Tuesday 30 March 2010

So you think Britain is a Nanny State? Random thoughts on Obamacare.

Well Britain is a nanny state.  And it's pathetic.  And it looks like America is heading down that road as well. 


Seems unrelated but I you'll see a lot more of this real soon. I wonder how much worse this is going to get when young healthy people who don't want to buy insurance are forced to buy into Obama's corporate/government co-op or under the threat of IRS bullying and fines if they don't comply.   The system will swell with expensive bureaucrats and lawyers (the only people who can even make an attempt to understand all the ins and outs of the new legislation) and the common people will be punished with restriction after restriction to "keep costs down".

The poorer states are already freaking out now that they are realising the cost of Obamacare, which is being  imposed on them by the feds in a very unconstitutional manner. Some of the states supported leftist reform.  But now that they are seeing just how high the costs are going to be, and realising that state funded services such as foster care, education etc are going to have to take major cuts they are trying to back pedal a little bit.   The country is already broke.  Americans are in for a shock if they don't think that Obamacare is going to restrict individual freedom.  The fat cats will line up at the government trough and manage to get richer as always.  But I think more than anything they should blame the republicans for all of this.  US healthcare needed reform but it was ignored completely for too long and the democrats saw their chance to expand the federal government and gain more control over people's lives using the guise of "protecting people from corporate evil" to achieve their goals..  In my opinion "reform" should have gone in a different direction entirely.  The left (like most groups) hates a monopoly where the rich get richer unless it's their own monoploy.  Now they have theirs.

The Medical Ward Sisters Song

To the tune of 99 bottles of beer.

5 little stressed out Sisters on the wards, 5 little stressed out Sisters , when one of those Sisters has a nervous breakdown and falls there will be 4 stressed out Sisters left on the wards.

4  little stressed out Sisters on the wards, 4 little stressed out Sisters , when one of those Sisters has a nervous breakdown and falls there will be 3  stressed out Sisters left on the wards.

3 little stressed out Sisters on the wards,3 little stressed out Sisters , when one of those Sisters has a nervous breakdown and falls there will be 2 stressed out Sisters left on the wards.

2 little stressed out Sisters on the wards, 2 little stressed out Sisters , when one of those Sisters has a nervous breakdown and falls there will be 1 stressed out  Sister freaking out on the wards.

1 little stressed out Sister on the wards,1 little stressed out Sister , when that one sister has a nervous breakdown and falls there will be 0  stressed out Sisters left on the wards.

And management loves it because they want to hire more purchasing officers and patient journey champions rather than pay for any form of qualified nurses.

What do you think of my attempt at songwriting?  I know, I know I should have a job at Sony. ; )

Monday 29 March 2010

Even More Fun at Mealtimes and Productive Ward

At 6 PM they send a food trolley up to the ward.  At 6:30 they take it away.

On this particular shift we had 2 RN's and 2 care assistants for the shift.  That was the entirety of the ward staff. No ward clerk to answer the phone.

There were 15 patients that needed to be fed.  The entire ward consisted of 30 patients.

Between 6 PM and 6:30 PM thirteen people rang for commodes.  This takes at least 20 minutes for each patient as you have  to find a commode, get two staff to transfer the patient onto it, transfer the patient back to bed and then wash the commode for 11 minutes between patients as specified by the infection control bitches.  They should do it themselves.  It might help them lose some weight.

Between 6 and 6:30 five people needed analgesia.

Between 6  and 6:30 two new admissions were sent up.

Between 6 and 6:30 four IV pumps beeped and alarmed because of empty bags, pulled out lines, occlusions, and air in the lines. Time consuming to fix.

Between 6 and 6:30 one confused patient fell.  She thought she was late for her bus.

Between 6 and 6:30 seven phone calls came in from family members who tried to talk my ear off and refused to get off the fucking line so I could get all the way back down the ward to my patients.

Between 6 and 6:30 one hundred and seventy drugs were due to be given.  170.  Most were not on the ward.  Many needed careful and time consuming preparation.

Between 6 and 6:30 one man had chest pain.  It looked pretty classic.  I had to page a medic (when I could actually manage to get a line out between relatives phoning).  Get observations, GTN spray, an ECG, bloods and 02.  I had to ignore the food trolley, and the call bells to do this and run past frail patients who were left with a tray of food that they couldn't manage to feed themselves.  When the medic came I had to give a load of other stuff to the patient, and organise a transfer to CCU as well as hand him over to CCU and ring his family and answer all of their questions.  I was quickly losing the ability to feed any patients.  I found myself wishing that these poor bastards would let me get off the phone as it was mealtime.

Between 6 and 6:30 recovery demanded that either myself or the other RN working with me escort a patient back to the ward from theatre.

Between 6 and 6:30 a consultant showed up to do rounds and his junior doctor snapped his fingers at me to let me know they wanted me to follow them around as they reviewed each of their 11 patients.

By 6:25 one care assistant managed to get all the trays handed out.  Then she started on the first feed. And it was then that kitchen started demanding all the trays etc back so that they could get them washed, sorted and get home on time.

I am not exaggerating.  If anything, I am being conservative with all this.

The productive ward fuckos have given us some new ideas to try in order to help is avoid malnutrition in our patients.  I wish I could scan the letter onto this blog.  They gave us 5 orders suggestions to facilitate meal delivery.

1. They will be buying red trays and red tops for water jugs to help the nurses identifty who needs to be fed.

2.  We are getting this giant laminated flow chart/ map of the ward that we have to fill in every mealtime identifying who needs to be fed in red marker.  If someone doesn't get fed we have to colour in their block with a green marker and if they are able then we colour in that block with blue pen. If they are NBM for whatever reason we use a purple marker.

3. All staff have to drop what they are doing and participate in meal delivery.  This is a dig at RN's who often leave meal delivery to the assistants because we have unavoidable ill patients, orders, and drugs due at mealtime.  The assistants cannot help us with orders, drugs, and ill patients.  ( I really don't think that they ladies crying for commodes and the man with chest pain would have appreciated being ditched at mealtime.)

4. We are to complete a nutritional care plan and audit.  A "nutrition score" must be calculated for every patient over the age of 60.

5.  Doctors will be told NOT to do rounds at mealtime.  (They have never complied with this rule on any other occasion so why the hell would they start now?).

Management thinks that they have covered their assess with these 5 objectives.  They can turn around and say "we have done this and that to help our nurses stay on top of malnutrition and be more efficient at mealtimes."

How completely dumbass is all of this?

Monday 22 March 2010

So Where is Anne?

I am job hunting.

And working a lot.  I was hoping that working double shifts would get me some extra cash but they are back to not paying overtime and we are getting extra time off instead.  Which, of course, leaves the wards even more short staffed.

I had the fright of my life yesterday.  Have to change details to protect confidentiality and all that.

I was on duty with one other RN and an an inexperienced auxilliary who did not know how to make a bed.  For the whole floor.

One of my patients was having a procedure downstairs and the department demanded, DEMANDED that the patient get transported back to my ward with an RN escort.  That means I had to go down there and bring him back. They are, of course, better staffed with less patients but for whatever reason the department staff always refuses to bring patients back.  We went back and forth for some time.  I told them that there was no way I could leave the ward to dick around down there waiting for porters and such.  But I got sick of them ringing me constantly and accusing me of messing up their list thus delaying patient procedures in their department.  I knew I wasn't going to win.  I know they don't understand nor do they want to hear about the short staffing on the wards.

Against my better judgement I went. And I got stuck down there waiting for them to get it together and then waiting for the porter.  I harassed them and reminded them that I really really needed to get back to the ward.

When I got upstairs I was wheeling this patient who immediately needed post procedure observations taken into his bay.  I peered into the bay across from his to see a young patient of mine looking very funny.  I ran to this person and it was obvious that this patient was in respiratory arrest. Was not breathing.  Still had a pulse though.  I dumped the post procedure patient (distressed that I was leaving him on a trolley in the middle of the bay--he didn't understand what was happening) and put the resus call out.

Holy shit.  This person has a history and was probably in the throes of a seizure while I was getting dicked about by recovery who couldn't be bothered to bring the patient back to the ward.  Following the fit, he stopped breathing.  And a I suppose it was several minutes later that I saw him.  I have no doubt if I had been on the ward, or if there was 1 RN per bay it would have been dealt with immediately.  The auxilliary didn't even understand that the patient wasn't breathing.

We have more patients going for diagnostics and procedures every hour that require nurse escorts than we have nurses to escort them.  The ward is almost always increasingly short staffed as a result.  So basically if we have 2 nurses and 2 auxillaries on shifts we are often left with two staff on the ward because of escorting.

I really fucking hate the people I work for.

I went to this study day/ meeting where we had our (old fashioned trained not been on a ward in 30 years) leaders telling us to read the reports on Staffordshire and cry for the suffering that was dished out by our colleagues.   They wanted suggestions about how to "improve" care and efficiency.  They want more with less but patient care will not be harmed and we will not be a staffordshire. They told us over and over that 20 billion is getting cut out of the NHS budget and that the current system is unsustainable.  They shut down and refused to discuss RN staffing when we mentioned it.  The even chortled. Sadly, they don't understand that it is cost effective to have more RN's at the bedside. 

Other head managers were at this thing saying things like "we are listening to our nurses".  He shocked me when he said it. Then I saw a journo and a photographer from our local paper  at the back of the room.   As soon as the journos split so did the chiefs. But they had a nice little photo in the paper with a "We are listening to our Nurses" headline.


Saturday 6 March 2010

Are They Hiring?

I just had a look at my Trust's current vacancies.

There are jobs for managers and administrators, purchasing officers, and HR.

Lots of them.

No Staff Nurse posts are being advertised.

They are advertising for more "apprentices" and aiming the adverts at teenagers.

It still makes me laugh when people say that the University education of Nursing is what has destroyed Nursing care.

You idiot.

If we actually had university educated nurses staffing the wards I would agree with you.  But the university educated nurses are stacking shelves at Asda while they try to find a job at the bedside.  Even if they only want to do noctoring and managerial stuff they cannot even dream of it, if they do not have years of experience as a bedside nurse first.

The vast majority of staff on the wards at any given time these days are untrained, uneducated but mostly nice if a little dippy carers who have never been to university and do not want to become Nurses.  It is getting to the point where we rarely have more than 1 RN per shift.  The Nurses are an aging workforce.  Most of the time that one nurse per shift is someone who trained back in the "good old days".  The majority of NHS staff who are actually qualified nurses trained pre project 2000.  Carers cannot help with drugs, treatments, orders, information organisation and action etc etc.  The lone nurse carries that on her own.  There are more drugs that need to be prepared and given than you can possibly, physically give.  That's the case even with the threat of getting sacked for a med error and getting struck off as a nurse at the forefront of your thoughts.  Even if your stomach is doing flip flops, due to fear that you are going to kill someone due to medication problesm, you still cannot do it.

In Victoria, Australia and California, USA the hospitals must staff their wards with degree nurses so well that no degree nurse is to have any more than 5 patients at a time. This is law.  The hospitals tried to resist these laws but patients were dying.  The law went into effect around the year 2001.  If one of her 5 patients gets unwell, she gets another real nurse to help out with her other 4. In the UK I start my shift with more patients than I can handle, then I get more and I have so many constant and unrelenting interruptions that I cannot accomplish a thing.  The only way to survive, and ensure my patients survive is to stay focused.  This makes me look hard---as if I am lacking in compassion.
 The  degree RN in California has a small number of patients which allows her to do everything for them.  Care assistants are few and far between. This is what they have over there, rather than untrained kids running around and one real Nurse trying to do it all for 30 patients like we have in the UK.  On a 30 bed ward in California you would have 7 real Nurses  at least (One in Charge), maybe one care assistant who is merely helping out rather than taking charge of the basic care, admin staff to answer the phone, domestics, dietary staff for a shift..   In the UK  you will have one real Nurse and 3 untrained kids on a 30 bed ward per shift and that is all. This is getting to be the norm.

You won't hear of any patients getting starved, neglected, and left in their own filth in Victoria or California.   And their staff nurses are ALL degree nurses. 

You think it costs too much to pay all that well educated staff?  Wrong again, they actually have lowered their costs by improving patient outcomes as a result of having strict, legistlated nurse patient ratios. If hospitals weren't so busy fucking around with government initiatives and interference this stuff would probably be automatic.



The second link is fabulous.  The hospitals would not be able to include care assistants and non direct care providing nurses in their ratio declarations.

Dehydrated: 12 hours of Hell

Had a lovely shift recently.

25 patients to one Nurse.  That Nurse was me.  My only help was an agency carer with no experience who could not do any lifting due to a back problem. Yeah. WTF.  I complained to the supervisor of the hospital.  When he informed me of the even worse staffing situation on other wards (worse!) I realised I was in for a long shift.  This was the staffing for 12 hours. For the last hour I was alone. And compared to other wards I was damn lucky I only had 25 beds and less overall acuity.

Two cardiac arrests.  Mostly down to failure to rescue.   I caught the first one as he was deteriorating just by luck I had a gut feeling to check in on him again. Now he wasn't talking.  I fast paged the senior medics.  I didn't think he would arrest quite yet but I like to prepare for the worst.   I was alone with an agency carer with no experience.  When I realised we might have an arrest I told the carer that we might and asked him a few questions to prepare.

Me:  Do you know how to put the arrest call out?

Carer:  No.  What is that?

Me: "Do you know how to do CPR" ( I could run to the phone and put the arrest call out if he could start the cpr)

Carer: "No"

Me: "If I yell the word CRASH you run your ass to the phone and dial xxx. Then you say "Doe Ward".  You have 5 seconds to do it, don't fuck up.

Thank goodness the registrar was up there 30 seconds later, and then  the patient really really deteriorated.  I am so lucky I caught onto it when I did rather than just finding a corpse in that bed.  I only got a chance to check back in on him by abandoning the turns, toileting round, and leaving people covered in shit.  I just got a feeling in my gut and heard a little voice telling me to watch him. By the way,why does the 85 plus crowd play in poo and facepaint with it?  I guess if I ever see 85 I will find out.  It's not always the confused and dementia patients who do this either. 

Two people fell out of bed whilst I was dealing with the crash.   They were , of course, left on the floor. Thankfully they didn't get hurt.And another one arrested.  That one was an expected death but a DNAR was never signed so we needed to attempt resus.  It failed.  But the first guy ended up in ITU.

People were extremely dehydrated.  I didn't get a drink or a scrap of food for 12 hours either so I was empathetic.  But even so, I still couldn't get around to them all and do anything about it.  God help them, the oncoming shift staffing was terrible as well.  At least I can get home at the end of the day and have a coffee.

So many people do not get the drugs they need and are prescribed.  This was even the case on the shift preceding mine.  Either the drugs are not there or the patient has some kind of problem that we cannot work around in the way that we need to in order to give the drug.  It's not as if we say "oh yeah, I am just not going to bother with that".

 Rang switchboard after I handed over and demanded that the chief executive get called (at home if necessary) and ring me back immediately.  I was half out of my mind at this point.

 Do you think he called me?

Yeah right.

Day off today.  Mr. Militant Medical Nurse is doing the cooking and the cleaning and nursing the nurse.

Wednesday 3 March 2010

The Department Of Stealth

Yes the good old DoH.  What the hell is their malfunction?
I read this today and I nearly choked on my coffee.

Nurses must be better trained and take more responsibility in ensuring patients are not malnourished, a hard-hitting report has warned.The Nutrition Action Plan Delivery Board report, commissioned by the Department of Health, found not enough attention is being paid by organisations or healthcare professionals to prevent patients from becoming malnourished
The DoH thinks that if only Nurses have more training then patients will stop starving to death in hospital.  Oh happy happy joy joy.  If only we understood that frail patients require assistance with their meals.  If only we were smart enough to realise who needs help!  ( We do know exactly who needs help, we just cannot get to them all before the domestic dumps their tray out of reach and then collects it in 5 minutes later).

What do nurses who work on large wards with frail elderly patients have to say about this?

No amount of training is going to help me feed 10 people simultaneously in 20 minutes while managing critically ill patients, getting interrupted by family members, doctors, path lab, pharmacy and answering every phone call that comes into the ward during that time.Management won't pay for a ward clerk but will formally discipline the nurse for not answering the phone promptly. We (nurses) asked the domestics if they could please not collect the trays back in until we could help everyone to eat.
e can't do it in 20 minutes, primarily due to interruptionsa and numbers.  We were told that it isn't their problem and the domestics will not be held up because the nurses want to feed patients.  Doctors ignore the protected meal times and show up to do their ward rounds almost the minute the trays are being handed out. These consultants demand that the lone nurse on duty immediately stops what she is doing to follow them around on the ward round regardless of the staffing levels. When the nurse refuses, because she wants to feed patients or administer much needed drugs (no other nurse around to do it) she is reported by the consultants.  And the DoH thinks that it is the nurses who need training about this?

I am a nurse working on an acute admission ward for elderly patients.

I know that from the experience on our ward, it's not a question of whether staff need more training to meet the nutritional needs of our patients but a the age old question of staffing and manpower.

That need to be addressed first and the care and attention our patients need will be met. As always, the crisis level of staffing goes on and managers sit proudly in their seats and say there is no more funding.

This isn't the first time the Department of Stealth has irritated me beyond belief.  They pulled a shitty little stunt during an unannounced visit onto my ward some time ago and I blogged about it.

The Nurse responded to her comments by talking about the things that I talk about on this blog. Nurse patient ratios that are unsafe (triple what is recommended by the International council of nurses, the RCN, and AMA etc) constant interruptions, poor facilities, untrained support staff, lack of management etc. The DoH visitor  responded with "It's not really about lack of staff and facilities is it? It's about dirty nurses not wanting to take pride in their work". She cocked her head in a funny manner as she said it, and actually smirked. She said it with a mock syrupy sweet voice. It was sick. One of our care assistants is a hell of a mimic and she repeated it perfectly for me, when I came in for the night shift that night. The very proud hands on nurse was just weeping at this point, as she handed over to me.

Does anyone want to speculate on just what it is the Department if Stealth is up too?  Are they just thick? Do they get a fabulous high off of wasting money on worthless reports?  Are they scapegoating nurses for things the DoH  cannot control?  Are they big government loving politically correct tits collecting a ginormous salary for doing sweet fuck all nothing except coming up with more and more stupid fucking shit to justify their own existance?  Discuss.  I would love to know how much they spend on producing these "reports" and coming out with this kind of rubbish.

The report warns that messages around nutrition are not getting through to frontline staff, possibly because national campaigns have focussed on obesity rather than the dangers of being underweight.

Yeah, the outnumbered Nurses are unable to each feed 10 patients singlehandedly in a strict 10 minute window because we think they will get fat if we do.  We are starving frail and already underweight 96 year old patients  because we are worried about obesity. Go DoH.  Where would we be without your wisdom and knowledge oh great ones. Yeah. If you want to spend money on something worthwhile, why don't you teach your staff to have some manners and decency when they step onto hospital wards.