Friday 28 January 2011

What it is like.

Back to the Medical Ward. Yay.


My 13 hour night shift was due to end  at 0700; at which time I have to be ready to give report to the oncoming Nurse.

Starting  at 5AM I had to:

Start a magnesium infusion, give calcium gluconate and  start an IVI with K then an addiphos infusion and take off a whole load of other doctors orders for a patient with deranged U+E's.  The addiphos probably won't go up till day shift. He could have crashed at any moment with a K that low and I didn't want to leave him.  He had bloods done over night and the results came back at 04:30. The doc wrote the new orders just afterward.  I had to run around like a nut just to find some magnesium to start and of course document every aspect of all of this.  All had to go through a central line.  As you know this is time consuming. 

I needed to get vital signs and obs on all 19 of  my patients by 7 AM.  If you wake the patients up before 6 to start getting all their obs they get angry.  If I didn't start before 6 they would never got done and we would potentially miss the signs of a deteriorating patient.

I had to IV fluids on someone with renal failure.  I had noticed his rubbish output at midnight but it took until 04:30 to get the doctor as he was the only doc on for multiple wards.  Bloods hadn't been done for days on this patient and I needed to draw them.

I was also trying  to keep the 02 on another patient, a confused patient who was desaturating without it and kept taking it off his face.  He has disorientation secondary to sepsis so he could not understand me when I asked him to keep it on.  He needed a mask rather than a nasal cannula.

At this time I also had to obtain,, mix, and administer 15 (yes fifteen) IV antibiotics for 8 patients that were prescribed them.  This has to be done by 0800.  Day shift starts at 0700 but doesn't even get out of handover until nearly 0800 so they can't do it. I had to do them and finish them by 07:30 AM.

I had 5 patients ask for controlled analgesia during this two hour window.  This again is very time consuming.  The system for obtaining and administering controlled drugs is a joke.

During this window I also had to be up to date on the current status of all my 19 patients. For example any little thing that changed with them on my shift I need to be onto right away.  Examples of this include changes in observations, neuro observations. fluid balance, blood sugars etc.  I had 5 diabetics.  I need to act on every little thing and document it and it all needs to be done right now.
I had to act on the fact that I just noticed that my patient who is being treated for a UTI is completely unresponsive with a low BP.  Had to call the doctor and wait for him to get around to calling me back.  Fast IV fluids ordered as well as a million other things that needed to be done ASAP.
Two patients who needed IV antibiotics woke up and pulled their IV cannulas out.  Two others pulled out their urinary catheters.  It was like a blood bath for all 4. 

I needed to monitor the patient on the IV insulin infusion closely.  His blood glucose still isn't right.  Something is wrong about this.  Her consultant wanted her to stay on this infusion over the weekend.  All night long I had told the house officer that the insulin infusion and the iv fluids that get hung with them were running out and that he needed to prescribe more so that I could hang more on the patient.  The only time the doctor came was at 4:30 in the morning.  I handed him the chart but he put it down and "forgot" to prescribe it before he got bleeped away somewhere else.  Called him again and he said that he couldn't "come back to your ward" for awhile.

I had to deal with the fact that a patient woke up in agony with a blocked catheter.  It needs irrigating.  It was draining a few hours ago.

Remember all this is what got thrown my way between 5 AM and 7 AM. I was the only RN for double digit patients.

There were two lots of IV frusemide to give. 80mg. They need to be set through a pump.  Got to watch those BPs because even though they are borderline (and I wouldn't give it if they were a smidge lower) these two chaps really need it.

I didn't want to leave the side of any one of these patients.  But my god.  Just standing in the treatment room mixing and preparing all these IV drugs is extremely time consuming.

I had to leave a few of the antibiotics for day shift.  Day shift was so busy that they didn't give the 8AM meds that I didn't give until nearly noon.

I got a phone call at 0600 to take a direct admission from A+E as there are no beds anywhere else.  The A&E nurse gave me report on my new patient. He is a drunk and combative alcohol patient who fell and hit his head. They  want neuro obs every 15 minutes.  He is sleepy but when he wakes up he knocks stuff over and hits. I didn't want to take this patient because the only empty bed I have is in a bay with 5 nice but frail confused elderly men.  He will need a lot of admission stuff doing as soon as he gets to the ward i.e. paperwork to get his admission orders sorted..  The rest of the admission paperwork and all other legally required documentation I will knock out after my shift ends by staying over unpaid.

And that is just some of it.  If I went into all the knowledge I have to have to manage those things we would be here all day.   If I fucked any of that up just this much I could be held responsible for someone's death.   Nurses are legally responsible for delivering the orders given by a doctor and monitoring patients.  And my list reflects my doing just that.

That was my lot to carry and carry alone.  I was the only qualified Nurse for those 19 20 patients There is no way that I can articulate on this blog how long it takes to prepare and mix and infuse and flush etc etc all those IV meds that were prescribed and due.  It takes a lot of time away from the patients.  Real hospitals have 24 hour pharmacies that make it their job to stay on top of new orders and mix and prepare and get to the Nurse these IV meds when they are do to be given.  My NHS hospital DOES NOT have this.  Even during the 9-5 hours that they are open they do not do that.  They just develop more paperwork for the Nurses to fill in so that we can actually get the drugs and not get fired for a med error by omission (not giving a prescribed drug to a patient on time).

The only help I had was a teenage cadet called Beth.  There was nothing in the above list that she could help me with.  Nothing. She cannot even do observations/vital signs or check blood sugars.  She is not a Health care assistant or a Nurse. I wish I had that lovely HCA from the surgical ward with me.  He was mint. Beth  refused to empty the catheters so that we could monitor an accurate fluid balance  because "that's gross".

Between 5AM and 7AM this is what Beth had to do:

Change a few beds
Help people to the toilet.
Answer call lights and tell patients that the Nurse will be there as soon as possible.  This confuses them since they think that she is a Nurse.  She is wearing the same uniform as me after all.
Serve hot drinks at 7AM (she puts a trolley together and just blows past anyone who appears to be asleep rather than waking them up and encouraging fluids). 

I would rather just do the drinks myself have seen my list of jobs happening at this time.
If anyone pees or drinks she needs to measure it and write the value on the fluid balance chart.  She didn't bother because she doesn't understand the point. As a matter of fact I asked her to do just that whilst my arms were loaded with IV meds, vital signs equipment, and new admission orders.   She just rolled her eyes at me and said she was "too busy" because she was "serving drinks".Doctors and Nurses could kill a patient if they don't have an accurate fluid balance.  Serving drinks took her all of 5 minutes since she ran past any patient who was sleeping or quiet.  Then she sat at the station on her mobile.

Beth cannot help me with anything on my list as she is not a Nurse.  But I must help her change those beds on top of everything else otherwise we get the cries of "those damn new fangled to posh to wash RN's leave all the real work to the care assistants".  And I just don't want to fucking hear it.

And at 07:30 she will be out the door on her way home regardless of what is going on in that ward.   She is not a Nurse, she is not licensed.  What does she care?  I will still be giving report.  Giving report on 20 patients takes a long time.  Who is looking out for my patients while I am handing over?  Beth will be on the Bus.  She doesn't understand what I have on my shoulders with those patients...she doesn't even understand what addiphos, deranged U+Es, hypoglycemia and sliding scale insulin means.  She has no idea what a Nurse does she just sees me flying in and out of rooms.   She tells the patients that she is a "real nurse" and a "nice nurse" because she is the one who serves them tea.  And they suck it up.  Most of what I am doing for them goes unseen by them.

Cadet Beth is real pissed off because she had to do the bed changes on her own mostly.  She will piss and moan to anyone she who will listen about how she was left to do all the real work (8 out of 14 bed changes; I managed to assist with 6 of them) because the Nurse "wouldn't help her".  The patients will tell her that she is the "nice nurse" who was kind enough to provide them with a drink and say "some others cannot be bothered with that because they think they are so high and mighty".  And the patients will say this too Beth whilst looking daggers at me.  They have absolutely no fucking clue what needs to be done to keep them alive and who is doing it.;  They get that the doctors are the brains who prescribe treatment.  And they get that nice nurses  staff like Beth "care" enough to give them a drink.  But they totally miss the knowledge bus on everything that is smack in between of that.  The bus took off and the patients are still at the station.

Beth was on her way home at 07:30.  I was still there on the ward tying up legally required loose ends at 9:30.  They stopped paying me at 07:30.  I think that without the new admission I may have made it out of there by 8:30 but nevermind.  My daughter was late for school.  Again.

Fuck this shit.  I want a clipboard job.  And when I leave I will be replaced with another cadet. And when that happens there will be one RN to 40 beds rather than one RN to  20 beds.

I love bedside Nursing but this is just too damn much.  It isn't Nursing that is the problems it is the working conditions.  The day shift nurse will be in for it.  When the consultants come in and see that the fluid balance charts are blank from the night shift (thanks Beth, you worthless slut) they will smackdown on the Nurse who happens to be standing the closest to them.

Imagine how different things would have been if this was the scenario:  Instead of just Beth and I for those 20 patients IMAGINE IF we had the recommended ratio of one nurse to 4 patients.  Imagine if each of those 4 patients were sharing one Nurse rather than all 20 sharing one Nurse and one cadet?  Imagine if each Nurse was able to do total care for her 4 patients......everything from dealing with IV infusions to changing their beds and encouraging a drink of tea.

I would stay in the job if that was the case.  But it will never be the case here.  NHS hospitals do not want to hire qualified Nurses to work at the bedside.  They do not want to pay for that.

When I finally left the ward at 09:30 I was near tears.  I was so rushed during those hours I was terrified that I made  a mistake and killed somebody.  I was afraid that maybe I hung the wrong meds on the wrong patients. I was afraid I missed somethingm like a low BP or a patient who had stopped fucking breathing.  OMG I hope that patient finally kept his 02 mask on.   I was afraid that one of the patients would go down to PALS and tell them about how I was the mean nurse who ran past them as they were shouting for help (I had to).  Oh but that Beth, she was lovely and made us tea....

Tuesday 25 January 2011

Had a Blast on the Surgical Ward. part 2

I just remembered one of the best things I experienced during my little shift on the short stay surgical ward.

His name was Sam.

No no no stop thinking like that.  Nurse Anne is a happily married woman.

Sam is an utterly fabulous health care assistant.  By the end of the day I called him Saint Sam.  Nurse Anne is a bit rusty with Surgical Nursing but I couldn't have failed with Sam on my team.

He was good with the patients.  He could do observations, blood sugars and he cared enough to let me know of any problems he felt were arising with a patient.  He even brought people back from theatre.

A good HCA is worth their weight in gold.  They may not be able to help with drugs and all that kind of stuff.  If I am the only Nurse on a medical ward for the shift I may have over 80 IV drugs to give.  That takes hours.  And Nurse's make drug errors and cannot get to their patients when they have that many IV's to do.  So even if I had a hundred Sam's working with me in a situation like that I would still be struggling and short staffed.

But if I  knew that Sam was keeping a careful, knowledgeable and watchful eye on my patients whilst I was tied up with Nursing stuff it would make me feel a whole lot better.  I wish we had people like Sam on our medical wards.  It would be a real help to know at least there was someone reliable to look at my patients whilst I was preparing over 80 IV meds and getting dragged on doctor's rounds and to the phone.  But we do not get Sam types on the medical wards.  We used to have Sam type HCA's but as they quit and retired they were not replaced.  And we got the kids instead. Sucks.  We have a couple excellent HCA's left in medicine but the rest of the care assistants are all kids/cadets/apprentices/auxillaries with serious knowledge and common sense deficits and a whole lot of attitude.

I asked Sam why he doesn't do his Nurse training.  He gave me a wry smile and laughed out loud.  " I am happy as I am.  From  my vantage point Nursing looks like a nightmare.   I used to work on a medical ward as an HCA and I know how the qualified nurses suffer.  As an HCA I don't have to fuck about with drugs, assessments, orders, doctors or take any responsibility.  And on the surgical wards things run more smoothly than on a medical ward. I just enjoy interacting with the patients and helping them out.  And it is great.  Why would I want to give up a job I love ?"

Our medical wards need to have good RN's and health care assistants.  I think the ideal ratio is 80% RN's to 20% health care assistants in the composition of ward staff.

But the current ratios we are working with are something like 30% of staff are RN's and 70% are cadets/kids/apprentices/axilliaries.  

The hospital lies and tells people that on any given shift their medical wards are staffed with 65% Nurses and 35% care assistants.  This is a lie. 

Anyway I tried to get Sam to beg for a transfer to my ward and he nearly fainted because he laughed so hard.

Forest Gump GPs and hospital Consultants all across the land are telling anyone who will listen that the problem is "degree nurses who don't want to work on the wards".  Bullshit.  Managers are turning away both older trained and newly qualified Nurses when they apply for jobs as bedside Nurses on the wards.  They would rather hire kids.  Cheapo cheapo productions.

Had a Blast on the Surgical Ward.

When Gladys is admitted to hospital she ends up on a medical ward due to her chronic COPD, diabetes, and Anemia.  She is sick and tired of the way these general wards are underesourced and has decided to make her feelings known to management with a nice hand gesture. 

Lucky lucky LUCKY me.  I showed up to work a shift on my usual medical ward last week. 

But the surgical ward downstairs was short staffed.  And we had 3 RN's.  They had one. And it was my turn to "float".  So I was ordered by the bed manager to work on the surgical ward. He didn't have to order me to go there.  I ran away from my ward and ran down there skipping and laughing,  so full of glee and joy was I.

It was I thought it would be.  Bloody fantastic.

Surgical wards are fantastic compared to medical wards.  Less patients, less drugs, virtually no confused and total care patients.....all in all it means that the Nurse is more in control of her workload on a surgical ward and can do the job better.  Surgical ward Nurses are not as destroyed emotionally, physically and mentally as Medical ward nurses.

We recently discussed this over on a fantastic blog called Diary of Benefit Scrounger.  The author of that blog is a woman named Sue.  She had recently had experience of an incompent medical ward.  Not long after she was admitted to a surgical ward and was shocked at the difference in care.  She felt secure and happy on the surgical ward.

I weighed in on Sue's comment section with my opinion on why the surgical ward Nurses have it together so much  more than medical nurses:

Again this doesn't surprise me in the least.

We have talked a lot on militant medical nurse about medical wards vs surgical wards.

I once worked on a surgical ward. Never was I so happy. I was one RN to 6 young, sensible, reasonably healthy stable patients having minor to moderate surgery and we had all the equipment and to resources we needed. We had a charge nurse without an assignment to back us up and we always had clerical support.

Then that unit was shut and my colleagues and I were moved to medical wards. That is when I began blogging.

On surgical wards not only do the nurses have less patients but their patients are less confused, less ill and less demanding. If the surgical ward nurse with only 5 easy patients gets an admission of a demented elderly patient pulling out his lines and tubes and spreading shit everywhere she sends him to a medical ward where the Nurse already has 20 such patients.

Medical ward nurses are NOT allowed to dump a patient somewhere else because they cannot handle him.

If a patient becomes medically unwell on a surgical ward he immediately gets sent over to the overwhelmed already medical nurse who already has more patients and more difficult patients than the surgical nurse has.

There is a lot that surgical nurses don't have to deal with.

A drug round on a surg ward is simple since most of the patients are not as acute or chronically ill as medical patients. It took me 15 minutes to get through the 8AM drugs on my 6 patients in the surgical ward. It takes me over an hour to get through the 8AM meds for 6 patients on a medical ward. And I have about 16 of them.

Surgical patients bring money into the hospital. Medical patients cause the hospital to lose money. It was explained to me that this is the reason for the discrepencies.  This is why medical wards are so underesourced causing medical nurses to struggle.

Surgical ward nurses also think that they are superior to medical nurses since they get better patient feedback and make less mistakes.

I thought this too when I was a surgical nurse. My eyes were really opened when I went to work on a medical ward.

Once another surgical ward at my hospital was shut and their nurses were sent to my ward to work. They were making wisecracks about "now we are on a medical ward we will do nothing but babysit and hand out commodes" and "It will be like a nursing home".

I came in for a night shift the next day and two surgical nurses had been on for the entire medical ward alone during the afternoon and evening. They were in tears. They couldn't manage the demented, the high patient load. One of the patients deteriorated with a severe medical condition and they didn't know what to do. They couldn't figure out a lot of what needed to be done and patients really suffered.

The wisecracks soon stopped after they got a taste of general medicine.

Care assistants on a surgical ward have a smaller easier work load and get paid at band 3. Care assistants on a medical ward break their backs and get paid at a lower rate on band 2.

There are no geriatric wards anymore. Geriatric patients go to general medical where they are mixed up with critically ill patients, psych patients, hospice patients,surgical patients who had a medical emergency on the surgical ward and social admissions for lack of coping at home etc etc.   The staffing levels of Nurses on these wards would shame a third world country.  The real Nurses are few.  The untrained care assistants are many. 

In short there is less chaos in surgery and what chaos that exists is easy to control. The surgeons round twice a day on the surgical wards. The medical consultants twice a week.

So you perceptions are very accurate.

and I should add to this that surgical wards deal with the same thing and over again with little variation. They refuse to accept patients that dont fit into a criteria that they don't want or do not feel like they can handle. Medical nurses are unable to do this and have to take anything and everything no matter how overwhelmed they all ready are.

Surgical ward nursing was fun but general medicine has made me burn out and lose my mind.

Then DinoNurse, an ITU Sister who often comments on Militant Medical Nurse, gave her tuppence worth.  As usual, Dino was right on the money and did a better job of explaining it all than I ever could:

Medicine is the blackhole of well, medicine lol.

On a more serious note- google "medical ward" and "foundation trust" and the number of closed wards seems to be growing. My own foundation trust lost an entire ward when the former hospitals merged. Last winter we had to open 2 entire wards to cope with the influx- pushed our agency budget through the roof. This year, had the powers that be learned anything? Of course not- yet again medical wards are full to bursting and the backlog is impacting on everything else. Our admissions units are warzones, quite literally.

This is the same UK wide. If you really want to raise awareness Sue, you need to be pointing out that in general surgical patients are younger, fitter and spend on average a week or less in an NHS hospital bed. If you have a chronic condition, by and large you will be treated on a medical ward unless you need surgery. Our ICU emergency admissions are generally medical in origin- chest infections, GI bleeds, DKAs, epilepsy complications- the list is endless.

Most surgical admissions are either elective ( because they have need for 24-48 hours ventilationn) or due to unpredicted bleeding (although obviously life threatening, fluid resus normally sorts this out quite quickly and they come to us for monitoring and inotropes.)Surgical wards do not do inotropes...however medical wards are expected to manage.

Any surgical patient who develops a "medical problem" will be turfed to medicine...the chest infections, UTIs- generally elderly and mostly leading to confusion and agression... Generally speaking, medical patients take longer to recover and require more input from nurses, physios, social services etc...Surgery can make money for a trust and medicine cannot.

Medical wards literally suck the life out of you ( staff and patients). What we need is guaranteed SAFE RN TO PATIENT RATIOS. I cannot stress this enough. 1 RN to 6 patients would be a step in the right direction. Ideally this should be reduced to 4 in an acute setting. A little story happening in an average trust every day- allegedly...28 bedded medical ward has 3 RNs on duty along with 2 HCAs. So each RN gets just over half an HCA and 9 and a bit patients. Ward has 6 bays of 4 beds and the rest are siderooms. So each RN has 2 bays and the siderooms are shared, so to speak.

 In one bay we have a confused old man who keeps climbing out of bed, the trust have helpfully provided a buzzing mat that goes off everytime he does this. There is also a very sick young diabetic in DKA in the next bed with multiple drips, sliding scale insulin and he should be on half hourly observations (minimum). Thats just one bay. The RN for this bay will should basically never have to leave the bay. In the other bay she is responsible for we have a GI bleed who is actively bleeding, having transfusions and has just been started on inotropes. He also needs a MINIMUM of half hourly observations. So the RN will bust her tail trying to keep up to date with the GI bleed and the DKA and hope that the old guy doesn't fall out of bed. As for the other 6 or so patients she is responsible for, well....need I go on?

Oh, and halfway through the shift the ward will lose an RN and an HCA to "help out" on a medical ward with even worse ratios. In the "bad" old days we would have created an "obs" bay and put all the medically unstable patients here, next to the nurses station- and we would have had 6 RNs/ENs on duty ( alot more trained staff than we have now). The DKA patient would most likely have been transferred to the ICU. This is the biggest problem today- patients are older, sicker and more complex. Many of those on medical wards would have been in the ICU 20 years ao. Unless we get safe ratios we are heading for the biggest fall imaginable. The NHS will dissolve into "social enterprises" that are still private in nature...and if you were the CEO would you want to waste all your resources on the medical blackhole? Didn't think so....

My day at the surgical ward was fantastic.  I had 8 patients.  All of whom were stable.  I had two post op lap chole patients who were doing great.  I was able to spend a lot of time with them talking about post op care and ensuring that they were safe and comfortable.  I had several pre op patients and admissions who were healthy and compus mentus.  This allowed me to spend time making sure that everything was in order for their procedures and also explaining to them what they could expect.  The drug round took 10 minutes. 
I couldn't help noticing the wall behind the Nurse's station on the newly redecorated, modern and refurbished surgical ward.  They had trust awards for "best at completing careplans" and "best at completing risk assessments" and all that.  They even had an award for "least falls".  Probably because all of their patients are youngish, not confused and have no mobility problems.  Yes, managment actually gave the short stay surgical ward an award for "least falls". No wonder they don't have any falls.  They have no fall risk patients and lots more staff.

 My medical ward has no awards.  Our confused elderly patients outnumber the staff 20 to 1 and there are lots of falls.  And we sure do not have time to complete care plans or risk assessments because we have critically ill patients that need 150 IV meds mixed up and given whilst we are trying to stop the confused elderly ones from falling, peeing on the floor and attacking other patients.  My ward looks exactly like something out of 1950's Russia except that it is a whole lot dirtier.  The cleaners on my ward like to flip off the Nurses and go for tea breaks.
 God, I hope that when I am old and confused that I have saved enough money for my family to hire a one to one carer to stay with me when I am in hospital.  Lord knows that my poor  ward RN, with a 150 IV meds to give and more patients than she can keep track of won't be able to help me.  I do have a savings account set up for that you know. 
General medical wards: The red haired step child of the NHS.

Sunday 23 January 2011

Judith Potts is at it again

I am actually really embarrassed for her.  She really isn't  doing her research before she writes these pieces.  Her ignorance is astounding.

Managers who support the pay freeze:

From this wonderful blog.

Salaries of NHS bosses who back increment freeze

Twelve senior NHS managers wrote to the Health Service Journal on Tuesday saying that staff should have their annual increments frozen for two years as part of a government cost-cutting programme.

The deal offered is that in exchange for the increment freeze, there will be no redundancies at Pay Band 6 or lower.

There is no such guarantee on offer for those on higher grades.

In effect this means that anyone on Pay Band 7 which starts at just £30,460 will be at risk of redundancy.

The increment freeze will come in addition to a two year pay freeze already imposed on NHS staff.

The managers say in their letter: ‘it is important that there is a considered debate about the issues based upon accurate information and we are seeking to encourage employers to have that debate with their staff and their staff sides’.

In the interests of providing accurate information and to encourage just such debate, here are the current salaries of all 12 signatories.

Maggie Boyle, Leeds Teaching Hospitals

£220 - 225,000

(Source: Annual report2009/2010)

Sir Robert Naylor, University College Hospital foundation trust


(Source: Annual Report 2009/2010)

Jo Cubbon, Taunton and Somerset Hospital foundation trust


(Source: Annual Report 2009/2010)

Peter Cubbon, West London mental health trust


(Source: Annual Report 2009/2010)

David Dalton, Salford Royal hospital foundation trust


(Source: Annual report 2009/2010)

Stephen Eames, County Durham and Darlington hospital foundation trust


(Source: Annual Report 2009/2010)

Mike Farrar, north west strategic health authority


(Source: Annual Report 2009/2010)

Andrew Foster, Wrightington, Wigan and Leigh hospital foundation trust


(Source: Annual Report 2009/2010)

Julian Hartley, University Hospital of South Manchester foundation trust


(Source: Annual Report 2009/2010)

Simon Pleydell, South Tees Hospitals foundation trust


(Source: Annual Report 2009/2010)

John Rostill, Worcestershire Acute Hospitals


(Source: Annual Report 2009/2010)

Chris Sharratt, Sheffield Children's hospital foundation trust


(Source: Annual Report 2009/2010)

Keep in mind that we have already had a pay freeze in effect.  Keep in mind that we are already paid a lot less than Nurses in other first world countries.  Keep in mind that we have a much heavier workload than Nurses in other first world countries  because of poor RN to patient ratios.  You wouldn't believe how many thousands of pounds I have had to pay out to childminders during the course of my career to watch my children during hours I worked that I never got paid for.   Keep all this in mind.  What kind of state would the NHS be in if they didn't exploit their frontline professionals?

Saturday 22 January 2011

Ward Nurse Suspended...

I received a cry for help in my email inbox this week.

It was from the husband of a registered nurse who has been qualified and working on the frontlines as a direct care Nurse for 30 years.

Recently she was left as the only experienced/qualified nurse for a very large number of ill patients on her ward. Like my hospital, her hospital as probably ignored the Nurses' complaints about short staffing of real nurses on the wards.

Her least ill patient was a man having minor surgery.  He was fine.  Never complained to her or about her.  He recovered well and went home.  All of you who work as acute care nurses and find yourselves as the only RN on a large ward know that you cannot give time to well patients without killing your sickest ones.

After this patient was discharged his wife  wrote a nasty note to the hospital complaining about the fact that she did not feel that her husband received enough one to one care. 

The Nurse who was on duty that day (my correspondant's wife) was suspended because of the complaint.  She has had over 30 years as a Nurse without a mark against her.  Sounds to me like she is at the top of her pay band as a bedside Nurse and they want her gone to replace her with a totally green and inexperienced newly qualified or a kid.  They are on lower salaries.  You see a lot of this in Nursing.  I had a good friend (and mentor) who was qualified for 40 years.  She was top of her pay band as a bedside Nurse.  They got rid of her over something completely made up and replaced her with a newly qualified Nurse on a much lower pay band.  Hospitals have been playing these games with bedside RN's since the late 80's when they decided that professional Nursing at the bedside wasn't worth spending money on anymore.  Once they decided that it has been nothing but cut cut cut.  Not only do they get rid of their most experienced bedside RN's but they don't replace those who quit or retire with staff of equal value, training or experience.   Many will blame well educated Nurses for the shitstorm that is hospital nursing care these days.  But the truth is that well educated qualified Nurses KNOW that they need to be at the bedside with their hands getting dirty in all aspects of patient care.   Hospital management does not give a shit know this. 

I have seen this kind of thing in my hospital.  Management won't accept liability and they won't deal head on with problems at ward level (lack of qualified staff).   And a Nurse or a Doctor becomes a sacrificial lamb.  I have no doubt that this Nurse will be reported by her hospital to the board of Nursing that she is licensed with for patient neglect.  In which case she is guilty until proven innocent and gagged from talking about how her ward was staffed and what was going on with her multiple other patients.  I have seen it happen.  I hope this Nurse has a lot of money put aside for legal fees.

Even though I detest Unions and think that they are worthless for health care professionals I do hope that this lady is unionised.  But then again, what will the union do about it?  Hospital chiefs laugh at the Nursing Unions.  We have absolutely no leverage and cannot strike.  I don't know how to advise the husband of this Nurse.  I hope that they can afford a good lawyer.

This post makes me think of a fantastic book by a journalist named Suzanne Gordon. She is not a nurse but she studies Nurses and has spent years shadowing qualified Nurses at work on hell wards.  She understands what is going on.  Her book is called Nursing Against the Odds but I think a better title would be "Oh My God what the FUCK has happened to Nursing care on the Wards" or perhaps "Don't Blame the Nursing Profession, asshole".

Great book if you get a chance to read it.

Tuesday 18 January 2011

Another article on Hospital care.

Should we bother writing to this woman and explaining how unrealistic her expectations were and how greatly she misunderstood the situation?  She is right about hospital care.  But yet she completely misinterpreted the situation.

Do you think she actually wants to know and understand or do you think she just wants to moan?

As I work in medicine at a district general hospital I know how long it takes to get new patients sorted.  I know how difficult it is to do the right thing with elderly people and how slow the system is to act.  But I think this woman just has it in for the frontline professionals.  She lacks insight and sense and takes it out on the Nurses and Doctors rather than the shitty system they work in.

The GP had been called to the residential care home in which she lives – Sylvia has severe dementia – because she had not been eating or, more importantly, drinking for 24 hours and was virtually comatose. The GP diagnosed possible pneumonia and asked that Sylvia should be put on a re-hydration and anti-biotic drip within two hours

The GP had to know that there was no way that she could be admitted and started on those orders within two hours. He must have been covering his ass. Tests have to be done in hospital and the hospital consultant has to see the patient in AAU long before anything can be started. A lot of ducks have to be line up in a row for a diagnosis to happen and the right treatment to be initiated.

Unfortunately, no assessing of Sylvia’s condition was carried out for several hours. I understand that recent policy in the NHS requires patients to be held for no longer than 4 hours in Casualty. Clearly, this does not apply to the “assessment” ward.

That is of course why they have assessment wards (AAU). There are not enough beds, staff (the right kind of staff) or facilities to meet the targets and avoid the hospital getting fined.  Management did this.

After waiting three hours, I approached a female nurse and explained about the GP’s wishes. Standing under a poster warning patients and their families not to abuse hospital staff, the nurse sarcastically answered me. “With all due respect, darling, it is for the hospital doctor to decide on diagnosis and treatment not the GP.”

That is 100% true. No hospital Nurse or hospital doctor can act on orders by a GP. The GP did not make a definite diagnosis. He did not have the diagnostic tests at his disposal to do that. It would hurt patients even more if the hospital staff did what this author believed that they should do. Hanging the wrong IV fluids or IV antibiotics could kill a patient very fast and a doctor's rule is "first do no harm". The Nurse of course can NOT hang IV fluids or IV antibiotics until the consultant has seen the patient and one of his doctors has prescribed the darn things. These places are so short of qualified staff (not unqualified staff ....lots of them hanging around) that I think they did well to get it sorted within 24 hours.

Eventually a doctor appeared. He was perfectly polite and, after examining Sylvia, took us to one side, explained that there were “quite a few things going on with Sylvia” and asked for our decision on resuscitation. Not having realised Sylvia’s condition was that serious, we were very shocked – not least because she had been left untreated

That is a bit silly. An elderly woman with severe dementia who has stopped eating and drinking could be at death's door regardless of pneumonia, IV fluids and IV antibiotics. Those treatments might have worked or they might have sent another organ system in her body totally screwy. Doctors are clinicians not psychic mediums. Medicine is not a cut and dried science that always follows a logical planned and steady algorithm. I bet her renal function was also a mess. Anyone (me, you, etc) could drop over dead at any time. An elderly person who is sick enough to get admitted to hospital is very likely to just crash at anytime regardless of anything the doctors and nurses are or are not doing.

He was correct to ask about rescus status. At this point there was no way for the medic to know how things would turn out for Sylvia.  I once worked with a young healthy nurse who fell over and died of a stroke in the middle of the shift.  If that can happen to her it can happen to an elderly lady at anytime, regardless of IV antibiotics and fluids.

The whereabouts of the consultant was a mystery. Neither he nor his team were in attendance, despite the fact that there were two other elderly ladies with chronic dementia on the ward.

Believe me when I tell you that this consultant would have had over a 100 patients with confusion, dementia and multiple other medical problems on many, many, different wards all over the hospital. It takes these guys something like 10 hours in a day to see all of these people just one time. Plus they have clinics and everything else. It is offensive for you to imply that he was bunking off and ignoring his patients.  If you tried to keep pace with his work day just once you would collapse.

Next morning I rang again – quite prepared for Sylvia to have died in the night – to be told that she was absolutely fine and could go home.

This is how it is with elderly people who have dementia. It is never cut and dried and you don't know what will happen. If they sent her home the next day it is highly unlikely that she had pneumonia, as the GP led you to believe. Older people with dementia often stop eating and drinking and have alterations in levels of consciousness. It may be an acute medical problem that needs IVs and other treatments or it may just be the kind of quick deterioration that happens to all older people as their bodies start to shut down. They often seem to rally, then get worse, then rally again. Not eating and drinking etc is normal for people when they get to end stage of life. And all elderly people are at the end stage of life and their bodies are going haywire and shutting down.  Fixing one problem causes another to start. If some IV fluids helped her come around  this time then that is great. But it doesn't mean that she is "cured". 

Pleased though we were, we wanted an explanation. Nothing tallied.

She is elderly. And elderly patients are complicated. There is no cure for old age. She was admitted to hospital. They did some tests. She came around and they determined that she was medically stable and they sent her home.

There is nothing else to tell. You are wanting instant answers and diagnostics and a cut and dried plan of care instantly. This is impossible in general medicine especially with elderly patients.  In other words, nothing tallies because you have no experience or education in health care.  If the hospital doctor and nurses explained this to you as I am  explaining it to you would not have liked it.

However, Sylvia was not sent home that day because she became unwell again.

Yep. Elderly patients go up and down like this because they are at the end of their lives. Doctors are brilliant but there are two things that they cannot do. They cannot cure old age or stop us from being mortals with bodies that give out.

I would imagine that she will deteriorate, rally, deteriorate, rally, deteriorate, rally many more times before she passes. All without a concrete diagnosis. That is normal. It is no different for elderly people in the United States, Canada, Australia etc.

I have numerous questions including – was Sylvia apparently ignored? Why is there no communication between the GP and the ward staff – and is this nurse’s opinion, of the GP’s ability to diagnose, commonly found in NHS wards?

It wasn't the Nurse's opinion.  The Nurse was telling you a fact.  A fact that should be obvious.  Even if the GP had wrote out orders (which he did not) and faxed them the Hospital nurse still would NOT have been able to act on them. The hospital doctor has to write the orders. The GP did not have the information to give safe orders.   A doctor cannot prescribe IVs etc without blood tests and xrays. The hospital doctor will prescribe what needs to be prescribed when he has all of his ducks in a row. If Nurses are to give IV fluids or IV antbiotics the order has to be written on a hospital drug chart by hospital doctors. Otherwise it is an illegal order and  cannot be given. Sylvia was not ignored. She was under the care of Nurses and Doctors who were already 4-5 hours behind on doing what needed to be done for the patients that they already had when Sylvia came through the door.

Why was there no polite, informed communication between the ward staff and me – I was not the only person sitting beside an elderly relative’s bed, not knowing what to do?

Did it very occur to you that:

 A. An RN cannot delay treatment for the 15 people she is responsible for to chat with relatives
 B.  The five unqualifed staff sitting at the Nurse's station cannot help me implement doctors orders or communicate with relatives.  A Nurse has to handle that all by herself all at the same time.  And there is only one Nurse for a large team of patients despite how many techs you see hanging around.
 C..That there was nothing to tell? It gets very frustrating when relatives sit around with nothing to do obsessing over every little detail and inventing these paranoid scenarios where everyone is trying to neglect and kill grandma and hide information from them.  Open your eyes a little.

there was no evidence of shortness of staff; indeed a lot of eating and chatting was going on at the nurses’ station.
From what I hear, Shitborough has some of the worst direct RN to patient ratios in the galaxy. It is lack of RN's that are the problem, not lack of techs and unqualified staff. 
You know not what you see. I know how wards are staffed in these places. Many of the staff you see at the station are not Nurses and Doctors. They are care assistants and techs. And even if I had a hundred of them working with me I would still be too short of nurses and doctors to get things done in a timely fashion. I once had a bag of IV fluids run out on a patient and it took me 5 hours to chase down a doctor to get him to prescribe more so that I could hang a new bag A few techs sat at the nurse's station drinking tea and chatting does not change how long it takes the doctor to get results of diagnostic tests so that he can order the correct treatment. I could have a thousand techs working with me on a shift. But whether they look busy or are sitting around at the station does not change how long it takes to get orders written by the doctor and implemented by the Nurse.

I think you are either very unrealistic or are simply shit stirring.  And please keep in mind that no hospital Nurse can act on orders or start any kind of IV therapy unless it has been prescribed onto the hospital system by the hospital doctors. Not under any circumstances ever.

I am also surprised that a medic told her that someone would ring from the ward with an update!  As a ward Nurse I am almost never in  a position when I can abandon those IV fluids and meds that I am hours and hours behind on starting on all those people to call relatives.  The only help I have are techs and assistants and they cannot make calls to relatives NOR can they  continue with my workload as I am sat around ringing the relatives of 15 different people to give an "update". 

And that's probably all there is to tell Mrs. Potts.  Hope that helps.


Monday 17 January 2011

Hold me Back

Well at least Journalists are allowed to have their little temper tantrums.  If I even look tired at the end of a 14 hour day of watching people die and about 10 relatives will go down to PALS calling me a sour faced bitch who needs smile lessons. Imagine if a Nurse or Doctor shouted "fuck it" or threw something down and shouted "fuck this I am not doing anymore"?  The camera never turns off for us, the loss of temper or frustration never gets edited out and we are always seen.  And compared to journalists we actually have a good reason to lose our cool.

I very nearly lost my temper with some visitors the other day.  To the point that I had to lock myself in a toilet to ensure that I kept my mouth shut.

It wasn't anything more than the usual nasty ignorant crap we get from them DAY AFTER DAY AFTER DAY over an over again. But it was like the straw that broke the camel's back.

I work with a Nurse called Amanda.  She works 3 shifts a week from 7AM to 9PM when she isn't doing night shifts.

Amanda is super.  At the end of every shift she stays over unpaid by hours to sort things like necessary paperwork and order checks to give the next shift a helping hand.  No one has asked her to do this.  She does it because she cares.  Can you imagine working a 14 hour day and then staying on by a couple of hours unpaid?

What she does is really helpful.  When I come on duty after her I am more able to get on with direct patient care because her extra work allows me to do so.  If she didn't stay over to do these things I would have to do it rather than getting straight to my patients.  Then they would accuse me of neglecting them.....

Last night at 9PM Amanda handed over to me as I was taking over from her.  She stayed on and did a whole bunch of stuff (answered the phone, checked orders, went downstairs to get me some blood etc etc).  This allowed me to get started with the bedtime drug round and check in on my patients simulatneously.  It was a big help as I also had a really unwell patient on top of all the other stuff that needs to get dealt with minutes into a new shift.

At 11PM, two hours after the end of her shift, Amanda was still at the Nurse's station.  She was doing some computer work for us Night shift girls that needed to be sorted at that exact time.  New patients had been admitted 10:45 PM  and their details need to be entered into the computer as soon as they arrive onto the ward.  Amanda kindly did this for me (I didn't ask her to) and it allowed me to continue with eyeballing all 19 of my patients, drugs for all of them, assessments for all of them, and deal with unwell patient's new orders.  

Had Amanda not hung around at the end of her shift I might have been so tied up dealing with all that shit that I might have missed something with a patient that could have turned into a mega catastrophe later on.  Thank you Amanda.

As Amanda was at the station at 11PM two visitors who had stayed late walked by her and spat "there is another 'angel' sat on her ass at the desk ignoring patients".   Pretty harsh words coming from a couple of cunts who probably don't work at all or ONLY work 8 hour days 5 days a week.

Amanda is a saint but she is stupid too.  Never make the kind of sacrifices that she is making.  The public just throws it back in your face.  I very nearly told those two visitors exactly what I thought of them.

I was already in a foul mood that day.  Earlier in the week I had a patient go into congestive cardiac failure secondary to fluid overload.  Her IV fluids had to be STOPPED. Or she would have died.  We gave her some IV furosemide and she improved.

Cue the family seeing her IV fluids stopped and marching up to me.  "Why are my mother's fluids not running?".  I explained about the fluid over load and the CCF but I wasn't getting through.  These people had already decided that I was trying to dehydrate their mother to death long before they spoke to me.  So they walked away from me and went up to a cadet nurse (thinking she was a nurse) and asked her.  Of course a cadet doesn't even know what CCF and fluid overload even is.  Then the family marched up to the Nurse's station where a doctor (who didn't even know the patient in question) was sitting trying to review some notes on a patient that was referred to him.

"Those two Nurses (pointing at me and the cadet as if we are criminals)  are trying to kill my mother by refusing to hang another bag of IV fluids".  

I thought this was pretty funny considering that we need an order from a doctor to hang more IV fluids and we CANNOT just hang them because we think a patient needs them.    And of course the order to stop IV fluids had come from the doctors anyway.

The doctor looked like a deer trapped in the headlights. He didn't know the patient but here he had some crazy family member who assumed that he was responsible for all patients on the ward and that he   was also the "supervisor"of the Nurses.  I don't think I have ever been hired, fired, or supervised by a doctor in 14 years of Nursing.  This relative was looking at me real smug, as if she thought she was going to get me in big trouble with the boss.  The meaner she got, the nicer I was and that really made her go mad.

I explained the patient's situation to the doctor.  He told the visitor the exact same thing I did.  And she was happy with his explanation.


This has more to do with visitors having a prejudiced and 19th century view of Nurses than it had to with any concern they had for their mother.

In the old days criminals and prostitutes were pressed into Nursing when they didn't want to be there.  They needed close supervision and threats to ensure that they didn't harm the patients.  During the American Civil War (1861-1865) woman were considered out of place as Nurses and soldiers who misbehaved were put on "nursing duty" as a punishment.  That was your Nurse workforce.

Fast forward to today.  Medical care is so complicated that even the Nurses need a good education to deliver it.   I had to work my butt off to get into Nursing school overseas.  I had to have top grades and be in the top percentage of my class.  I had to pay a lot of money out to qualify and take an expensive state board exam.  I have to pay a lot of money out every year to stay qualified and continue to update my education.  If I didn't do all that I couldn't be a Nurse.

I never would have made it if I didn't want to do it and take it seriously.

But members of the public still think that Nursing is a "terrible" job that losers are forced into doing.  Therefore they think they have to stay on top of us.  The viewpoint is also exacerbated by the fact that Registered Nurses are the lowest paid of the public sector professionals in the UK.   This isn't because they actually deserve less.  A hospital RN has a lot more on his shoulders than a teacher or a cop does.  Nurses  are undervalued in a system that is forced to make financial cuts on the frontlines of health care.  

In countries like the USA a bedside direct care Registered Nurse earns far more than a police officer and a teacher.  They earn more than most 3-4 year graduates upon the start of employment. I was out earning my stepsister ( who holds a master's degree in journalism from Medill) immediately upon my first job as a bedside  RN in the USA.  I provided direct patient care (all aspects of care from cannulation, to orders to shit cleaning) to a team of 7 patients.  I think that gives people over there the idea that maybe just maybe Nurses  are a bit skilled, important, and serious about their work. 

These negative views held by the British public are all the more inflamed and reinforced by the terrible state our hospitals and patients are in as a result of poor RN staffing, resourcing, incompetent management etc.

I hope that this blog has helped people to see that there is more going on here than the simple "Oh the Nurses are just a bunch of pigs who don't want to be bothered" scenario.

But I don't know I don't know if it is even possible to educate people about what is going on in our hospitals.  They just want someone to blame when the idea that their loved ones and themselves are not immortal.  They want someone to blame when they cannot accept that sickness and old age are ugly horrible things and that medical science doesn't have all the answers.

Reminding myself of all this helped me to keep my mouth shut and not go into smackdown mode when those people insulted Amanda.

Let's watch Bill O'Reilly meltdown one more time.  Isn't it just so stressful to be sat a desk reading for a teleprompter?  Christ if anyone at my hospital acted like this ever we would be gone. Immediately.

Imagine this little princess having to deal with constant interruptions whilst she was trying to calculate a drip to stop someone from dying and getting blamed for their death.

Here is another one.  Aren't these reporters so professional?  These guys would be the first one on the story if a Nurse panicked and shouted "oh shit" when she realised that her 16 year old patient stopped breathing.  I am sure that the patients and relatives would be running to PALS and the papers if they heard an explective come out of the mouth of a Nurse.  Makes me laugh.  He doesn't look like he is having a tough day at work to me.  None of them do.

Saturday 15 January 2011

Housekeeper hell

I recently posted a comment in the comments section on my Wow, Peter post about the housekeeper re arranging everything on the ward so that equipment was impossible to find in an emergency.   This was done because the previous set up was an inconvience to her.

Now I can top that story. Or just add to it really.

Another housekeeper who works about 5 hours a day 4 days a week recently insulted a medical doctor of ours.

He was preparing a tray to draw some bloods on a patient.  Just as he got it all together his pager beeped and a voice came through it : " CARDIAC ARREST WARD 15, CARDIAC ARREST WARD 15".  His patient on a ward 3 floors away had just stopped breathing.  He dropped the tray on the counter top and ran down there, as is his duty. He ran like an athelete to get down there and help his patient.

The housekeeper came into the treatment room a minute later, saw his phlebotomy tray, and went nuts because the doctor "didn't clean up after himself".  She went on and on about his "laziness" and "lack of consideration".  He did not leave any kind of mess, just a tray with a syringe and blood tubes and some gauze.  He would need that later when he came back from the emergency to draw bloods on my patient (a very difficult person to get bloods from).

She began to put all the equipment back.  I told her that he would need it all again in about an hour or so and to leave it.  She continued with the "lazy bastard" stuff.  I let her have it.  I couldn't help it.  This medic was probably going to be working a 12+ hour day and he should not be worried about tidying things up to make like easier for the housekeeper.  None of us should, I tried to explain to her that unlike her he has real responsibility and cannot delay treating a patient to make life easier for her.  But I didn't get through that thick skull of hers.  She was still pissing and moaning about it an hour later.

Shocking isn't it.  And it happens all the time.

If you want to read more about lack of respect for Nurses and Doctors from the supposed "support staff" go here:

We have a hell of a lot of lazy and crap staff in the NHS who need to be disciplined and fired.  But you won't find this amongst the professional nurses and doctors.  We have a registration to protect.  We take our jobs seriously.  It is the low paid crap that we depend on that let us down constantly and are never dealt with that is the problem.

At 6 in the morning I had a patient deteriorate and as I was dealing with him all the other patients were ringing and shouting for help.  Where was my health care assistant (the only other member of staff I had with me)?  In the kitchen washing jugs and setting up for breakfast because the domestics would give her a smackdown if they came into work at 7AM and stuff wasn't done for them.  She was actually afraid of them.  I told the HCA not to worry about those slags and to give me a hand on the ward instead.  The domestics came into to work and started on the HCA for not doing jobs for them and I told them off.  Then they complain that they are being "bullied".

These people are untouchable.  They are never disciplined or dealt with.  The trust wouldn't hesitate to get rid of a Nurse or Doctor if something goes wrong but it seems as if everyone that we depend on just fucks around.
I had a ward clerk sat on the computer telling me that it wasn't her problem if the phone was ringing and that the Nurse should answer it.


I could go on.

Friday 14 January 2011

No unsocial hours pay.

I just received a worrying email.  I have promised the author that I will not give out the details of his/her trust location. 

The trust that this person works for as a Nurse is trying to stop unsocial hours pay.  The pay rate for nights, days, weekends etc will all be the same basic rate.

The unions are getting involved but if Nurses cannot strike how much power will they have to really fight it?

If this goes through in one trust it will go happen in others.

All staff Nurses work a mix of day shift, night shift, weekday shifts and weekend shifts every single month.  Currently they get paid a slightly higher rate for working unsocial hours.

Our shifts are different every week.  We work on no kind of pattern . The working week goes something like this for a staff nurse.. 

Monday 7AM to 3 PM.
Tuesday  2PM to 10 PM
Wednesday 7AM to 3PM.
Thursday day off. 
Friday 8PM to 9AM saturday morning.
Saturday off.
 Sunday 7AM to 3 PM.

The following week:

Tuesday 8PM to 9 AM
Wednesday 8 PM to 9AM
Thursday off
Friday 7AM to 9PM.

Ridiculous isn't it. My body clock is messed up.  Every week has that kind of mix of shifts. But the fact that we get a slightly higher rate for doing nights keeps my monthly wage at a certain level.

If this goes through they will see their wages fall by hundreds of pounds a month.  I know I would.  I do lots of nights and weekends.  And there is no opting out of them even if they refuse to pay unsocial hours.

This is not a good thing to happen at a time when cost of living is skyrocketing.

More staff nurses will quit.  Hospitals are having to close beds because of lack of staff.   That is how extreme the nursing shortage (which results from nurses refusing to work at the bedside because of poor conditions) is getting.  The staffing has become so bad that even management knows that the situation is bad.  Usually they will just keep beds open and make 2 RN's take 30 patients and then 6 more admissions.  But when the best you can get is one RN for 36 beds then beds close.

Lets hope that the plan to cut unsocial hours pay is all talk.

Thursday 13 January 2011

Wow Peter.....

I think Dr. Peter Carter has actually possibly grown a pair.  I think I am turned on.  Well, not really. 

I wanted to inform you of a very important development relating to the proposals to freeze the incremental pay for all NHS staff in England in exchange for a "no compulsory redundancy" guarantee for some staff.

Today, the RCN rejected the proposals, calling them "illogical" and said they were an "attack upon hard-working nurses". This decision is due to be ratified by Council next week.

The RCN took this decision after hearing the strength of feeling from members who have contacted us by email, via our Facebook page and by post and phone.

Over the past few weeks you've told us how angry you are, you've told us what impact the proposals would have on you and you've said that you want to see the proposals rejected. We listened.

Today, I'm asking you to tell decision makers why your increment matters to you. You can tell us what you think by uploading your thoughts to the new Frontline First video wall.

Asking you to give up your increments when in return only some would have a guarantee of no compulsory redundancy is, frankly, just not on.

We are also highly sceptical that the Employers would be able to deliver on job security. After all, the RCN's Frontline First campaign has already identified 27,000 jobs earmarked to be cut in the NHS.

Tell decision-makers why your increments are so important and why this proposal was so unacceptable, both to you and the future of patient care. Record your short film today on a mobile phone or webcam.

The proposals also coincide with the increase in VAT and continuing anger over bankers' bonuses. Nurses and healthcare assistants did not argue against the two-year pay freeze announced last year as you accepted the argument that 'we're all in it together'. However, we fail to see how this is true when bankers are walking away with bonuses (when you bailed them out) and nursing staff are being asked to take yet another pay cut.

Enough is enough.

Yours sincerely,

Dr Peter Carter

Chief Executive & General Secretary

The RCN will be correct if they reject the proposals.  We are already working for free much of the time........ in horrid conditions that a private sector employee could never imagine.   I am counting the minutes until I return to the private sector myself.  Jobs have been going for years unofficially(via natural wastage i.e not replacing retiring, immigrating, sectioned under the mental health act staff nurses). 
Not matter how much cash they save it will NEVER EVER HIT THE FRONTLINES. The NHS could have a windfall of 100 trillion pounds.  Not one penny would trickle down to the frontlines. Not one.  Even if they did save a ton of cash via pay cuts and redundancies we all know that our patients will never see any benefit from that, and neither will we.  We will not only be impoverished but we will be the scapegoat for all the patient complaints.  We can't function as it is.....
Government is untrustworthy.  And we should all be giving the finger to them.  They take a lot of money off of us, have always artificially suppressed our wages and do not deliver what they promise for our patients.

Friday 7 January 2011


For some reason I woke up this morning thinking about something that happened years and years ago.

It was around the time I first went to a medical ward.  The nu-labour targets hadn't messed up everything yet.  And our staffing was pretty good.

I worked a late shift on a 25 bed ward and there was 4 of us staff nurses and 2 care assistants for the ward.

One of my patients started with maleena and massive amounts of coffee ground vomit.  She was only in  her 40's or 50's.  We swung into action.  She was becoming unresponsive.  This is a GI bleed and it is life threatening.

Two of us (staff nurses) focused on her.  The other two staff nurses managed the rest of the ward and deal with all the other patients. The medic was straight on the job and after he took one look at her the reg was there as well.   This happened right before visiting hours.  Her family arrived to see her in a hell of a state.  I briefly and gently explained to them what was happening.  One of the HCAs took the family down to the day room and made them tea,coffee and comfort food and stayed with them.

The doctors were throwing out orders left and right. And the other staff nurse and I dealt with it quickly and efficiently. Diagmostic tests, blood, IV's you name it we sorted it. And we managed to keep her clean and comfortable despite the fact that she had a massive gastrointestinal bleed that was causing bloody shit to poor out of her bottom and bloody puke to come out of her mouth constantly.

She survived. As a matter off fact she walked out of the hospital a week or so later.

I was so proud of the doctors, the nurses and how well everyone dealt with the situation.

I miss those days.

Thursday 6 January 2011

Conversation with a Moron

I recently had a bit of dialogue with a rare specimen of a human being on the comments page of the article linked above.

I decided to post about here because people who think like this are 100% responsible for the decline in Nursing care that we see today.

This person (I think it is a woman) seems to think that a Nurse can be overloaded with patients with no limits on numbers and acuity, and still function.

She thinks that most NHS nurses are incompetent because of the following list.  (keep in mind that most NHS general ward RN's are taking on 15 patients each and that years of intense research have shown that the maximum number even the best nurse can take and not make mistakes is 4-6 on a general floor). 

" I am often involved in investigating untoward clinical incidents. The majority of times they arise from a chain of small mistakes which when put together cause a very serious situation, much like the well know “Swiss cheese” model.

Many of these small mistakes are made by “experienced nurses” many that have good academic qualifications. Examples of these mistakes include:

• Omitting to administer prescribed medication

• Administering the wrong dose

• Failing to administer medication at the appropriate time

• Failing to report that medication has not been administered

• Administering medications to the wrong patient

• Leaving drugs potted up on bedside tables

• Failing to recognise a deteriorating patient

• Failure to record observations

• Failure to report a deterioration in patients condition

• Failure to rescue deteriorating patients

• Poor documentation
None of the above “require the person who is delivering the treatment to be extremely on the ball” and being “short staffed” or “underpaid” is not an excuse for failing to carry out basic duties which are what the above are.

To her it is as simple as "Nurses are crap and incompetent and no  omissions and errors should occur matter how many patients have"

It is physically impossible to document, catch onto changes in condition  and administer drugs on time and correctly when an RN has a patient load that is too high.  I have worked enough 14 hour shifts without a break to know this is 100% true.  I do not believe that a person is capable of investigating "untoward clinical errors" on a general ward properly or devising schemes to avoid future mistakes UNLESS HE/SHE HAS RECENT AND FREQUENT EXPERIENCE WORKING ON SAID WARD FOR FULL SHIFTS AS THE ONLY RN FOR 15 PATIENTS. This person is an example of why I feel that way.

Let's review the research once again.

This had some alarming conclusions. It showed that when a nurse is assigned more than four patients, the risk of death goes up by 7% for each additional patient. So if the risk of death for each patient is 7% when a nurse is taking care of five patients at a time, that risk goes up to 42% for each patient when that nurse’s workload goes up to ten patients.

There is so much more if you want to google this issue further.

Most hospitals in Britain have dangerous RN to patient staffing on their general wards.  The formula that management uses to determine staffing levels is flawed.  I have heard our chief exec, our nursing director, our matrons etc say that a ward is "sufficiently staffed" when it has one RN to 10 patients.   This is, of course, wrong.   That Nurse is going to make mistakes an fail. Throwing more apprentices and care assistants at the problem doesn't help when I am in the middle of a drug round and getting interrupted constantly during it to deal with things that only an RN can handle.

The thing about the NHS is that they overload their frontline RN's and put them in situations that no one could handle no matter how compassionate, intelligent, caring, or hardworking they happen to be.   When untoward incidents occur they use it as an excuse to disrespect Nurses even more and cut them off from even more resources.  It is a catch 22.  Pretty soon we will have one RN running between five 30 bed wards and they will say that the bad care and omissions in care are down to her "laziness".

Do you see what kind of fucking clueless morons we have running the show.  I have never seen a general medical ward in the NHS where the RN has less than 10 patients.  Most of us have up to 20 patients per RN at a time.  The powers that be have never even heard of safe staffing studies and they won't bother to look at them because they think all the problems are down to "bad nurses".  And as a result they will continue to deny us the resources we need to do our jobs. 

Nothing will ever improve until the dinosaurs working in the NHS that hold these ridiculous opinions start to die out.  Until they do Nurses will not win and patient care will continue to deteriote despite Nurses working harder than ever.

When I tell colleagues abroad that over here in the NHS the RN takes 8,10,12,20 patients on a general medical ward without 24 hour pharmacy and other back up etc etc they want to know "how the hell are you people getting out of there at the end of the day without making 150 drug errors in one shift".  The Nurses who have said this to me are award winners for bedside clinical excellence.  Yet they would refuse to work in the NHS because they KNOW that they would make mistakes working in these kinds of conditions.

But our little commentator over at Nursing Times thinks that these mistakes and omissions are merely occuring because Nurses cannot be bothered with basic nursing or are uncaring. She is wrong on both accounts.

Tuesday 4 January 2011

Poor Child.

Hospitals need to bring back old fashioned Matrons to kick some ass and knock certain people into line.  And I am not talking about Nurses and Doctors.

What happens when:

Hospitals cut back on staff and beds when demand is increasing?

What happens when wards are full of patients who cannot be discharged for social reasons thus slowing down the flow through A&E?

What happens when drug seekers/ addicts and people with minor illnesses are overwhelming A&E's and demanding urgent attention?

What happens when Nurses and Doctors cannot even triage and assess really sick patients properly because of out of control drunks smashing the place up (a constant thing in A&E) and patients arriving with chronic back pain harassing the staff and making ridiculous demand after ridiculous demand? 

What happens when a family brings great grandma into A&E for abdo pain and by the time they complete all of her tests it is 0200 AM.  The tests show that she is fine and can go home.  Just has wind. There are no beds in the hospital anyway and A&E is backed up with critically ill people waiting to be seen.   But all this family can do is piss and moan about how unfair it is to send their medically stable  and precious grandma home at 2AM and they demand she stays the night in the A&E cubicle.  Then granny makes demand after demand overnight, expecting to be waited on because she is elderly thus stopping the staff from assessing, triaging, and dealing with the potentially critically ill people. 

It is an accident and emergency department for christ sakes!! It is not a place for you to go because you ran out of pain meds for your bad knee or you feel nauseous and your GP is closed. ARGHHHHH. 

It is not a place for your elderly relative to get babysat because she is too precious to have to deal with being discharged and driven home at 2AM and you really don't want to deal with her anyway. 

It is not a place to go for a pregnancy test and then scream the place down because you are not getting seen to first (duh, the damn things are £5.99 at Boots).

 It is not a place for you to go for a morphine fix and stab yourself in the finger and drip the blood in your urine so that we think you have kidney stones.  It is not the place to go because you have been constipated for 2 days.  It is not a place to go because you are mad at your GP for not giving you antibiotics for your viral cold.   It is not a place to throw a temper tantrum because things are not going your way.  It is not the place you should go to demand junk food and snacks from a Nurse that is running around trying to hang blood and implement docs orders for the critically ill.  Especially if you walked yourself into the place.

Oh yes we are SO sorry that the patient with chest pain and shortness of breath was taken in first despite the fact that he came in after you and your sore thumb.  Eye roll.

ER's and A&E's are so overwhelmed with this kind of SHIT that they cannot function.  When the hell are we going to get over this "customer service" crap and start being strict hospitals again where matrons demand that the patients and visitors compose themselves and follow some rules?  If you are not as sick as the others you are not first priority!  Let me tell you what happens when the public abuses the ER's of the United States and the A&E's of the UK.

This happens. 

Important things get missed.  Really sick people wait to long.  The quiet patients who complain the least are usually sicker than the fat twat who walked himself into A&E with a "stomach ache"  demanding a chocolate bar and some Pepsi..
Poor little thing.  It was an extremely rare illness that strikes quickly and is easily missed with all the coughs, colds and flu out there. But I would think that if she had urgent attention she might have been luckier.  Why didn't a sick child like her get immediate attention?  Because of Emergency room abusers.  This dying little girls father had to fight his way past hordes of drunks and ER abusers to get his kid seen. He was right to shout loudly. Had he not done, the staff never would have heard him over the tantrums and moaning of the people who merely have minor illness and the rowdy drunks trashing the place and beating up on staff.

Five hours she waited.  Five hours of the Nurses and doctors dealing with drunks, and people with minor illnesses who think they are entitled to be seen first and then scream the place down.

If you have ever worked in A&E, you'll know what I mean.  If you haven't worked in A&E you will probably not have a clue...

Monday 3 January 2011

Great Post over at Mental Nurse...

of course all the posts are great at Mental Nurse....but this one is just good enough to eat.

Typical nursing care is coming in to a job that you don’t like and doing your very best to help people.

Typical nursing care is trying to do the seemingly impossible.

Typical nursing care is doing your utmost to work with a smile, while working somewhere that isn’t your chosen branch of nursing because there were less than 100 HCA/support worker/nursing assistant posts across the entire country last you checked, and you don’t want to leave your family/partner/social networks and move cross country for one of the few jobs available which hundreds of people are applying for.

Typical nursing care is providing the best care you can, when management are changing perfectly good consumables for inferior products creating potential infection risks, all because it will save a pittance over the course of a year but improve their financial management stats for the CQC.

Typical nursing care is trying not to grumble when your expected to do the same job for £3,500 less a year, despite the government saying people earning under £21,000 won’t face pay freezes or pay cuts.

Typical nursing care is having to courteously listen to people espousing their little stink nuggets of wisdom, despite their obvious lack of medical/nursing training or any experience WHAT SO EVER.

Typical nursing care is having to face patients despite wanting to cry, because you know you can’t give them the standard of care you know they have a right to.

Typical nursing care is looking patients to apologise, because unfortunately, accidents happen, as is the nature of being acutely ill.

Typical nursing care is not telling ungrateful patients to go fuck themselves, despite them making underhanded, disparaging comments like “that’s not [insert reason here] typical nursing care“, when your that tired, that thirsty, that sore, that sick of working on orthopaedic wards without proper manual handling equipment that you don’t care if the roof caves in on your head, you just want the shift to end ASAP.

These things shouldn’t be part of typical nursing care, but they are. And I hope the government, management or what ever all powerful deity is in charge of the NHS pulls their heads out of their collective arse before nurses get so hacked off that they get politicised.

All in all I’m pretty frustrated!

As am I.

Saturday 1 January 2011

How Sweet

I love and admire nurses.

Oncology nurses and ostomy nurses. Radiation nurses and post-op nurses. And those essential, always-there-when-you-need-them, round-the-clock nurses. (And though most of my experience is with female nurses, I admire male nurses, too.)

Now this isn’t some abstract infatuation, based on seeing “South Pacific” one too many times. I’ve been hospitalized six times in my life, and the medical personnel I came to know best — and like best — were the nurses.

To generalize: Nurses are warm, whereas doctors are cool. Nurses act like real people; doctors often act like aristocrats. Nurses look you in the eye; doctors stare slightly above and to the right of your shoulder. (Maybe they’re taught to do that in medical school?)

My most recent dependence on nurses came in 2008 and early 2009 as I was treated for an aggressive Stage 3 prostate cancer. But more about that later.

My first vivid nurse memory comes from the summer of 1970 at Exeter Hospital in New Hampshire. I was 12 years old — almost 13 — and a benign tumor in my right knee needed to be cut out.

Read the rest here.