Sunday 27 June 2010

A Very Angry Patient

And her anger is justified. Justified to the tenth power.

Many times on this blog I have posted about nursing cadets and apprentices. These are the untrained 16 year old kids without a shred of nursing knowledge that the hospitals are hiring these days instead of real Nurses.   The real Nurses (the few of us that there are) are just running between too many patients because the cadets can do so little.

I have worked with a couple of cadets who are diamonds in a sea of shit.  There is no knowledge there but they were mature for their ages, hellbent on becoming good nurses someday,and willing to learn.

The rest of them suck.  And they don't care either.  They don't want to become Nurses.  They just want a few quid to go out with and the hospital pays them slightly more than McDonald's.  The immaturity and attitude problems are unbelievable.  They are not vetted properly. How I miss my older, experienced health care assistants who are mostly gone.  How I miss all the experienced Real Nurses who have left and not been replaced by other Real Nurses.  I could cry when I come onto shift with no one but inexperienced cadets who cannot do anything to "help".  The public assumes that these kids are some kind of Nurse or something as they are wearing uniforms and handing out bedpans.  Therefore the patients and visitors are not realising the true extant of the staffing problems.

One of these cadets really fucked off a patient and her husband.  Let me tell you what happened.  I wasn't on my usual ward but had been moved to another for the day as they had no staff.  Neither did my ward but I was still taken from it for the day. *Details all changed as I comply with Hippa and always maintain confidentiality.

Older lady with congestive cardiac failure.  Very swollen, very little output.  Given massive amounts of Furosemide, a diuretic which makes a person wee for England.  This drug helps their bodies get rid of all that excess fluid that is making it hard to breathe.  Google congestive cardiac failure, fluid overload, and furosemide if you are confused.  I don't want to explain it all on this post.  We also keep these patients on fluid restrictions.  Therefore they are not taking that much oral fluid. 

The third time this nice lady rang her call bell for a commode  to pass urine she expressed to me her worries that she was "being a pain, a right nuisance".

I reassured her that she most certainly was not a pain.  I told her that it was an excellent thing that she was passing so much urine because it shows us that the drugs are working and her condition is improving.  She had other medical problems in addition to failure that was making her short of breath.  I also reassured her that she did right in ringing for a commode rather than trying to walk all the way down the hall to the toilets. I reinforced the need for the fluid restriction to keep her from any further overload.  I was happy with the patient.  She seemed happy with me. All good.

Lovely lady, no trouble at all.  Not a bit.

I had 20 other patients and was caring for them when this nice lady rang again for a commode.  Vikki Pollard, a 17 year old cadet (NOT A NURSE or even a trainee nurse)  who was busted recently for 20 smoke breaks a shift answered her bell. 

Vikki was the only other person I was working with for this group of 20 patients.  Vikki did not want to be at work.  She has no interest in nursing and never plans on becoming a nurse.  She wants a paycheck.  It was very easy for her to get a job at the hospital since the trust has decided to hire people like Vikki rather than actual Nurses. Vikki has no knowledge of CCF, diuretic medications, respiratory problems, congestive cardiac failure etc etc.

So Vikki answered this lady's call bell about 30 minutes after I was out of the room and said this to the patient:

"OMG I can't believe you are ringing again. Why can't you be bothered to get up and walk to the bathroom.  Stop drinking so much if it makes you wee like that".

Vikki of course had sat through handover with me that morning.  She heard that the patient was a CCFer on diuretics etc etc.  That fluids were a bit restricted etc etc.  But Vikki sleeps through handover and none of that information registers with her.  There is so much of this information about all the patients that I am caring for that it is physically impossible for me to stay on top of Vikki's whereabouts and explain it all to her. 

The next time I went into the patient's room she was quiet and didn't say very much.  When her husband came into visit she unloaded to him.  He cornered me and let loose wanting to know why some "young nurse" spoke to his wife that way 30 minutes after another nurse told her that passing urine so much and ringing for a commode was fine.

"You people don't know what you are doing"

"That young nurse as an abomination and should be struck off, so much for educating nurses at Uni"

"My wife is very hurt". (feelings)

Was he wrong?  Only in the fact that he thought Vikki was a nurse and believed she could be struck off.  She isn't actually a nurse so  she isn't registered with any professional body to be struck off from.  She certainly hasn't had nurse training or ever attended university.  It takes an education to understand the situation of these patients and be truly compassionate.  I will most likely take the heat for this as I am the one with the nurse registration.  The trust doesn't want to lose the cheap untrained labour. But they want to lose qualified nurses.

What could I say to this man?  Other than apologising and agreeing with him what could I say to make it better?  I can't deflect all responsibility onto Vikki Pollard because I am the patient's nurse.   I did try to explain to the husband that Vikki was an assistant and not a nurse and therefore she did not understand the situation.  But there is no excuse for the way she spoke to the patient and I agreed with him on that.  I spoke to the chief nurse about it all.  Nothing has been done.  They are still reducing the number of qualified nurses at ward level (both old and new trained) in favour of these young kids and novices.  Both the older trained and new uni nurses are on their knees being so few in number and they cannot find jobs on the wards.

What to do what to do.

This is where the argument that nurses are "uncaring as a result of being university educated " Falls apart.  I studied so much pathophysiology and pharmacology in nursing school that I understood this patient's situation completely (from a nursing, if not a medical perspective). Had this lady rang her bell 50 times an hour to pee my knowledge would have allowed me understand why and demonstrate compassion as a result of that understanding.  Poorly educated and poorly trained carers are more likely to lose their rag with these patients as well as very demanding patients because of their lack of knowledge.

But thanks to the likes of Melanie Phillips, Frank Field, Iain Dale, and Minette Marin,   the hospitals will continue to get away with poorly educated carers in the place of nurses.  And not only that, but we will have poorly educated old fashioned trained nurses who cannot deal with the demands of modern patient acuity.  * Edit They would be able to handle it if they had decades of experience under their belts.  But new recruits to nursing will not have that, or the support that the nurse's who trained in the 70's had.  This is due to poor staffing.  If some of these self professed nursing and nurse education experts (who have never studied nursing , let alone understand what a nurse actually is) get their way and remove nurse training from university the hospitals will be even more full of Vikki Pollards as both qualified and unqualified staff in the future.

What to do what to do.

Thursday 17 June 2010

Interruptions and Medication Errors

MONDAY, April 26 (HealthDay News) -- Distracting an airline pilot during taxi, takeoff or landing could lead to a critical error. Apparently the same is true of nurses who prepare and administer medication to hospital patients.

A new study shows that interrupting nurses while they're tending to patients' medication needs increases the chances of error. As the number of distractions increases, so do the number of errors and the risk to patient safety.
"We found that the more interruptions a nurse received while administering a drug to a specific patient, the greater the risk of a serious error occurring," said the study's lead author, Johanna I. Westbrook, director of the Health Informatics Research and Evaluation Unit at the University of Sydney in Australia.
For instance, four interruptions in the course of a single drug administration doubled the likelihood that the patient would experience a major mishap, according to the study, reported in the April 26 issue of the Archives of Internal Medicine.

Ha. I will have about 38 interruption during the course of the 0800 drug round.

Experts say the study is the first to show a clear association between interruptions and medication errors.
It "lends important evidence to identifying the contributing factors and circumstances that can lead to a medication error," said Carol Keohane, program director for the Center of Excellence for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston.

"Patients and family members don't understand that it's dangerous to patient safety to interrupt nurses while they're working," added Linda Flynn, associate professor at the University of Maryland School of Nursing in Baltimore. "I have seen my own family members go out and interrupt the nurse when she's standing at a medication cart to ask for an extra towel or something [else] inappropriate."
 Yeah you're telling me.
Julie Kliger, who serves as program director of the Integrated Nurse Leadership Program at the University of California, San Francisco, said that administering medication has become so routine that everyone involved -- nurses, health-care workers, patients and families -- has become complacent."We need to reframe this in a new light, which is, it's an important, critical function," Kliger said. "We need to give it the respect that it is due because it is high volume, high risk and, if we don't do it right, there's patient harm and it costs money."
 Yeah one problem with that.  The public (who cannot see both sides of the issue will accuse us of "lacking in compassion" for prioritising patient safety over customer service for visitors.
About one-third of harmful medication errors occur during medication administration, studies show. Prior to this study, though, there was little if any data on what role interruptions might play.

For the study, the researchers observed 98 nurses preparing and administering 4,271 medications to 720 patients at two Sydney teaching hospitals from September 2006 through March 2008. Using handheld computers, the observers recorded nursing procedures during medication administration, details of the medication administered and the number of interruptions experienced.

The computer software allowed data to be collected on multiple drugs and on multiple patients even as nurses moved between drug preparation and administration and among patients during a medication round.
Errors were classified as either "procedural failures," such as failing to read the medication label, or "clinical errors," such as giving the wrong drug or wrong dose.

Only one in five drug administrations (19.8%) was completely error-free, the study found.
Interruptions occurred during more than half (53.1%) of all administrations, and each interruption was associated with a 12.1% increase, on average, in procedural failures and a 12.7% increase in clinical errors.

Most errors (79.3%) were minor, having little or no impact on patients, according to the study. However, 115 errors (2.7%) were considered major errors, and all of them were clinical errors.

Failing to check a patient's identification against his or her medication chart and administering medication at the wrong time were the most common procedural and clinical glitches, respectively, the study reported.

In an accompanying editorial, Kliger described one potential remedy: A "protected hour" during which nurses would focus on medication administration without having to do such things as take phone calls or answer pages.

The idea, Kliger said, is based on the U.S. Federal Aviation Administration's "sterile cockpit" rule. That rule, according to the Aviation Safety Reporting System, prohibits non-essential activities and conversations with the flight crew during taxi, takeoff, landing and all flight operations below 10,000 feet, except when the safe operation of the aircraft is at stake.
Likewise, in nursing, not all interruptions are bad, Westbrook added. "If you are being given a drug and you do not know what it is for, or you are uncertain about it, you should interrupt and question the nurse," she said.

So does anyone want to come on here and tell me that airline pilots are lacking in compassion because they won't converse with the passengers during take off?  Oh wait.  You have respect for airline pilots and understand that they have a lot of responsibility and that there are grave consequences when they make errors.  You don't understand this about registered nurses.  Nor do you have that kind of respect for doctors anymore.

When one junior doctor is running between over 250 patients you throw tantrums when he won't immediately drop what he is doing to speak to you. Again.  When it takes him 4 hours to meet with you because he has  critically ill patients on this 16 hour shift of his you call him lazy.  

Try that to get away with that rubbish next time you are on a passenger jet.  Start screaming at the stewardess and demand that the pilots come and speak to you this this just as they are doing their pre flight checks.  Yell and carry on  that the airline staff are lacking and compassion and uncaring because they won't meet your demands.  Justify it by saying that you are "scared" and "stressed".You will be on the floor, belly down and  handcuffed with an airmarshalls boot on your back before anyone can say "obnoxious ".   This is because the airlines put SAFETY as a priority over CUSTOMER SERVICE and there are punishments for those in charge at management level.  Hospitals don't do this.  That is why thousands of people die  needlessly every year in hospitals and are hardly EVER dying needlessly 30,000 feet above the atlantic ocean packed like sardines in a flying missle carrying fuckloads of flammable fuel.

Go ahead.  I double dare you.  Interrupt a stewardess while she is doing the airline safety demo and demand a ginger ale.  When she says "no". Roll you eyes, tell her she is lazy and tell her bosses she couldn't "be bothered".   The airline will deal with you if you act like that.  Stewardesses are in a situation where it is very unlikely that anything will go wrong.  In hospitals is very likely that things will go wrong.  Yet they have these kinds of protections and they also have ratio laws that limit the number of passengers per stewardesses.  Nurses have no control over the number of patients they are responsible for whilst on duty.

I wonder how much of this lack of respect for hospital staff  is down to medical dramas that depict nurses as a gaggle of people standing around the nurses station who have nothing to do but wait for a visitor or a patient to require service.  They depict one patient that has a team of doctors at his bedside at all times carrying out all bedside care i.e. monitoring vent settings and drip calculations.  No wonder the public's mind is warped.  No wonder they get pissed off at the staff.  Over at allnurses many of the nurses are saying that the only way to get through and keep your patients safe is to avoid all eye contact with the relatives and keep moving.  This isn't because of the reseasonable visitors who ask questions and mention concerns.  It is because of the visitors who are unreasonable and who are not kicked into line by management. Everybody suffers...the patients....the good relatives....and the Nurses and Doctors.  I think they have a bigger problem with these kinds of relatives across the pond.

Even without interruptions the number of mistakes are rife.  I would be willing to bet that most of those are down to the Nurse rushing to get everything done for too many patients rather than nurse incompetence.  Then you have to take into account that the RN has to take over pharmacy, physio, housekeeping, and clerking duties when they are short staffed.  The short cuts we have to take are unreal. And we are still not giving the patients the amount of time that they expect.

I wonder if Virgin Atlantic hires RN's?  I wouldn't mind an Air Marshall to have my back when I am at work.  Should I talk about violence against staff in my next post along with our lack of security guards  or do you want to hear about the young low paid not yet a care assistant who really REALLY  angered  a patient?  All without breaching confidentiallity of course.

Wednesday 16 June 2010

A Nurse with Sense and thoughts on Relatives.

Every once in awhile I see a comment out there in blog land that really hits the nail on the head.  I found this comment over at jobbing doctor.  It was written by Dinonurse who should really have a blog!  I was trying to explain that there needs to be controls over the numbers of relatives ringing the wards.  That maybe we should enforce the one relative rings about the patient and speaks to the other family member rule.  It is the job of the nurse to communicate with family and try and keep the next of kin updated.  But one nurse to 22 patients? Imagine what happens when each of those patients has 10 relatives each ringing throughout the day and demanding a chunk of the nurse's time?  No nurse will be effective if she is on the phone with relatives 40 minutes out of every hour, repeating herself.

Rrecently I was delayed for 10 minutes getting to Mrs. Smith with her blood because Mr. Tate's relatives grabbed me in the treatment room to ask questions.  I wanted to help them but had to get away as fast as I could as blood bags cannot be left sitting around or they go bad and hurt the patient when they are infused.  After talking to Mr. Tate's relatives I went back for Mrs. Smith's blood.  Then the phone rant.  It was another one of Mr. Tate's relatives.  Got off the phone with him and went back for the blood.  The phone rang again.  It was Mr. Tate's neighbour wanting all the same information.  Got rid of him.  Went back for the blood.  Then Mr. Tate's relatives grabbed me again in the treatment room to explain the same thing to another relative who had just arrived. I had to throw a very expensive bag of blood away, order another unit and Mrs. Smith's treatment was delayed.  None of Mr. Tate's relatives felt that I spent enough time with them even though I put another patient's health on the line to give them the time that I did.  When they were nicely asked to try and communicate the information to eachother they responded with a "no, it's not convientant for me to do that".

Now imagine that each nurse has this going on with the relatives of up to 22 people all day long.  The nurse is the only one who can answer phone enquiries, give drugs and treatments, and catch onto changes in condition that require a medical review.  The rest of the staff on the ward are care assistants and cannot get involved with any of this.  Love the care assistants but they don't magically turn into nurses who can carry on with the drugs just because I got tied up with families.

Even the nicest nurses in the world are cursing the relatives under their breath when not one of the IV drugs that were due between 6pm and 9pm have been given because not only are visiting hours occuring around that time frame, but phone calls are still coming in.  You might have to repeat the same chunks of information to 5 members of the same family in 20 minutes. 

One relative (must be the named relative on the admission form) rings or questions the nurses.  And it is his job to let the other relatives know what is going on.  If you are visiting and have a concern to raise with the nurses by all means do it.  But beyond that it gets dangerous.  Relatives are important.  Patient care is more important.  The very last thing that a lone RN on a large ward can do is pull away from patient care to deal with your dysfunctional family dynamics.  Talk to eachother.  You can also make an appointment with the medical team to get a very detailed explanation of your loved one's situation.  I cannot believe that you want me to pull away and abandon my patients yet again today because you, your seven siblings and mum's partner do not want to speak to eachother and each want to call the ward separately.  It is bullshit and I am calling you out on it.   If you mum was my only patient I would happily give you all the time in the world and go through the notes with you.  If I had other nurses to continue with the workload I would leave them to it, make you a drink, and explain the treatment plan to you.  But I don't.

Back to Dino's comment.

Want to know why nursing care is deteriorating?

Want to know why the mean nurses "cannot be bothered" to speak to the relatives?

Want to know why "nurses" today seem so unprofessional and unaware?

Check this out:

A bit late into the fray...heres my tuppence worth (for what its worth). The NHS is in its death throws and nobody is brave enough to tackle the root one could have envisaged just how far medicine would have advanced in the last 60 years. The original thinking was that everyone would work for a living and pay NI and rarely end up in hospital having to take back some of the money. Nowadays many acute wards are filled with patients who have never really paid any NI (and please, I am not "having a go" just stating a fact) or if they have, a stint on the ICU will quickly cancel out all that they have paid in.

Long ago, staff nurses on acute wards were expected to look after 4-6 patients. They had ENs and auxillaries and students to help them. They had senior nurses and sisters who were clinically active (not stuck in an office) and each "firm" of doctors had their own ward (hence you also had the HO and SHO around on your ward most of the time.) Jump forward 30 or so years and now the acute wards are filled with patients who would have been on an HDU or even an ICU in the 70s. The patients are often older, have more complicated medical histories, people generally are living longer but are not actually that healthy.
Add to that that the culture in the UK has always involved drinking and smoking heavily not to mention the ever present problems with crack and other IV drugs. Medical treatments have moved on quickly. Take an MI patient for the 70s if you had a "community arrest" -hell, if you arrested in hospital you had little chance of you get thrombolysed and PCI'd and stented and statins etc etc. GI bleeds get scoped and stabilised and ICU admissions if needed, ICU patients get horrifically expensive drugs (APC anyone?). The cost per patient has drastically increased BEFORE you factor in the cost for nursing/medical care. There lies part of the problem...more acutely ill patients with expensive therapies...the NHS managers know that in order to pay for the meds and the rehab etc they have to save money and the easiest way is to replace nurses with HCAs.
Afterall they can do most of the "nursey" stuff right? Wrong, they can do very little of the stuff that an RN has been trained to do...jump forward another 20 years and you wll not find a qualified nurse outside of the ICU. Many of the acute wards where I am are already full of APs and HCAs...these are not nurses. The one poor staff nurse that is on for the shift has TOTAL responsibility for the lives of 28 patients.
Now I understand that this has been said before but really think about this. Imagine that you are responsible for 28 people. One of them suddenly deteriorates and requires your input...what happens to the other 27? Next time you visit a relative on an acute ward, count the number of RNs and then compare the number of HCAs. Count the number of patients with IV infusions and then work out in your head if it takes 20 minutes to sort out an IV infusion just how much time is left for EVERYTHING ELSE? Nurses do not run for their own health so if you see one running past you, they are heading for the crash trolley or a bag of noradrenaline not tea and biscuits! Sorry if this sounds unfeeling but at the end of the day, nurses are supposed to be there for the patients...if your relative was having a heart attack and the patient in the bed next to them was having an acute asthma attack ( both potetially fatal) would you be happy if the RN was stuck on the phone?

Tuesday 15 June 2010

NHS Maternity Ward "Nurses"

Nurse Anne is grumpy and is feeling like being very picky this morning.

Over the last few years I have seen many news articles about maternity ward "nurses".  They are depicted as lazy and unhelpful.  This woman thinks she saw maternity ward "nurses" sat on facebook.   No doubt she saw staff on the computer.  Staff have to do lots of work on the computer, in real time rather than later when all the patients have had their needs met.  Otherwise they get their asses handed to them on a plate..  But rest assured that the staff in this situation were not nurses.  You must also realise that social networking sites are banned from hospital computers.

Head over to mumsnet type forums and you will often see mothers bitching about the "maternity ward nurses".

I find this very amusing as maternity wards in the NHS do not employ Nurses.

 There is not one maternity ward that I know of that has RN's on staff.  Not one.  Maybe some have RN's on staff but I have never seen it.  Feel free to correct me if I am wrong.

NHS maternity wards employ Midwives and health care assistants. That's it.  There are no generic nurses on staff there.  None.

Your average maternity ward will have too few midwives running between too many patients.  The only other staff involved with patient care are the health care assistants who cannot help with very much, who have no training and who might as well be sat on facebook for all that they are allowed to do.  

They are not Nurses as they have no training, and no registration.  They cannot answer a lot of your questions when the midwife is busy because healthcare assistants are not trained at all.  They cannot give you pain meds, sort out your drip, nor can they deliver a baby.   They are not given much in the way of information about your situation.  They probably aren't allowed to know anything about you because they are not registered professionals with training.  They are not allowed to get involved with your discharge.  And the overloaded midwife is running her ass off. It's not their fault that the trust is hiring these people instead of qualified staff.  It is not the overloaded midwives fault either.  For all the good health care assistants who are good there are 10 who are young, immature, and quick to give the two finger salute to the midwife if she tells them to get off facebook.  Management does nothing about the cheap labour with attitude.  If they piss off the cheap labour they might have to hire qualified staff! Gasp!

If I hear one more person bitching about maternity ward "nurses" and how stupid or lazy they are I will blow a fucking gasket.  Maybe if these "nurses" were actually NURSES they would have been able to deal with your questions/problems whatever.   Maybe if they were qualified professionals who knew your situation and were allowed to deal with stuff they wouldn't be sat on facebook.  Did it ever occur to you that your lack of care is down to a lack of midwives. No wonder these midwives are so damn grouchy.  I love maternity.  I love babies and I am fascinated with childbirth.  But I wouldn't walk a mile in the midwives shoes for all the money and gold in the world.   I would love a job on the maternity units assisting but I would never retrain as a Midwife.  The lives of all those precious mums and babes in my hands with no staff and no resources.  I'd flip out real fast and that would make me your run of the mill miserable midwife.

I think it would be quite helpful to the midwives to have professional registered nurses assisting them in the maternity suites.  I may not be a midwife but I had loads of maternity training in my nursing program.  I think I could assist the Midwives very well.  Too bad there is no chance of getting a job on maternity because THEY DON'T ACTUALLY HIRE FUCKING NURSES ON THE MATERNITY WARD.  Not in my neck of the woods anyway.

If anyone does know of a maternity unit that hires real nurses drop me a line a

Maybe if the public and the media could actually get their semantics right they would have a clue about what is going on rather than that uninformed paranoid hysteria that they direct to frontline staff.  But they refuse to listen, and management takes advantage of their lack of understanding.  Same shit different specialty.

Rant over.

Saturday 12 June 2010

Weekend Admissions and DEATH

Shit pic because it's American but I love the slogan.

I would just like to add a thing or two to this daily mail article.

The true story here is the fact that the hospital does not want to PAY for any kind of staff (especially senior staff) to work out of hours.  They just don't want to pay for it.

Many senior nurses (and myself) have REQUESTED REPEATEDLY to work nights, holidays, and weekends as it fits around our husbands 9-5 weekday jobs. 

During the week when my spouse is working it is impossible to get nurseries that fit in with a nurse's random ungodly shift hours.

  I would save hundreds and hundreds of pounds a month and a lot of stress for myself if they would allow me to work all weekends and nights.

I want the  weekend shifts and the weekend and holiday nights.


They will not allow me to do all nights at the weekends and weekends generally because I am senior staff.  At least I get some.  If I was a SISTER I would be banned from doing any of them. But no fear of that since they are refusing to promote anyone due to costs.

I only get them once in awhile.  The Ward sisters and other staff nurses who are senior to me are banned from working nights, weekends and holidays.

I would imagine it is the same with the medics.  Maybe some medics out there can enlighten me.

Don't any of you believe that this situation exists because staff do not want to work unsocial hours.  Far from it.  I would only want to work weekday social hours  if I could work 9-5 which is impossible as an acute care Nurse.

Nurses are middle aged women with kids.  Most of them are in my shoes, rather than wanting to go out and play on a Friday night.

I'd also like to add that I am pretty damn annoyed that the DM is focusing on medics and not discussing how a lack of senior experienced nurses at ward level harms patients.