin

If you any of you are new to this blog you may not realise who Minnette Marrin is or what she has done to get on my bad side. 

Minette calls herself a journalist and has written extremely poor and badly researched articles about UK nurses for The Dail Fail and The Times.  I blogged about it here.

 The only thing that Minette's articles proved is that this woman has absolutely no understanding about what the word Nurse really means..  People like Minette think that any person who gets a job caring for patients in a hospital is  a Nurse.   There are many members of staff employed by the NHS to care for patients.  Most of them are not nurses and do not have the level of education that a Nurse has completed. If I have learned anything about the British press it is this:  To them, the term nurse is an umbrella term that is used to describe a worker who cares for patients.  Those of us with actual brain activity understand that the term Nurse is a professional title that one can legally use when they have completed enough high level education to register with the NMC.  Then you have jump through many hoops in the form of continuing education and payments to keep that registration.

The minimum level of education required to legally call yourself a Nurse makes the 3 years at university that a social worker, teacher, or an english major complete look like a walk in the park.  It is only the UK where those people are paid more than RN's.

Most people employed by hospitals to care for patients on general wards are not actually Nurses.  They can do tasks here and there but they cannot pull together the entire picture, give medicines or understand the rationale behind their actions.  They cannot assses or see the big picture. This leaves the few nurses around running between such a large group of patients that they are extremely ineffective, only barely managing to get most of the important drugs given during the course of their shift.  In order to do even that they must only focus on the drugs, to the exclusion of everything else.  It's horrible.  This situation makes it impossible for the Nurse's to do basic care and when basic care gets left to the care assistants important aspects of the patient's condition get missed.

I am not the only Nurse advocate who was upset by Minette Marrin's lack of insight and her promotion of lies and myths that undermine nurses and cause our hospitals to be even more dangerous.  The Center for Nursing Advocacy (now known as 'The Truth About Nursing') has also let her have it.  Despite  what Dr. Crippen has said about the Centre in his previous rants they are not an organisation promoting nurses as the new doctors.  They are not trying to turn nurses away from the bedside and into noctorhood.  Quite the opposite actually. .

Their brilliant piece about Minnette Marrin is  here.

Marrin's column did cause us to have concerns about declining standards, though nursing was not the focus of those concerns. (Marrin herself suggests, with admirable modesty, that even journalists may not deserve to be considered "professionals.") Marrin does not seem to understand the broader educational requirements of modern industrialized societies, which actually need more and more people with advanced training to create and manage all those wacky new gizmos (like the one on which she wrote her column), and fewer and fewer people to haul bricks and plow fields by hand. Increasingly, decent jobs require significant university education. But fortunately our current task is limited to addressing what nursing is and what nurses do.

Nursing is more about thinking than "washing." No one can be an "excellent" nurse unless he is also "bright," because nursing requires advanced health care knowledge and critical thinking. It is a distinct health care science led by thousands of scholars with doctorates in nursing. Nurses must initiate and administer complex treatments, monitor patients for subtle changes in conditions, teach patients how to regain health or live with their conditions, and advocate for patients with a range of other professionals, including physicians. In these ways, nurses save lives and improve patient outcomes every day.

But nurses who lack advanced training or intellect cannot effectively do that work. How does Marrin think nurses make "important clinical observations"--with feminine intuition? People in general may "vary hugely," and we appreciate Marrin's admission that at least some nurses might be "bright" and "academic," but good nurses, like good physicians, cannot vary hugely in every respect. You cannot be a good nurse if you're not bright, or not good at what nurse Rose on Grey's Anatomy memorably termed that "boring science stuff." Of course nursing also requires intimate physical work and good interpersonal skills, but so does medicine, and no one equates that profession with the "non-academic" aspects of the work. Nor does anyone argue that, because new physicians are often clueless about patient care, their extensive formal training is useless or even detrimental. Instead, new physicians gain practical experience through clinical training. So do nurses. In fact, physicians rely on nurses to spend significant time providing them informal training when they are new. Educating physicians too is quite a challenge if you're "not particularly bright."

There is compelling evidence that more nursing education leads to better patient outcomes. A Linda Aiken study found that hospitals at which only 10% of the nurses had bachelor of science degrees (BSNs) had twice the mortality rate of hospitals with 70% BSNs. A Needleman / Buerhaus study found that increasing the ratio of registered nurses (with 3-4 years of college-level training) to licensed practical nurses (with one year of *vocational* training) to the 75th percentile in all US hospitals would save 5,000 lives and $1.05 billion in total costs, decrease hospitalization by 1.5 million days, and decrease hospital expenses by 0.5% per year.

In fact, this is not Marrin's first foray into the supposed simplicities of nursing education. In August 2009 the U.K. press carried many items about a recent report detailing distressing cruelty and neglect by some nurses. One of these items was an August 30 Times column by Marrin headlined "Fallen angels: the nightmare nurses protected by silence." In it she argued that the problems stemmed not from a lack of resources but from a "cultural collapse" within nursing. Marrin attributed that decline partly to efforts to increase nurses' "professional status with a university degree," which had led them away from "old-fashioned bedside" care. But of course, good bedside nursing requires advanced university-level training, just as it requires compassion and physical skills.

It seems more likely to us that the weakness of nursing in many current settings, and the apparent lack of compassion some nurses display, is due less to a misplaced desire to attain higher status than it is to the weakness and lack of resources that are the natural results of low status and the contempt Marrin herself displays. Marrin recognizes that U.K. nurses receive "poor pay" and suffer from the handmaiden "stigma." She just seems to think nurses should be happy with all that. Maybe such forbearance would keep the "angels" from "falling." But when a profession is not respected by society, when it is subject to abuse and neglect, it is more difficult for practitioners themselves to respect it.

That last line bothers me a bit.  Bedside Nurses understand what they do.  It is the people who manage us who do not.  When nurses have 20 patients each it should be easy to see why they appear to be uncaring.  If you cannot spend more than 30 seconds at a time with any patient then you will appear callous.  The Nurses are not uncaring.  The problem behind the uncaring image is actually short staffing.  But other than that  The Truth About Nursing is spot on.  The poor image of Nurses perpetuated by the media in this country is the number one reason that care in our hospitals is so bad. 

When people cannot distinguish between a Nurse and a poorly or untrained assistant it gives penny pinching managers a license to not staff their wards in a safe manner.  If people do not think that nursing care is complex and important, the wards do not get staffed and resourced or invested in.  If I am one nurse to 20 patients they will suffer and die whether I have 2 care assistants helping me or 10 care assistants helping. They will not get their medicines, the doctors will not be given proper information or detailed snapshot of the patient condition. They will crash and it will not be noticed in time.  Crucial aspects of care that care assistants do not understand will get missed completely.  

Nursing at the bedside in acute care is too challenging mentally, physically, and emotionally to keep on doing with no respect and little pay.  The RN's run for the hills and your NHS overlords love it because they would rather have poorly paid unprofessional assistants around than actual Nurses.  They know that the public is so dumb that they will refer to the teenage care assistant as "that young nurse" and think that the ward is staffed with such nice "young nurses" who "brought mama a cup of tea". This line of thinking  is killing thousands of patients every year.  It would be barely tolerable if we were working with the internationally recognised safe ratio of one RN to 4 patients.  But what goes on in the UK with RN to patient ratios is absolutely obscene.  And that is exactly what led to this here.  Make no mistake about it.

The Truth About Nursing website is promoting a book called Saving Lives: Why the Media's Portrayal of Nursing Puts Us All at Risk.  Some excellent reviews here.

The Truth About Nursing announces the publication of its leaders' new book Saving Lives: Why the Media's Portrayal of Nurses Puts Us All at Risk. With striking examples and an irreverent style, the book explores nursing stereotypes from TV shows to the news media, and it explains how these images affect real-life decisions about nursing. The book also offers a comprehensive plan to help everyone improve nurses' image--and public health.

Poor understanding of what nurses do undermines claims for adequate staffing, and leads to a lack of resources for nursing practice, education, and research. All of that means worse patient outcomes, including death.
One study I read showed that RN staffing levels at the bedside had a more significant impact on patient care and survival than board certification of Doctors.  And that makes sense because it is the RN who implements all of your doctor's orders and treatments.  You may have a brilliant doctor with brilliant diagnostic ability but he will not be at your bedside.  Even with that brilliant doctor on your case you are still very likely to die when your overwhelmed nurse is unable to implement the doctors treatment plan and monitor your condition.  Even with a brilliant doctor  on your case you can still perish as a result of medication errors made by a rushed off her feet staff nurse, you can succumb to infection or malnutrition.  The doctors cannot fix some of the errors we Nurses make. 

If your RN has 20 other patients you could easily become a failure to rescue statistic.  Remember that the nurse is at your bedside, it is her legal responsibility to monitor you and understand the ins and outs of your disease process and your treatment ordered by the Doctor.  Remember  that the Doctor is usually the second person to know about your change in condition, and that untrained care assistants are not educated enough to know what the doctor needs to be made aware of regarding a patient's condition, nor can they implement any kind of treatment plan.

If you get time and have the inclination be sure to check out The Truth About Nursing website.  And don't forget to drop Minette Marrin a line.  Journalists benefit from higher level education as well, and you can help her out with that.

Monday 22 February 2010

Some Nursing News to Ponder

This week in the Nursing Times we have a couple of articles that caused me to have the usual reactions:  "WTF?" and "Sigh".

The first article lead to my 'WTF' reaction is here.  I would like to know how we are going to implement any of this when hospital managers refuse to communicate with frontline nurses, listen to their views or acknowledge their existence.  Even our ward sisters are not allowed any say over how they staff their wards.  And those people (sisters) are anything but passive.  They are outspoken and they are ignored. The fact is that 99% of the deterioration in the public's view of nurses is down to horrific levels of care secondary to short staffing.  One of our hospitals main managers (non clinical) turned his back on the Sisters when they formed together to explain the problems with poor RN to patient ratios to him.  And he has refused to discuss it or meet with any nursing staff ever since. 

He did issue a mandate ordering the registered nurses to stay on top of audits or else.  He was told that we don't even have enough qualified nurses to fire fight or manage basic care on any shifts let alone play around filling in audits.  His response?  "Audits ARE basic nursing care" and "you are not short staffed".     I'd love to know what kind of matrix they use to assign appropriate staffing numbers at my trust.  Maybe it works on whatever planet he is from but it sure as hell doesn't work here on earth.

Then we have this.  Waste of time really.  It has always been considered wrong for anyone who is not on the NMC register to call themselves a Nurse.  It isn't the HCA's who are calling themselves nurses.   They just don't correct the patients who call them nurse because it gets too confusing for the patients.  The public are calling the HCA's nurses because they don't really understand what a nurse actually is or what the term nurse means.  Joan Public thinks that if she has someone who is kind and washes her hair for her in hospital that she has one hell of a good "nurse". 

A large proportion of the activities that an RN undertakes to keep Joan Public and the ward's 30 other patients alive is completely invisible to Joan.  So Joan she disregards the RN and promotes the HCA as the good nurse.  The reality is that the RN has a higher workload, total cognitive overload, longer hours and more responsibility than the HCA ever will....for only a few £ an hour more.  The RN also has the fear of god in her.  But to Joan's untrained eye the HCA "cared" for her while the RN ran about "doing paperwork and tablets".   Oh Joan, if only it were that simple and easy.  The  Registered Nurses never would have run away if it were that easy.

Thus the shortage continues because it is just to hard to do this for no recognition.  There is too much responsibility and no control.  Run from the wards guys, run.  Run like hell if you are studying to be a registered nurse and don't look back until they swear on their lives that they will fix it.  Run.  Australia is very nice.

Sunday 21 February 2010

A Question for the Doctors.

You say that you have no problems with ward nurses and that you understand that they are in an impossible situation.  You say that the ward nurses who do real nursing have your respect and that it is the noctors that you hold in contempt. 

So why is it that the consultants only ever yell, scream at and abuse the ward nurses over lapses in care? 

Anyone overhearing your rants would think that it is the ward nurses who believe that they are above basic care .  Or they would be given the impression that the ward nurses don't want to be bothered staying on top of nutrition and hydration. 

You know that it is impossible for them to stay on top of it for all of those people. You know that they only have untrained carers to help and that is why fluid balace charts, weights, and observations are not getting done properly.  You know the nurse can't leave the carers on the ward while she  attends ward rounds because that will lead to even more fuck ups and blunders that will cause the nurse to get a smack down. You know that the ward nurses are getting denied training to keep their skills up and are interrupted so frequently that they cannot even see their patients or read the charts.

If you want to let nursing profession have it, why not go for the throats of the noctors, the nurse managers, and the matrons who have not only accepted cuts in nurse staffing on the wards, but look the other way and refuse to go down there and give a hand?  Why soley go for the staff nurses?

Explain it to me.

The Nursing Students.

There seems to be a lot of myths about modern nursing students here in blog land.  I see these same kinds of lies and distortions repeated in newspapers and conversation everywhere.  It is like some kind of weird groupthink situation.  People jump on the bandwagon without having any idea about what they are talking about.  What do you know about what educational requirements a nurse requires to do her job safely?  What do you know about what he/she studies in nursing school?  Unless you have experienced it firsthand, the answer is that you know fuck all nothing.

Myth number 1:  Nurses do not need to be university educated.

Well, as of right now anyone who actually qualifies as a nurse is university educated.  If you want to be a nurse you either need to do 3 years on a diploma or 3 years on a degree.  The difference between the degree and the diploma is one essay. It is tougher than your average 3 year degree at university and it needs to be.  Many of our nursing students are older and are taking nursing on as a second career.  They have previous degrees.  I have a previous degree and I agree with the majority that nursing school is harder, more work, more to learn, and more pressure. It may not be law school or medical school but it makes degrees in things like english, social care, history and teaching look like a walk in the park. 

 Very few of these graduates are getting jobs on the wards because managment thinks that cheapest is best.  They are hiring untrained kids off of the streets instead.  These people cannot do the job of a nurse but are staffing the wards instead of nurses.  This means that many aspects of patient care gets left undone because the untrained kids are incapable. 

  Bring the Enrolled Nurses back and you will have one EN on a shift for 30 patients, with the rest of the staff being untrained, uninterested, and unregistered kids.  If you take nurse training out of the university and train RN's under the old fashioned method the same thing will happen.  Anyone who has any training needs to get paid more than minimum wage and is legally bound to speak out about problems.  Management does not want anyone like this staffing the wards.  They want untrained cheap labour. If you even have a smidge of training they don't  really want you.

Let us not forget that as the education level of your bedside RN increases, your risk of dying and complications decreases.   If that RN is given too many other patients, with either no one or only poorly educated untrained kids to assist her, your chances of survival plummet..  You want stats?  Look to the right hand column on this blog's home page.

Myth 2: They pulled nursing students off the wards to go to university.

Bullshit.  All nursing students have to do at least 2300 hours working on the wards or they do not graduate. Fullstop.  Good essays and exam grades will not save you if you haven't put in your time working on the wards. The university education of nursing students is in addition to ward trained vocational training.  The ward based and nurse theory training  occurs simultaneously with their classes at university.  My nursing student worked three 14 hour shifts and a 12 hour night shift last week on the wards. And they have their regular school work as well.  The nursing students in the 1970's could function as a nurse because worries about liability did not stop them from giving drugs or caring for a group of patients unsupervised.  A student could take half the ward as a primary nurse back then and any mistakes were swept under the carpet.  These days, a student nurse cannot do anything without being under the direct supervision of the RN.  This means that they cannot just go off and take on a group of patients while I cover the other half of the ward.  It is down to liability.  If something happened to a patient, and the barristers found out that a nursing student involved was caring for patients in the way that a nursing student is the 1970's was, all hell would break loose.  The hospital would lose a very big lawsuit.

Myth 3:  Nursing students  sit at the desk doing paperwork and protocols.

I have two degrees, one in nursing and one a bit liberal artsey. I have been a university educated bedside nurse since the early 90's. I have never had anything to do with writing protocols, nor I have seen protocols.  So why would a nursing student?   The nursing students are taking care of patient needs that their nurse mentor cannot get to because of high ratios.  They bust their arses doing so but often have no one to show them properly how to do things.  We show them the very basic basic paperwork that needs to be written to get the patients the things that they need and documentation that is required for the lawyers.  And we don't even get that stuff done well.  The students come to the ward with packets of paperwork for their nurse mentor to fill in and sign off to prove that they know their stuff.  

There is no time to do this whilst on duty as the only RN for a large number of patients.  I have found that the only way to get through the initial interview, the midplacement interview, and the final interview is to come in unpaid on my days off and meet with and assess my student.  Then we sit down and check off whether or not she can insert a catheter, dress a wound, etc etc. The hospital and the university know that the nurse mentors are in no position to mentor properly but both institutions cry "no money, no money" when ideas such as  official clinical mentors in addition to ward staff are mentioned.  My nursing school  (non UK) had official clinical mentors in addition to ward staff to work with the students.  These clinical mentors came to the wards with us from univeristy. They worked for the univeristy.  But they were also experienced staff nurses at the hospital we were training in. Believe me, this is the way to go.

I love mentoring so I don't mind even coming in on my days off unpaid for the odd hour or two. And it is a good thing I don't mind because you don't get a choice about whether or not you mentor if you work as an RN in an NHS hospital.  Mentoring is required to get your yearly pay increments.  It is a requirement to go through the gateway. So if you don't do it you don't get your normal pay rise, and that is all the pay you get for it.  I am getting a new student tomorrow to follow me for the next few months.  His first shift with me is tomorrow.  He had his first shift on the ward on Friday.  That was my day off so I ran into work for an hour to meet with him and plan his learning objectives etc and do the initial interview.  We will have no time for that shit tomorrow when he is following me as I will be the primary nurse for many patients. 

Myth 4:  Nursing students are supernumery.

Everytime I hear that line I laugh and laugh and laugh.  Nursing students are still very much unpaid labour used to staff the wards. If we have students on the ward, our manages use that as an excuse to get rid of care assistants and not book any agency carers for the shift.  I have often been left with a large number of very ill patients and only a nursing student working with me. Most of these students jump right in, get their hands dirty and do the best that they can.  It is chaotic.  It is disorganised.  It is a terrible learning environment for them.  They learn nothing but how to take enough short cuts to ensure that they can answer 150 call bells a minute. I will try and show a first year how to do a bed bath and what kind of assessments they need to be making when doing a bedbath, and how to tie all that in with what the medics are doing for the patients.  I will get 30 seconds into something like this before I am called away and have to move onto something else.  The interruptions are relentless, constant and never ending when you are on a ward nurse. The student ends up just learning as they go without their mentor teaching them the right way.

Recently I blogged about taking a critically ill patient who should have gone to ITU (no beds).  The nurses on his short stay surgical unit couldn't handle him so the site manager turfed him to my ward.  He was in no state for any kind of transfer.  He needed one to one constant care.  I thought my student was about to see her first crash and  quizzed her about what she needed to do in that situation.  This situation left my nursing student caring for my other 14 patients alone.  She could not medicate them, or do IV's or many other things because it must be supervised for legal reasons (i.e. trust doesn't want to get sued) so those things just got missed.  She did what she could do: the vital signs, the basic care, catheter care, fluid balance charts, call bell answering, etc.  She ran her ass off without a break to stay on top of all that for all those people.

DinoNurse has seen the same things at her hospital:

Why exactly should the NHS be left to sort out social services, housing, bills, pension payments et etc? Why should acute beds be blocked whilst relatives drag their heels over picking where to bundle granny off to? Acute wards then get turned into halfway houses and management types assume that they can scrap the RNs and staff these wards with HCAs...never mind that such a mix of acutely ill and frail, uber dependent patients is a recipe for starvation, infections and disaster. Just last week I transferred an HDU patient to a medical ward staffed by 2 RNs and a student. No HCAs or APs. Place looked like Beruit. After handing over BOTH RNs asked when ICU would be recruiting agin. Out of guilt I phoned the unit and stayed to help do the IVs so that they could try and feed some of the patients. Then I helped the student to bedbath the half a dozen patients that were still in wet beds. Enter floor manager just as I am wheeling the overladen skip to the sluice to rebag it..."oh sister, why aren't you in the ICU?" Gave him one of my famous Lisa Simpson stares..." agency were booked but didn't show" he stammered...then turned on his heel and RAN back to his office. I swung by on my way back to the ICU and informed him of the IR1 that would soon be landing on HIS desk for a change.

Myth 5:  Modern Nursing students are to posh to wash and to clever to care:

It strikes me as hilarious because I haven't seen any evidence of this in over a decade of nursing and over 5 years of mentoring. If anything, the nursing students are so bullied and harassed by the health care assistants(who think that the students exist to ease their workload) that they do not learn enough about professional nursing before they graduate. Nursing students are knee deep in shit cleaning and basic care for the entirety of their training. This is a component of proper professional nursing but it is not everything, not by a long shot. When they qualify and are thrown onto the wards as the sole RN for a large number of patients they struggle as a result of spending more time with the care assistants than the nurses whilst they trained.

The nursing student has to be strong. He is a year from graduating and has spent his placements working for the care assistants while his overburdened mentor struggles to do her job. Now he is scared. In no time he will qualify and he doesn't feel that he has spent enough time on the aspects of care that only a registered nurse can accomplish. He has spent all of his placements bedbathing and working for the care assistants doing basic care. He decides to stand his ground. He tells the care assistants that he will be doing the drugs and the assessments, the admissions and the discharge with the nurse today. He is going to stick to the nurse like glue and learn how to keep track of and process the vast oceans of information that a nurse needs to stay on top of for all these patients. He is going to learn the system he has to be able to manipulate in order to do his job. He is going to handover to the oncoming shift. This is a crucial skill. He needs to be on top of everything to avoid disaster and he needs to learn how to do it. In no time he will have a nursing license and he will have to do it all with no support. He realises this, his mentor supports him and he tells the care assistants that he is going to stick with the nurse this week rather than helping them do all those turns and feeding as usual.

The health care assistants do not understand why he has taken this stance. They think he is disrespecting them. They think that he is on his high horse, uppity and snobby and imagining himself better than them. They think he is lazy and that his university education is causing him to believe that he is above the basic care that he has been doing all these years of training. They get angry. They resent not having his help doing all that physical labour. He is an extra set of hands that they need. Then they tell anyone who will listen that the new nursing students think that they are above basic care.

Many nursing students are not strong enough to say enough is enough to the care assistants.  There is so much pressure on students to just be that extra set of hands all the time. Then they qualify and all hell breaks loose. I have seen more than one new RN sacked for errors. The reasons for these errors is because their placements consisted of working for the care assistants rather than learning how to be a nurse. When they qualified, they were unable to make the transition over.

That is of course, assuming that they can actually find a job when they qualify.  If they do manage to get a job on the wards they will run away screaming a year later.  The sheer volume of patients they will be expected to take care of at once without any support are absolutely brutal and it sucks the life out of you.  This  in conjuction with general working conditions on the wards achieve a level of abuse that most people cannot take and remain sane, well balanced and articulate.  We do lose far to many of them before that first year is up. 

The problems on the general wards these days are a result of a lack of trained, experienced, educated and registered staff. The vast majority of the staff on the wards should be well educated and registered. This is cost effective and it stops patients from dying. The reality is that the vast majority of staff on the wards are untrained, uneducated novices doing a learn on the job approach. They are apprentices, care assistants and nursing students. We don't need to go back to old fashioned vocational nurse training in order to get cheap and free labour by non academic but caring people. We have that now. We have far too much of it.

I'll never understand why people blame university educated nurses and nursing students for the mess we are in. You need to be looking at the people who control the ward budgets...and those people are not nurses.  They are not ward sisters or matrons or nurse managers either.

We need more proper well educated RN's staffing the wards full stop.

Wednesday 17 February 2010

The Police: Meet PC Bloggs

Doesn't sound like they have been having a good time dealing with the pressure of targets, and dealing with paperwork to make it look like the powers to be are doing a fine job.  This is another group of people who are trying to do an important job with their hands behind their backs.

"999... what is your non-emergency?"

Julie Spence thinks that the public do not expect police to attend every 999 call.

If she's referring to people who dial 999 to ask how to boil an egg, or because they need to renew their driving license, she probably has a point. And it is perhaps unfortunate that her quotes in the above article are put in conjunction with a report of a man who called 999 to be told no police were available, and was then get beaten up by his assailant.

However, her remarks reflect a Senior Management Team blindness to the reality down on the front-line. During my first month as Acting Sergeant, I was the duty skipper on a Friday night. At about 1am I ran out of troops: my seven or eight PCs being either in custody or at other emergencies. Over the next hour there were a number of unresourced jobs, and at least four of them running simultaneously were of a nature where the public would expect the police to drop everything and attend:

A 'no requests' 999 call with a female screaming at the top of her lungs in the background.

A guy being beaten up by a group of five others.

The pressing of a 'high risk' domestic violence victim's panic alarm.

A burglary-in-progress: three masked intruders smashing in a window to someone's house.

I had literally no staff to send. My inspector had no staff to send from other areas. The next areas over again had no one. The jobs were not attended.

Three hours later I returned to the station and logged onto the terminal. The four above jobs were still there, unattended, along with ten or fifteen less urgent ones (involving missing teenagers, assaults where the victim just got home from hospital, burglaries from last night). I updated the inspector that we still had four 'grade ones' unattended.

'Well they're not exactly Grade Ones any more, are they?' was the response.

As the rest of my team was still not back from their commitments, I drove to the four locations myself to establish that- bizarrely- the woman had stopped screaming, the guy was not lying in the road, the high risk victim's alarm had stopped, the burglars had run off. As it so happens, my inspector was right: by the next night the jobs had transmogrified into missing teenagers, assaults where the victim just got home from hospital, and a burglary from last night.

Since the above, our minimum staffing levels have decreased, we now have a single-crewing policy, we aren't allowed to drive more than a certain speed even on 'blues', and we're under more pressure than ever to detect priority crime which means carrying out lengthy enquiries into every incident no matter how minimal the chance of conviction.

No doubt my blogging about this will be labelled 'undermining public confidence' in the police.

Well I have news for CC Spence and Blandshire's Senior Management. It isn't blogging about unresourced jobs and under-staffed response teams that scares the public: it's under-staffed response teams. It's picking up the phone in your hour of need and no one coming.

If you don't like us blogging about it, DO something about it.

Well said.

What I would like to know is why doesn't the daily fail refer to the police officers themselves as uncaring and lazy for not being able to attend to every emergency that gets called in? 

They are immediately defended by the Daily Fail as being hindered by government targets or management cock ups.  Their senior managers are blamed rather than the individual PC.

When a lone  nurse caring for 20 critically ill patients by herself is unable to answer a call bell to bring someone a vase for their flowers because she is up to her eyeballs in preparing and administering life saving meds the Daily Fail labels her uncaring and cruel. 

What about when a registered nurse has 5 critically ill patients who need one to one monitoring and intervention at mealtime (no they don't just suddenly get well so that I can leave them and feed people) on top of 7 patients who all need to be spoonfed at the same time?

 What about that fact that the nurse has 20 minutes ONLY from the moment the food gets brought out until the moment the domestics collect it back in?  Have you ever spoonfed 7 people in 20 minutes?  People who take 15 minutes each to process and chew one bite?  Even if I did leave the ill patients who will die if I leave them to feed the others I would still fail to get anyone fed.  In this situation the nurse is accused of intentionally starving people. Papers like the mail  never look at what our senior managers are doing. 

My Trust still thinks that losing RN's and staffing each ward per shift with 1 or 2 RN's and 3 untrained assistants saves money.   It kills people, it costs money and it completely stops the RN from being able to function at all.  They are aided along in this premeditated murder and encouraged to keep RN's away from the bedside by a media who will slam the nurse for failings in care without looking at what else was going on during the time that the failings in care occurred. 


If you remember anything I ever wrote on here remember this line:

If you do not know who many other patients your RN has and understand exactly what is going on with those patients, then you DO NOT understand why you were not attended to or why failings in care occured.   So don't even start with the "my nurse didn't bother" bullshit.

I wish someone would explain that to this asshole,  Frank Fields MP.

Sunday 14 February 2010

OH MY GOD. The Daily Mail published a Truthful article/ Discharge Hell

Thanks to Glamorganist for drawing my attention to this article

This isn't scare mongering.  It is true. I have seen this very kind of thing with my own eyes.  Female medical patients always get the least in the way of resources, staff and facilities.  It is TRUE TRUE TRUE.  Any stable patient, including surgical patients waiting for an operation can end up in a cupboard of course.  But mostly it is female medical patients who are actually medically stable that get the honour.

You know I hate the Mail.  But credit where credit is due and all that.

They force us to wake them up at 3AM  because they want to transfer these patients to a holding area that may or may not be staffed with real nurses and get the acutes from a&e onto our ward.  The holding areas are staffed with people who can handle a medically stable little old lady who is waiting for a bed.  But they cannot handle the acutes from a&e and mau who are breaching the targets because we have no beds.

"Nurse Anne, just refuse to wake patients up for transfer to a cupboard" you say?  I did that once because I knew that the little old ladies' families would have me for breakfast when they found out that gran was moved to a day surgery suite not equipped to handle medical patients at 3AM.  The  site manager did it herself (moved Granny) behind my back while I was with another patient.  I was wrong to refuse however.  The acute patient needed the bed more.  The acute patient could have died without the bed. Gran would not have.  I just didn't want to get bitch slapped by Granny's daughter.  Of course I was the one left to tell the daughter that she was moved at 3AM.

Do we really have to put people in supply cupboards or hallways?  

At my hospital they go to a storage hallway that is used as a day surgery suite 9-5 monday to friday.   There are no commodes or bedpans.  No linen.  The drugs that medical patients are usually on are not there.  I would find it extremely uncomfortable to sit in there all day and all night and I am a fit and healthy middle aged woman.

This is how it usually goes:

The hospital has been on alert all week because of a lack of beds.  This kicks into high gear overnight when a&e clogs up with drunks. At 1 AM the bed managers realise that there are now more sick patients in a&e  who need to be admitted than there are free beds in the hospital. 

75% of the ward patients  are medically stable and do not need to be in hospital. But they cannot be discharged. 

The manager opens up a cupboard or a hallway to take these A&E patients.  But she doesn't have any RN's to staff it because there isn't even enough of them on the wards to even cover ward patients.  There is only one RN on each ward and those wards are full of people who need an RN.  She only has untrained carers to pull off the wards and use.  The sick A&E patients cannot go to the cupboard staffed by the carer.  The stable ward patients waiting for discharge who aren't on any IV's or anything can go to the cupboard, staffed by the carer and the really sick patient in A&E can go to the ward with the RN.  The stable patients are okay for awhile with a babysitter rather than a nurse.  Of course they think that the babysitter is a nurse anyway so they are none the wiser.

The stable ward patients  may have dementia, they may not be able to walk or feed themselves.  It isn't due to sickness, just old age. They are waiting weeks for the social workers to see them as required before they can be discharged. They have to be declared medically stable and ready for discharge for the social worker to even think about finding time to show up onto the ward and assess.  Then they have to wait weeks for a nursing home to be identified.  Once that happens we wait weeks for the nursing home to come and assess the patient.  In the meantime a stack of paperwork has to be filled in by the staff nurse and sent to social workers.

 One nurse to 15 patients does not have time to dick around and only will attempt to do that paperwork if she gets all of her patients nursed properly.  If the paperwork gets done it is because we stay over after the end of our shift to do it after a new staff nurse takes over from us.  The delays in filing the necessary paperwork delays everything else.  I know people think that staff nurses are sitting around doing paperwork all of the time.  But in reality we blow 95% of it off and only do the crucial the ones you need to get life saving drugs that you require immediately.  And that 5% is very time consuming.

Once the nursing home asseses the patient they let us know whether or not they will accept her into their facility.  After that happens more forms have to be organised and completed by the RN-who has 150 meds to give and patients screaming for help.  I once a saw a community social worker phone the ward and order the RN to have a long and complicated care profile form filled on for a patient he was trying to place.  The RN did not have time to do it because of patient needs.  An hour later, the social worker arrived at the hospital and was on the ward.  He backed the RN into the corner and told her that if she didn't make these forms a priority than she wasn't a "real nurse".  She was the only RN for 14 patients that day.  10 of them were acutely ill.  The patient in question was stable and fit.  She just needed placement in a care home because she was forgetful.

 The social worker sat with a cuppa and stared the RN down until she did it. Well, actually I did it for him because my patients were okay and I felt like I could leave them long enough to fill in the profile and get the social worker off of our backs.  Once upon a time we had hospital social workers who did this stuff.  Now we have community social workers and hospital discharge nurses who just order the sole staff nurse for 15 needy patients to do it.  Whether a patient is going home with carers 4 times a day organised by the SW, or to a care home, or to a nursing home the staff nurse has to complete a whole lot of paperwork to set any of it in motion.

That brings me to the next problem
No only is the discharge process for medical patients a mess but the fact that there are no stepdown, rehab, or nursing home beds available EVER also slows things down. Even if the nurse blows off her patients to do the social workers job for her, the fact that there is not enough community care /carers and beds really slows things down as well. 

The community carers will go in 4 times a day but not at night and that is when Gladys really needs someone.  The residential home has no beds but won't take Gladys because she needs two staff to walk rather than one some of the time.  The nursing home won't accept her because they think she is to fit to be there.  The rehab facility won't take her because she is incontinant. And there are no beds at any of these places anyway. Oh and even if there was, I don't don't have the time to sit on my ass and fill in forms for social workers to set the process in motion. It is going to take me 8 hours just focusing on the drugs to get my really sick patients treated.

In addition to all these stable patients being babysat on acute medical wards we have another problem.   They have reduced the number of hospital beds (PFI anyone?),  they have NOT increased any care beds, nursing home beds, rehab beds, or community carers that see to people at home.  The number of elderly people out there is dramatically increasing.  And we have targets that mean that 98% of patients who come through the door must be treated in an artificially compressed time window.  If they are not, the hospital is punished by losing even more funding, which stops them from having any hope of actually adding more beds.  They only get funding and money if they can meet these targets.  No one thought to give them the beds and the staff and the support so that they could actually meet the targets.  The targets have to be met before they can get any funding or have any chance of being able to build beds.  Fail at the targets and your hospital actually gets fined rather than funding.  So if you fail at the targets you have no chance of getting money to build the beds that you need.

Therein lies the problem.

When everything finally goes through 6 weeks after granny was declared medically stable and fit for discharge and she gets that care home bed there is another form we have to send off to the SW.  Then we can arrange transport. Two days later granny will be back in a&e because of a "funny turn" i.e. a mechanical fall described by nursing home staff as a collapse and increasing confusion.  She will get bloods, ecg's, a ct scan etc so that the medics can cover their asses.   Maybe it looks like she brewed a nice hospital acquired chest infection while she was here two days ago.  IV Tazocin is ordered. 

And another little old lady who is on the ward awaiting a care package on discharge will be shoved into a cupboard to get granny number 1 out of A&E before she breaches the targets.  It is decided that granny can't go back to the care home now, she actually needs a nursing home.  So the whole entire process has to start again with the hospital RN working for the community social workers and filling in forms for social services.

The hospital chiefs CANNOT admit this stuff to the surrounding community because if they do, their heads will role.  So they come out with garbage like "uncaring nurses" "Incompetent doctors" "too many staff off sick" and they tell the members of the public who complain that "The ward sister will call a ward staff meeting about your grandma being put in a cupboard so that they understand that this should not happen.  We strive to provide the best service and are sorry about your disappointment".  What a joke.  Half the wards don't even have ward sisters because they retired/ran away screaming and the managers will not promote or hire anyone to "save" on labour costs.

If you have read all that well done.  Can I just say something to any consultants who may be reading this?  It really doesn't help matters AT ALL when you walk onto a ward and say in a loud booming voice for everyone to hear "I discharged Mrs. Smith two days ago.  Why is she still here?  Why haven't the nurses bothered to organise a nursing home for her yet?"  Seriously man, Fuck you.

Friday 12 February 2010

A Tale of Two Shifts

Don't worry.  I am not going to go all Dickens on you.  I am longwinded enough already.

Once upon a time in January 2010:

Monday Early Shift:

Two staff nurses (and 2 untrained agency carers with their fingers up their  noses) for 30 patients.  Nurses receive written warning from managers that we must attend ward rounds and drop what we are doing to attend them as soon as the consultant steps foot on the floor.  Staffing is not an excuse to miss them.  There are 8 different consultants.  Was on ward rounds from 8:30 until 11:30.  Didn't even get half of the 8 AM tablets started until half past 11.  That means that 4 hours into my shift I hadn't seen most of my patients at all.  The ones I did see only had me in the room long enough to throw their tablets at them. Then the next lot of consultants came at 12:15 and kept us until well after 2 o'clock.  They don't move very fast, these consultants.  I don't think anyone was fed.  Sometimes 3 of them will show up at the same time and all stand there talking at once demanding that the lone nurse follows them around.  We don't know when they are coming and can not plan for it.

I was supposed to finish work at 3 PM.  I left at 7 PM.  Unpaid for 4 hours.  I accomplished nothing in the 12 hours I was there and barely saw my patients. Patients deteriorated.  Tablets were rolling across the floor.  God knows who had what, or if they ate, drank, voided, were turned or if there were any new orders from the medics.

This is the norm these days.

This is the norm before people start calling in sick.

Thursday Early Shift:

A miracle happened  Thursday and I enjoyed it immensly because it may never happen again before I leave.

We had 4 experienced staff nurses and 2 experienced health care assistants to 28 patients.  Two of the four staff nurse (myself and Jane) had also been on Monday AM.  Our ward sister was also there on a management day and we actually had a ward clerk to answer the phone for part of the morning.

I had 7 patients to medicate for the 8 AM drug round, which I accomplished by 9 AM even
 though I took the time to assess them and help them with their breakfast.  There were no longer an IV's.  But no one was for discharge due to social cirmcumstances.   At 9:15 I was bedbathing and care planning. Only 3 consultants showed up for rounds.   Everything was done and ready to go.  The health care assistants finished off the bed bathing etc while I organised and implemented all the consultants new orders.  I got a lot of extra things done as well.  I took a 45 minute lunch break to make up for the 4 hours unpaid  and lack of a lunch break on Monday.  While I was eating my patients were cared for by another RN.

I feel very refreshed, like I just had a long vacation.

What were the patients' and the consultants view of all this?  "Oh you nurses are so much better than the ones who were here on Monday. Those lot either ran around frantic (Jane and I) or had their fingers up their noses (agency carers)"

Um, we are the same nurses who were here on Monday with a lot more in the way of help and resources!!

Now wonder management gets away with short staffing.

Tuesday 9 February 2010

An article about the Kids from The Sunday Times.

This article is better than the usual rubbish that we get about nurses.  But the headline pisses me off;

Novices do Nurse's Job

They did hit on a lot of good points.  Then they fucked it all up by implying that nurses brought novices into the hospital to avoid hands on care.  Nurse have no control over hiring, firing, staffing matrixs, or skill mix of ward staff at any given time.

It is true that our hospitals hire people off the street and throw them onto a ward dressed in a nurse's uniform.  They are not even training them to be health care assistants  anymore.

These people are thrown right onto a ward instead of trained and experienced staff.  Absolutely.

The problem I have with the article is the headline really.

"Novices do Nurse's job"

Oh no they are not.  They are incapable of doing a nurse's job.  They are there on the ward.  They may wash patients and make beds if they feel like it.  But these things are a far cry from an accurate description of a real nurse's job.

If I am working on a ward as a nurse and the only other staff I have with me are two or three apprentices/care assistants then there is ONE nurse on duty.  This article makes out that it is the nurses who are wanting to dump all this work onto the novices and that really leaves a bitter taste in my mouth.  The lone nurse simply cannot attend to everything by herself.  She knows what needs to be done, she knows what the consequences are.   She starts out doing the things that only she can do (this is the stuff that makes a huge impact on patient survival) and she delegates the easy stuff to the novices. There is no other way to do things if you are the only nurse.

As the only nurse I am on my own with all the:

Medications  (40 minutes out of every hour of my time for much of the day)
Drips/calculations and monitoring
NG tubes,
Diagnostic tests organisation and preparation
discharges (complicated and time consuming)
communication with doctors, physios, pharmacy, path lab, specialists (they all go through the nurse rather than talk to eachother)
assessments to avoid "failure to rescue"
wound care
Peg feeds (I have never seen a care assistant change any kind of a drip bag)
suction/trach care
02 delivery and management
post procedure management and care
communication with family members (I cannot get 2 minutes straight free of this to see my patients)
specialing the critically ill patient but not leaving that bedside except to grab supplies and fast bleep the reg.
documenting every single thing that has been ordered for or is happening with every patient
managing and implementing blood transfusions
pressure area care

The novices don't even really know what any of that stuff is.  I singlehandedly have to stay on top of all that for 20 people whilst getting interrupted literally every two minutes.  When the heck can I do a bedbath?  I should be doing it for assessment reasons but something has got to give.

And in addition to all that I need to do basic care so I can see my patients general condition and bring any problems to the attention of the doctor.  But certain aspects of basic care are about the only things that novices can help me with.  I need to beg the novices to please clean and turn my patients when I am tied up with blood transfusions and doctors rounds.  I need to be apologetic towards them for not doing it myself.  Everyone just thinks that the nurse wants to dump the basics onto the kids rather than get her hands dirty. Nurses will sometimes abandon things that should not be abandoned in order to assist the apprentices with basic care, trying to prove that she is not "too posh to wash".  Then blood transfusion reactions do not get picked up quickly enough.

Recently I was 2 hours into my shift and still hadn't even seen most of my patients at all.  One of them took a turn for the worst and was dying before our eyes.  I was tied up with that, trying to ring his family to come in.  After that was over I made a series of attempts to check on my other patients.  Notice I said attempts.  Everytime I headed down the ward, phone calls came in and I had to backtrack to the phone. Their drips were empty, dressings were on the floor, cannulas were tissued, catheters were pulled out, people were in retention.  The apprentices were on the ward, but they don't get involved in that stuff.  They just come to tell me it needs to be done.

Finally after an hour of fighting, I got to the bedside of my first patient out of 20 who looked like she has been cooking a nice hospital acquired chest infection or had possibly aspirated.  She was laying flat and sounding pretty bad chest wise.  The apprentices would have bed bathed her and left her flat. God knows what they fed her but I doubt it was pureed enough. Her oxygen sats were low, 72% and her only past medical history is dementia.  I had just put the 02 on her face and sat her upright.  I needed to get some obs, could tell she was pyrexic.  She isn't on antibiotics as she originally was admitted for a collapse ? CVA.  She hasn't seen a doctor since 9AM Monday morning.  It is 4PM on Tuesday.  I think I need to get her seen. 

Smack in the middle of this two apprentices come into the room.  "Anna, there is a phone call at the station for you, it sounds urgent.  The ward clerk told us to come and get you".   Once we had a good but very part time ward clerk but she is away and has been replaced with shite.

I left my patient and walked all the way back to the nurse's station.  It was ambulance control.  They wanted the birthdate of a patient they had transferred out that morning.

Does anyone want to tell me why the ward clerk or the apprentices could not look through the discharge book or the notes and give the birthdate out to ambulance control?

This kind of shit happens every time I make an attempt to see a patient. All I am doing is backtracking to the phone, and praying that my patients are okay in the hands of the apprentices.

No.  The novices are not helping the nurses or doing a nurse's job.  We work for them I think.

A man who commented on The Times article wrote this:
As for the DofH quoting a rise in qualified nurses since 2007 of 8,563; it means nothing if they are passing their responsibilities to healthcare assistants. The increase in nurse numbers is just adding insult to injury.

Those DoH stats are a lie.  The few RN's on the ward are left with no choice but to delegate because the tasks that only they can do are overwhelming.  And it isn't the paperwork, unless you count the ten forms I have to fill in 20 times an hour to obtain life saving drugs ordered by a doctor.  The rest of the paperwork gets completely blown off to the point that we get in trouble over it.

When the apprentices and care assistants  are pissing and moaning and whining about being ordered to do bed baths on their own you have to remember this:  These kids have absolutely no idea about what the nurse has on her shoulders, nor do they understand how complex and time consuming it all is, nor do they understand the consequences of her not delegating tasks to the untrained staff.   It is the mere simple minds  who look at this situation and  say "the nurse doesn't want to get her hands dirty"