Glossary of Terms and Mythbusting: The Nurse Image

I always find it very difficult to get my points about nursing, staffing, and patient acuity across to your average Joe.  This is the case no matter how I present my point of view.

Why is this?  Let's look at what Joe thinks he knows about hospitals, nursing, and doctors.  If Joe has never worked as a real nurse  or spent an huge amount of time in an out of hospital just where the heck has he learned about nurses, doctors and hospital structures?

He has learned what he knows from the media.  Most likely from the entertainment industry.  This is absolutely tragic.  No  medical TV show, film or novel has ever even come close to depicting nurses in an accurate light.  Shows like ER, House, and Casualty stay stuck  on ancient and ridiculous stereotypes when they portray nurses and their professional relationships with doctors.  Children's books that introduce pre-schoolers to the concept of who is who at the hospital depict nurses as angels who hold your hand and doctors as the boss who is in charge and delivering every aspect of your hospital care. Again, this has no basis whatsoever in reality.   It merely promotes stereotypes.  Journalists and hospital administrators are a victim to this way of thinking.  They just really don't know any better. Nurses themselves have never been able to verbalise just what it is we are responsible for or what we do.  Probably one of the most important things that we could as a profession is let go of the angel stuff and focus on explaining that compassion is important but not anywhere near enough of what it takes to be an RN.  An RN needs knowledge, high level skills, analytical and critical thinking skills and further education all the time.  We know that a lack of these characteristics in an RN kills patients regardless of how caring he may be..

 So why do we never get these aspects of our jobs across  to the public?  Why do we merely focus on the angels with wings stuff when that describes such a small part of who we are and what we do.  I am going to throw together some ideas for educational posters and adverts that promote nursing in a realistic light later on.  Until people understand what an RN does we have no chance of getting them to understand why a person who has been an HCA for 20 years is nothing like a nurse, and why short staffing kills.

But for now I am going to add a glossery of terms for average Joes who are conditioned to have a poor view of nursing secondary to woefully inaccurate media portrayls of nurses and doctors.  No wonder they think the hospital nurses are mean and uncaring?  Casualty has taught them that nurses work for doctors, hold hands, and if they are not doing as they are told it is because they cannot be bothered! Joe has a poor image of nursing and then he comes into hospital and the nurses are not doing what he expects. Then Joe thinks that nurses are crap.  TV either depicts nurses as evil murderers,  poorly educated empty headed waitresses who give injections, or they go in a whole other direction and try to make out that nurses are smarter than doctors.  All of these things are extremely destructive to nurses image.  We are not stupid.  We are not smarter than doctors.  Further education in nursing does not equal "closer to becoming a doctor".  We are educated in nursing, not medicine no matter how far we go with our education.  We are not angels with 19th century notions of virtue to uphold who are above being held accountable.   We are highly educated and skilled professionals who also need to be caring. So are doctors and social workers.  We all just do different things in healthcare.  And if we screw up just this much they'll haul our behinds infront of the nursing boards and possibly a judge in a courtroom.  So we are most definitely not angels  with halos who exist in a realm of lovelyness way above censure and the law.

Back to the avertising ideas later.  I want to have a militant medical nurse glossary of terms.

Registered Nurse:

A highly educated professional who has completed three years of practical and theoretical training. Research has shown repeately that the more education a bedside nurse holds the better equipped she is to save the lives of her patients as a bedside nurse. Look up degree nurses at the bedside doing nursing care and patient mortality rates.  But nurses require vocational training as well.  Completing your training as a nurse at a well respected school of nursing is not enough to call yourself a registered nurse.  You have to cough up some serious money and become registered with your country's (or state/province) board of nursing. You must do this at regular intervals (annually in the UK and cough up some cash) or you are no longer a registered nurse and cannot work as one in any healthcare setting.  IF your registration lapses it doesn't matter how many degrees or certifications you have, you will completely be unable to do things such as administer medications etc in a healthcare setting. 

You have to do copious amounts of continuing education and prove it to the board to renew your registration. Your board of nursing can strike you off the register if you harm a patient or take an unsafe assignment and don't blow the whislte on staffing. This is regardless of the fact that your employer is utterly hell bent on not staffing and resourcing wards, forcing their RN's to take too many patients, and forcing other kinds of unsafe assignments on them.  Non Clinical managers cannot be struck off of any kind of register.  They are merely put on leave and paid large amounts of cash or they are put into another highly paid bullshit job.

Registered nurses take on a group pf patients when they arrive to work and are legally mandated not to abandon those patients until another RN relieves them of duty and receives a handover.   They are responsible for understanding enough about disease process and pharmacology to monitor for deterioration in condition.  They need to understand enough about disease and human anatomy to ensure that the ill patient does not get worse as a result of things like immobility and poor nutrition.  They need to ensure that the physicians plan of treament to diagnose and treat a disease process is implemented correctly and they need to be able to implement these things without killing patients.   That on it's own requires a lot of education.They need to know what drugs can do what damage and what to look out for in the unwell patient.  What happens if you push to much fluid into a congestive cardiac failure patient?  If your patient with an infection suddently crashes out his blood pressure and becomes tachycardic what needs to be done?  The RN is with the patient 8-12 hours a day.  The doctor is with the patient 5 minutes a day.  I can learn a 100 things about your and your nursing needs by walking you to the toilet or asking you about the weather or how you liked your dinner.  This has a huge effect on what I will need to do with your plan of care and what I need to communicate to the doctors.

Many patients have anywhere from 2 to 6 different doctors involved in their care and it is the responsibility of the nurse to coordinate and communicate between these doctors to ensure that the patient is getting the right care and that everyone knows the plan.  Many times (especially out of hours) we are communicating the patient situation to an on call doctor who has never before seen the patient and does not know that particular patient.  IF you are not able to grasp what is going on and cannot communicate this to the doctor your patient is screwed.  If you are worred about dehydration, cannot get the patient to drink and are calling the doctor for orders for fluids you must make sure that you mention that the patient has a history of CCF otherwise you could overload him with fluid and kill him.  If your patient is more hypoxic and short of breath than usual and your are calling the on call doctor your must be sure to tell him if the patient is a COPDer etc etc etc.  Otherwise you could make things worse by blowing 02 at the patient.  A nurse needs to know how drugs interact because she has multiple doctors prescribing things for one patient without looking at what the other guy is doing.  If a mistake happens with that, the RN gets nailed. Keeping on top of this stuff is not medicine it is nursing.

You need to know when to withold prescribed drugs due to an unexpected change in condition that causes the prescribed drug that was at one time necessary, to now be dangerous.  The RN is with the patient, not the doctor.  It is her job to catch this stuff and her ass if it all goes wrong. I could go on forever.  I am not doctor, a mini me doctor, a wannabe doctor, etc etc.  Nurses are hired and fired and discipline by the nursing directorate and NOT doctors.  Doctors are not ward based and although they are brilliant at what they do, they do not know enough about nursing to have a say about nursing.  We are not a subspecialty of medicine.  We are a different profession entirely.  We cannot function without doctors and they cannot function without us.

Doctor:


I am probably about as ignorant about doctors as they are about nurses (and believe me, they don't understand nursing at all).  But here we go.  A doctor is an extremely highly educated individual who has at minimum something like 5-6 years of training at school and than years of training after that.  They are 100% in charge of officially diagnosising a disease process and prescribing treatment.  The amount of stuff that they have to know to recognise and treat illness is insane,.  They are scientists of the human body.  They spend very little time with the patients, especially on general wards.  They do not know what goes into implementing the orders that they give or how a nurse stops a patient from getting worse or dying as a result of their illness and treatmentsjust  by using basic nursing care.  They do not know that nurses have responisbilies other than assisting them.  They think that the nurse is only caring for their patients and ignore the fact that she is handling 10 patients and 16 different physicians who are AWOL.  They are brilliant at medicine.  But diagnosing and prescribing is only one (large) peice of the puzzle that keeps you alive in hospital.  You can have a brilliant, perfect doctor but if your nurse is stupid you could die.  The nurse is at your bedside, monitoring you for change in condition,  ensuring that your diagnostic tests are performed and that the doctor is made aware of any results or changes.  If I ditch these things to spend my time mopping floors and holding hands I could get someone  hurt or killed.  This is the reality of how hospitals are set up.  I bet you thought that doctors were always with the patient managing all aspects of care with  nurse there to assist him and that the doctors hired and fired nurses!  You saw that on the TV show Scrubs didn't you? 

Doctors have, for years, pushed the stereotypical view of bedside nurses as being nothing but useless waitresses in order to inflate their own egos.  They have aided and encouraged the poor and misleading media portayals of nursing.  They were the first people to do this.  The situation has deterioted so badly, that even our own nurse leaders, who left the bedside years ago, are denying that bedside nurses are important.  Even our leaders are focusing on the angel crap and not educating the public about how important bedside nursing is and how knowledgable you need to be to do bedside nursing.  Everyone has been conditioned to have disdain and disrespect for bedside nursing.  Even nurses. Even nurse academics are pushing the idea of bedside nurses being "losers" and refusing the admit that it is indeed a difficult and challenging occupation that requires skill and knowledge  Nurse academia only seems to know how to "promote" nursing by portraying nurses as mini doctors.  Now people hate nurses even more.  Doctors have contributed heavily to this situation and now they are moaning and whining about nurses leaving the bedside to become noctors and penpushers.  Hey Doc, thanks to you leaving the bedside to practice a science that I am not qualified to practice is the only way to get a raise or a shred of respect from anyone. Why can't we all just admit that bedside nursing is crucial to patient safety, and that bedside nurses needed to be highly skilled and educated?  We, as a society, won't admit this and it has led to cost cutting hospitals denying the importance of real nurses at the bedside and replacing them with unskilled and uneducated care givers.  Make no mistake about it, this is lethal and it is not cost effective.  They savings they are making on labour costs go out the window when patients are experiencing expensive after expensive complication as a result of lack of RN input. It ruins the bedside nurses who are left with so many patients and information to work through that they cannot function and it harms and kills patients.  And that brings me to my next group of people who work in the hospital.

Healthcare assistants/ unlicensed assistive personnel/ care givers:

Hospital administration is no different than your average Joe..  They don't understand or value professional bedside nursing so they felt that there was really no need to keep paying all these nurses.  They lost nurses via natural wastage and replaced them with carers.  Now a nurse has 15 patients to keep track of and nurse rather than 5.  Health care assistants or nice,  often  hardworking, they do basic care and many of them are bright.  Some hold degrees in history or English lit etc and were never able to get a job in that field. Others are pre-med or pre-nursing students trying to earn some money.  Others can barely read or write and have no interest whatsoever in becoming a nurse.  They are simply there for the paycheck. If you walk onto a general ward these days and see 6 members of staff in Nurses uniforms, at least 4 of them will probably be care assistants.  They won't have had any nurse training.  They are not licensed and cannot be "struck off".  The RN takes the fall for anything that one of these carers does wrong.

 Healthcare assistants may now be staffing the wards instead of real nurses but they cannot take over for nurses.  They can only do small aspects of basic care.  This isn't even close to being a snapshot of the whole picture of what a nurse does.  Sometimes they bathe all the patients because their RN has critical patients.  They do some blood pressures and maybe change a dressing.  Then they declare "hey I am just like a nurse, I do most of what she does".  Not so kiddo.  Not so.  About 90% of what is going on in that ward is way over the heads of the care assistants, even if they have been a care assistant for 20 years. Most of the things that I, as the nurse, are responsible for or  am troubleshooting are things they have never even heard of nor do they understand what I am doing and why.  They don't get why I can help them with baths some days but not others.  They think it is because the nurses don't want to be bothered.  They see their jobs as 90% of what nurses do, even though it is really only 10% barely. I don't think some of them could even pronounce the word acuity.  They are doing basic care without the additional assessing and planning that goes with all that and not pulling the information together.  I do work with smart care assistants however and I do listen to them.

Lets look at the 30 bed ward I worked on years and years ago.  We might have 6 registered nurses and 2 auxillaries on duty for a day shift. Yeah really.  The most senior nurse took charge.  The other five of us staff nurses each took on 6 patients each.  I had 6 patients, to assess, monitor, medicate, care for, and keep track of.  The auxillaries helped out rather than taking charge of hygeine and basic care.   I was there also doing the bedbathing and basic care too.  I needed to in order to get a handle on my patients conditions.

Fast forward to a 30 bed medical ward in  2010.  Now if we are lucky we get 3 RN's.  99% of the time we have 2 RN's.  Sometimes (and this is getting worse) we have one RN.  Over the last decade hospital administrators have decided that nursing is so retarded that untrained people can do it.

Let's go with the typical staffing  these days of 2 RN's and 3 care assistants for a large general ward.  If there are two RN's we split the ward in half and take 15 patients each.   Now I have 15 patients to monitor, assesse, medicate, and keep track of with no charge nurse back up.  And patients are sicker these days and they are in and out of hospitals quicker so we have to do more with less time.  I am so over my head with all the drugs, information, monitoring, family member questions, multiple doctors for each patient etc etc that I am left completely unable to deal with the basics.  That side of things are getting left almost 100% to untrained and unregulated care assistants.  They can do a bedbath but they cannot extract the knowledge about the patient condition and act on it like a nurse can. Things get missed.  Some carers don't take things like pressure ulcer prevention and nutrition seriously because they don't understand the consequences nor can they be held accountable.  And they have too many patients to feed anyway.  We have more care assistants but they are still always going to be outnumbered by patients who need help.  I can't get on top of those basics eitherwhen I am the sole RN for so many patients.

This has been a fucking disaster.  It is a mess.  You walk onto a large general ward nowadays and you will not be able to find anyone who has a clue about what the hell is going on.  The care assistants are not really able to explain rationale for treatments, or drugs, nor do they read notes.  Most of what is said in shift handover goes completely over their heads.   They are merely concerned with who is allowed to eat and who is incontinant and telling anyone who will listen that they are the "real" nurses doing all the "real" work.  And  still there are more patients to feed and clean than there are nurses and care assistants.

It is a mess and until people start understanding the importance of knowledgable bedside nurses and why staffing is important  it is a situation that is going to deteriorate even further.


Mark my words.  If something isn't done the level of basic nursing care on the wards is going to get worse.  And no amount of magic red trays to "help nurses understand" that some people need help with meals or dignity lectures is going to help.

If by sheer luck anyone reading this is a member of the media or involved in the entertainment industry please realise that every time you depict nurses as nothing but compassionate brainless angels, handmaidens, servants,  or mini doctors you are contributing heavily to this problem and you are hurting patients.

If you want to learn more about this from a real writer/journalist who has been studying issues in nursing since the early 80's I suggest you check out any book ever written by Suzanne Gordon especially nursing against the odds.  She is the only non nurse I know who really gets it.  All I have done is this post is rehash a lot of what she is saying based on my personal experience.

Feeling Nostalgic and Sad.

I'm reflecting on the past and feeling a bit down.

 Is it because I want to go back to the days where the wards were resourced and staffed  so that Nurses could do their jobs? 

Am I getting sentimental over the days when Matron showed some kind of interest in the wards and patient care? 

Am I reflecting on what the wards were like when patients were less ill, stayed in hospital until they were better and market obsessed management weren't pushing as many acutely ill and frail patients through the system with as few nurses as they could get away with?

Am I sadly longing for the days before  management consultants who have no understanding of health care dynamics brought in crap ideas from America to restructure wards and staffing thus destroying nurse care, ruining nurses themselves and killing patients?


Nah That's not what is bothering me at the moment.  Those days all disappeared in the very early 90's.  A little before my time as a Nurse.  I think I had two good months before it went south. Can't miss what you don't know.
I am sad right now because I miss Dr. Rant.    He hasn't blogged in a long time and I don't think he's coming back.  Breaks my heart.  Nu-Labour probably raised his blood pressure and caused him to stroke out and die.

Click on the following:

Bring

Back

Dr. Rant.

Please.

Calling all general ward NHS RGN's: Some questions.

Not to leave out all the CCU,ITU, and A&E nurses but your units are a completely different structure.

I am hoping to hear from RGN's who work in (or recently worked in) general surgery, general medicine, geriatrics, --any large ward really.

I have learned a lot from my own blog via comments/emails etc.  I have learned that things on my ward are much easier and better than some other wards.  I have learned that we are a hell of a lot worse off than some others.  In short there are wards functioning well in the NHS and others that are hell on earth.  I am in the middle-purgatory perhaps.

I will start this.  Please continue in the Comments Section on this Post.  I hope I get some replies!  This is totally anonymous, I have no idea how to find out where or who you are.

1.Qualification: RGN

2.Ward: Acute Medicine/general Medicine/Geriatrics/Surgery

3.Beds: 18-30 depending on if they open our second hallway in a bed emergency or if they give it to surgery.

4.Real Nurse staffing per shift: sometimes one RN, sometimes 4 Rn's. We might get lucky and have 4 nurses to 18 patients show up one day but one will usually get taken away to staff another unit.  I have seen 1 RN to 30 in my time.  2 nurses  to 18-30 patients is the most common number.  Not good considering 1-6 is safe only for non confused non acute patients.  My patients are acute and confused.  Mostly confused.

5.How many HCA's do you have per shift including cadets? Is your ratio of untrained to trained staff  increasing? We have either 1,2,3,or 4 HCA's per shift.  One will get sent away if we have 3 or 4. And as with nurse staffing, these numbers have no bearing on patient acuity.  We can have 30 beds,with really sick dependent patients with 2 nurses and 1 HCA or we can have 18 stable geriatric patients  with 3 nurses and 3 HCA's.

6.Does your ward staff by acuity?  Do you get another trained nurse to care for your other patients if one of your patients becomes critically ill and needs to be specialed?  If you have sicker patients on the ward than usual do you get another RN? Or more HCA's?  If you move from 2 patients who need to be fed to 18 patients that need to be fed does your staffing adjust for this? 
Not on  my ward. Not by a long shot.

7.Do you ever get sent to staff areas that you are completely unfamiliar with and get expected to take over as the primary nurse for a group of patients? Yes

8.Does your hospital have a good, solid plan to cover sickness ,staff absence, increased acuity or dependency without pulling from one ward to another or using agency? No. Mine only gives us untrained carers from agencies, not nurses.  To cover RN sickness they pull staff and leave one ward short to cover another short ward.

9.Have you ever in your career worked an 8 to 12 hour shift without a break due to  chaotic, unpredictable, dangerous ward conditions? Are your patients in danger in any way when you do take a meal break? Yes. I recently ditched 12 hour shifts because I am getting to old for this shit. When I do take a meal break it leaves like 2 or 3 staff on the wards, not all nurses.

10.Do you have a senior charge nurse (without her own patient assignment) on every shift to coordinate and back you up.  No.  But research shows that I should.  I used to have a senior charge nurse without her own assignment coordinating and supporting the staff nurses about 5 years ago.  Makes a huge difference.

11. Do you ever see your Matron or get guidance and support from him/her? No Mine does not approach the wards.

12. Are you pressured into leaving very ill patients to push multiple discharges or take admissions (which are time consuming and complicated).  Does this happen during meal time? Drug rounds?  Yes. Yes Yes.

13. Are you given any kind of block of uninterrupted time to see your patients and care plan for them?  No. Not at any point in an 8 or 12 hour shift.

14.  Have you ever seen a patient suffer a complication (dehydration,pressure sores) or failure to rescue because you or a colleague could not get to him fast enough? Yep.

15.  When you fill in incident forms about short staffing is anything done? Not really.  They might band aid for awhile or send a letter saying how they are hiring another 18 year old with no experience.

16. Are you able to mentor nursing students,new staff, untrained carers with no experience properly on your ward? No. Hell no. And I am very dedicated to doing just that.

17. Does the physical design of your ward work against you and cause inefficiency?  Mine does, it is ancient.  But other wards at my very hospital have a good design. It makes a huge difference.

If anyone can take the time to give me honest answers here I will really appreciate it.  If your ward is great, let me know and if not let me know.

The Policeman's Answering Machine applied to Nursing.

I am feeling a little silly today.  We need one of these answering machines for Staff Nurses.  Especially considering we never get to answer the phone. Disclaimer:  This post is meant for a laugh.  I know that the stress of having a loved one in hospital will make the most respectable person lose it and lash out.  It's okay.  Really.  Unless you hit me.

Police Department Answering Machine

Here is the Nurse version.  All said in a highly annoying customer service type  generic computer generated North American accent. A voice that is just way too happy and joyful.

Thank you for calling Godhelpus Hospital.  We are unable to answer the phone right now because management won't pay for a ward clerk and the horrifying low numbers of nurses have patients so sick that we cannot leave them to answer the phone.   There is one working ward phone and it is a long way away from the patient area. Please select from one of the following options.

If you would like to complain about a nurse with 20 patients not giving your father one to one care or being there everytime he kicks off a slipper or needs the toilet Press One.

If you want to yell and say things to the nurses such as "I pay your wages with my taxes" whilst ignoring the fact that nurses also pay taxes and work a hell of a lot of unpaid hours which helps save the hospital money and they get the same level of care  then Press 2 now.

If you want to call an ambulance to bring you into A&E to fix your sore toe and then scream at the short staffed a&e staff, all 3 of whom  are working their tits off trying to save a 9 year old with multiple stab wounds and complain about "being made to wait by uncaring staff" Press 3. 

If you want to disregard the laws and rules that forbid nursing staff to give information to anyone over the phone except designated next of kin and demand information about your friend and then accuse the nursing staff of being a bunch of worthless whores who want to withold information just to upset you off Press 4.

If you think that being someone's neighbour for 20 years, their brother, or their best friend automatically allows you to designate yourself the next of kin over the phone despite the fact that the patient's wife is the designated next of kin  Press 5.  And don't forget to call the nurses miserable cows from hell because they couldn't (for legal reasons and ehtical reasons) tell you the results of your mate's scan.


If you want to complain about the fact that there are never any nurses in sight except at the nurses station, and then complain about the fact that the one nurse to multiple patients with no ward clerk to help isn't always answering the phone quickly  when you and everyone's else's relatives call Press 6.  I can either be at the station answering hundreds of phones calls or chasing up info to answer your questions OR I can be down there with the patients.

If you want to call the nurses lazy and uncaring because your 102 year old grandmother had a massive stroke, is now unable to walk, talk, and swallow and has to go into a nursing home because she cannot be rehabilitated Press 7. Don't forget to remind us that if only we had bothered with her she would have recovered.  We did bother.

If you want to ask questions we cannot possibly answer  in an area as complex and chaotic as general medicine such as "when is the doctor coming to do his rounds" and "When will Gramps be discharged" and "When will he have his scan" Press 8.

If you think that nurses and doctors are immune to becoming ill, do not understand what it is like to have elderly relatives in and out of hospital, children with disabilities, spouses dying of cancer, cancer ourselves, etc etc and want to accuse us of not understanding the other side Press 9 now.  Don't forget to call us lazy, uncaring, ignorant bitches.

If your best friend/brother/neighbour/inlaw etc is on the Hospital Board of directors and you want our names so that he can sort us out press 10.

If you want to threaten me with a lawsuit for not ignoring our other, sicker patients to be your relative's personal servant Press *1.

For all other queries, stay on the line.  And be prepared to stay there for until flying cars and vacations to the moon are the norm .

.

Yeah, they pretty much sums up the 45 minutes out of every hour I spend running to the ringing phone and getting pimped by family members.  Maybe once in awhile we will get a polite genuine person asking a question.

Ahh I almost forgot. 

If you are social services, pharmacy, the discharge managers, a person who carries a clipboard, a retired nurse who last worked in 1983 and wants to give us a talking to,  a district nurse or  ambulance liason don't press any buttons and don't stay on the line.  Please hang up.

Thank you for calling  Holyshit Ward at Godhelpus Hospital. Have a great day and enjoy your health care journey.

Should they Bring back Enrolled 'ward trained 'Nurses?

Nope.  I don't think so. 

 I believe that under such a system we would still have "team nursing".  Team nursing sucks.  It worked great back in the 70's but there is too much information to keep track of as well as disorganised  chaos now all thanks to medicine advancing and higher costs  

Team nursing came about during WW2.  It is the system in which our older, traditional trained nurses are familiar.  It works properly only when ward structure is meticulous and well organised.  I happen to believe in primary nursing.  This doesn't mean that I am not a team player however.  I will drop everything to help a colleague who has a patient in trouble, or is in trouble herself.

Have you ever wondered why you have noticed loads of staff in nursing uniforms hanging about when you visit your mum in hospital...yet no one seems to have a clue about what is going on....no one can give you any answers..... none of the patients are recieving their drugs on time.......and the only person who does supposedly know what is happening  (mum's RN) didn't realise that your mum just had a dangerously low blood pressure reading 10 minutes ago?  Does any of this sound familiar?

This all happens because Registered Nurses are running between too many patients, with less qualified staff to assist them.  It is a system that doesn't work.    Some people are saying that we should bring back enrolled nurses to help the RN's. EN's are an improvement over HCA's but a cost cutting NHS will just use them incorrectly, as they do with the HCA's.

I don't want enrolled nurses ( EN's  as they were known) around unless the hospital is going to add them in addition to safe registered nurse staffing ratios .

They won't do that, they will only use them instead of registered nurses.  Before you accuse me of knocking EN's please read on.

People generally seem to think that degree educated registered nurses don't do much in the way of ward training and that we need to bring back ward trained nurses (EN's) to improve care.  That is a motherload of crap.  We need to do lots of things to improve care, but not that.

Where do I begin.

The degree students have to do nearly 3000 hours of ward time/placements to qualify. The degree students are working shifts on the ward all the time.

During the weeks and weeks of their placements they are working full time shifts on the ward.

They are supposed to be supernumery but they ARE NOT actually supernumerary.

They are thrown right in at the deep end, doing all kinds of basic care. Take it from someone who is currently practicing as a staff nurse and who works with students. This is indeed how it is in 2010.........   current nursing students spend thousands upon thousands of hours mucking in on the ward.

The  idea of bringing back traditional trained nurses (or EN's) as well as degree nurses is a good idea on paper but it is a total fail in reality.

The reason for this is that TEAM NURSING DOES NOT WORK anymore.

Team nursing is what you are actually pushing by arguing that they should bring back EN's. Team nursing is when you have an RN's, EN's and auxillaries all caring for a large group of patients. It doesn't work. It fails because the RN has to be on top of everything that is going on for 30 people and no matter how many EN's or care assistants she has, the RN is overwhelmed.

Team nursing means the right hand does not know what the left hand is doing.

What we need is for a degree trained RN doing everything and having a small enough patient load to do EVERY aspect of her patients care herself. This is cost effective and it is the only thing that works.   Giver her a care assistant to be used only in case she runs intro trouble but my god, leave basic care to the RN's primarily.

I don't want an EN or an auxillary sharing my patient load because I want to do everything myself for all the patients. The majority of RN's I talk to agree. Primary nursing is the only way to stay completely on top of everything that is going on. 

If you throw more patients at me along with EN's and care assistants instead of Registered Nurses then fuck up after fuck up after fuck up occurs.

Yes, nurses having more technology, drugs, and medical stuff to do these days. We do indeed and staff nurses get held responisble for any screw ups with these things.

 But in order to do those high tech things well, I also need to be doing basic care myself. Otherwise I am not seeing the whole picture. And neither are the EN's or the care assistants. When there isn't anyone at all seeing the big picture, all hell breaks loose.

If I am delegating the basics to an EN or HCA then that means that I am probably the only RN on shift and I am overwhelmed doing drugs for the entire ward , doctor orders and rounds, relative enquiries, and fire fighting  for all 30 beds. This is overwhelming even if I have 100 care assistants/EN's to help with the basics.  

Just the sheer number of relative enquires either in person or by phone is overwhelming when you are an RN with  only 10 patients. The questions these people ask are usually only answerable by the RN.  If I have 10 patients I have 10 families on back and I can barely get any patient care done.  I can barely ge away from their phone calls and interruotions long enough to actually see any of my patients.  There are just so many interruptions. Constantly.

Under the plan to bring back EN's, the RN will be the lone RN carrying all the the things that the EN's and HCA's cannot do . She will be overwhelmed. Meanwhile the EN's and HCA's will be merrily making beds and gossiping without a care in the world.  Whenever a relative makes an inquiry or a patient becomes acutely unwell, the EN' s and HCA's will just dump that onto the RN and happily go on their jolly way making beds.  And the RN will be managing 5 critically ill patients that she cannot even get to because she has the relatives of her other 25 patients on her back.

I want 4 acute patients or 6 non acute patients maximum and I want a charge nurse without a patient load on shift to back me up and organise the ward . I want to do EVERYTHING, EVERY nursing intervention for my patients myself. Myself. I cannot do this with 30 patients no matter how many EN's or HCA's you throw my way. Even if I have hundreds of EN's and HCA's with me doing the basics I am still going to have too much information to process, too many interuptions and total cognitive overload.

A growing body of evidence is showing that a well educated RN doing everything for a small number of patients  is the only safe, effective, and cost effective way of doing things.  The WW2 ward structure planning is still in effect now, just with less qualified staff.

What I am trying to say is this: If you throw  EN's and HCAs at me instead of Registered Nurses then I have to keep track of everything for the entire ward as the lone RN. No can do.  Not these days.  It is impossible. 

And that is the case if I am sharing my 30 bed ward  with 1 EN or  100 EN's in a single day.

What they are doing right now in hospitals  is essentially team nursing. 

What we have now is the hospital managers saying this:  "It's okay to stick one RN with 20 patients because we are throwing care assistants at her.  She can  medicate, all 20 patients,  keep track of information for 20 patients, get interrupted to take questions from the families of 20 people with nothing in place to control the number if interruptions she is getting  etc as long as she has a few less qualified staff around to make her beds and wash her patients.  Do you really think that it would be any different if they brought EN's back? 

They would probably have one EN in charge of a 40 bed ward with no RN and a few care assistants to help.  That is how NHS management does things, the cheap fuckers.  Not only do they currently have a world war 2 era ward structure in place on the wards ......  but they have it with less qualified staff at a time when patients are sicker and the stakes are higher.  Even in the last ten years, patient acuity and costs have SKYROCKETED.  Nurses in 2010 are dealing with sicker patients and have to do more for them in a shorter amount of time, with less qualified staff.  Fallen angels my ass.  I actually think that nurses today are much nicer than their yesteryear counterparts.  The older nurses just had better ratios, resources, back up, and smaller workloads.

And this kind world war two era mentality  by managment and dinosaurs is why things are so shit.  The idea of bringing back EN's is a good one on paper but not actually implementable because team nursing is outdated. Let's move away from it entirely.  Staff the wards with RN's, and when RN's have safe ratios then you can add in the assistants to assist with care rather than taking over care  when they are not qualified to do so.

A Tale of Two Books

Nurse Anne always has her head buried in a book, but I tend to avoid fiction like the plague and it's rare anymore that I touch anything that isn't completely history or science focused.  If you want to check out a couple of books to read in the New Year have a look at these links. 

The first one is "Nursing Against the Odds"  by Suzanne Gordon.  Loved it for the most part. If there is anything that I learned from this book it is this:  The NHS, the media, the NMC, the public, and our chief nurses are doing everything WRONG when it comes to retaining nurses at the bedside and maintaining/improving the quality of patient care by nurses. Oh wait, I pretty much already knew that.  We are set up to fail from the get go.  This is true  no matter how caring and serious about quality nursing care we are or how many unpaid hours we work extra after 12 hour shifts with no break.  Patient care still sucks.

In the United States and throughout the industrialized world, just as the population of older and sicker patients is about to explode, we have a major shortage of nurses. Why are so many RNs dropping out of health care's largest profession? How will the lack of skilled, experienced caregivers affect patients? These are some of the questions addressed by Suzanne Gordon's definitive account of the world's nursing crisis. In Nursing against the Odds, one of North America's leading health care journalists draws on in-depth interviews, research studies, and extensive firsthand reporting to help readers better understand the myriad causes of and possible solutions to the current crisis. Gordon examines how health care cost cutting and hospital restructuring undermine the working conditions necessary for quality care. She shows how the historically troubled workplace relationships between RNs and physicians become even more dysfunctional in modern hospitals. In Gordon's view, the public image of nurses continues to suffer from negative media stereotyping in medical shows on television and from shoddy press coverage of the important role RNs play in the delivery of health care.

Gordon also identifies the class and status divisions within the profession that hinder a much-needed defense of bedside nursing. She explains why some policy panaceas - hiring more temporary workers, importing RNs from less-developed countries - fail to address the forces that drive nurses out of their workplaces. To promote better care, Gordon calls for a broad agenda that includes safer staffing, improved scheduling, and other policy changes that would give nurses a greater voice at work. She explores how doctors and nurses can collaborate more effectively and what medical and nursing education must do to foster such cooperation. Finally, Gordon outlines ways in which RNs can successfully take their case to the public while campaigning for health care system reform that actually funds necessary nursing care.

"The journalist Suzanne Gordon provides a powerful depiction of nurses' struggles to keep patients alive in an unsafe health care system. Read this book to see why national health care quality goals will not be achieved until nurses' work environments are fundamentally transformed."--Linda H. Aiken, University of Pennsylvania

And then there is the book I just finished titled "Mao's Last Dancer".  I have absolutely no interest in Chinese culture or Ballet yet I couldn't put this one down.  The real story in this is one of human interest.  Li Cunxion narrorates  a fascinating glimpse into the history of Chinese-U.S. relations and the dissolution of the Communist ideal in his life.  I knew Mao was one bad guy but never really understood what went on in China during the great leap forward as well as I should have.   The portrait of life under Mao as painted by the author, is so vivid that I nearly wept. Unrelated but I hope that humanity's natural tendency to whine and want everything taken care of for them by big brother never sends us back down the road to communism. Yeah, bring on the shitty comments about my  ignorance.  Yawn.

Raised in a desperately poor village during the height of China’s Cultural Revolution, Li Cunxin’s childhood revolved around the commune, his family and Chairman Mao’s Little Red Book. Until, that is, Madame Mao’s cultural delegates came in search of young peasants to study ballet at the academy in Beijing and he was thrust into a completely unfamiliar world. When a trip to Texas as part of a rare cultural exchange opened his eyes to life and love beyond China’s borders, he defected to the United States in an extraordinary and dramatic tale of Cold War intrigue. Told in his own distinctive voice, this is Li’s inspirational story of how he came to be Mao’s last dancer, and one of the world’s greatest ballet dancers.

So that's a boring blog post for you all.  Have a good one.

Slapheads: RGN version

I am a big fan of Mental Nurse and wanted to copy their slaphead series. They've done RMN,s, HCA's, Patients, etc in their slaphead posts. Here I go with an RGN's version, the militant medical nurse way. If you think I am a shameful copy cat just let me know in the comments section.

Of course none of the following applies to myself or my current colleagues. We are super nurses and should have a cape to go along with our superpowers.  I have run into some real freaks over at HCR Manorcare in my years and years of nursing. 

Indeed I have, in my time, run into all of the following charactors listed below. Repeatedly. Maybe you have as well.

Coasting till Retirement Colleen- Colleen did her training long before I was born.  She used to be a fantastic nurse but years of abuse from patients, relatives, colleagues, and management whilst doing an impossible job has destroyed Colleen's spirit.  She is a shell of a human being with it's life force sucked out.  She arrives to work.  and then bursts into tears and does the bear minimum that she can get away with just to get the hell out of there.  She snaps at people, locks herself in the treatment room, and looks at students as if they are crazy. Her colleagues have to pick up her slack. She has calenders all over the place, counting down the next year or so until she retires.  She have has pen marks on her arm, counting down each minute until the end of her shift.  Every painful second gets Colleen closer to retirement. Amen.



Nerdie Nellie---- Nerdy Nellie is going to drive yours truly into alcholism and I don't even drink.  Nellie is usually a twentysomething new nurse who takes her job so seriously we have nicknamed her psycho.  She comes into work two hours early, unpaid, and leaves two hours late, unpaid and goes over everything with a fine tooth comb repeatedly.  If anything goes wrong on the ward, even if it has nothing to do with her she starts weeping and throwing herself on the floor screaming "I'm sorry, I am such a crap nurse, it is a privilidge to be here and I don't deserve it because I am awful".  She does observations about twenty times more than necessary.  She gets a thousand things done in the time it takes the rest of us to get 10 things done. She never takes a break even if we are not busy because she does not feel that she is deserving.  Nellie will work 15 hours straight through on a non busy day, and then apologise to the patients for not being good enough.  She spends all of her time outside of work reading nursing journals.   If another nurse makes and omission or mistake Nellie goes mad.  After she finally does leave work, she calls the ward 10 or 20 times to make sure that all the patients are okay and that she didn't forget anything.  All night long. Forgetting is easily done when you have total chaos and too many patients.  It upsets all of us but Nellie actually needs medication and a CPN.

 Nerdy Nellie and Coasting it Coleen must never be put on duty together or on the same day because sparks fly.  A nightmare from hell is Nellie coming on duty and taking over from Coleen.  HOLY. SHIT.  Meow.  But out of all of them , Nellie's  are  clinically excellent and what I want for my nurse if I am unwell.  That is what stops me from strangling her to death.   I did ask her once if she ever stopped blaming herself and took a good hard look at patient ratios and multifaceted systems errors.  Her eyes glazed over and she stares off into space.  It gave her something to think about.  Nursing education tells nurses that everything is their fault, even the doc's errors and management incompetence.  The universities are churning out  Nellie's at an alarming rate.  Time to buy stock in pharmacutecal companies that make anti-anxiety meds and anti-depressants.

Lazy Len.... Typical lazy male staff nurse (ooohhh I am going to get some shitty comments for saying that).  Len does nothing on the rare occasions that he shows up for work.  Nothing.  I don't know how the hell these Len's get away with it.  He is a master at passing the buck.  A master.  None of his patients seem to have any pressure ulcer documentation.  The reality is that Len just never bothered to look at their skin etc etc etc etc.  He hangs around with Pervy Peter and management Molly.

Management Molly... Molly qualifed in the 70's and hasn't been on a ward since.  She love magnets, paperwork, targets, and describing the  nurses who actually have the balls to show up on the wards as "lacking in compassion".   She is clueless.  She has no idea what is going on.  Once in a blue moon she will do a quick ward walk through on a day where two RN's are struggling to make order out of chaos and care for an appalling high number patients with no staff and resources.  She will interrupt them to say "well you don't look very busy, here is a 40 page catheter audit to fill in on every patient with a catheter. "  She likes to refer to patients as customers and clients and talk about their journey's through healthcare. But she will not go anywhere near one.  I don't know what she does all day but entire forests are dying and she drinks more tea than exists in all of China.  When you try and explain to her the actual situation on the wards her eyes glaze over.  She has no idea what you are talking about and thinks that you are really nothing but complaining rif raf, complaining for the sake of it.


Crazy Connie....I have run into a few of these and they make me shiver with terror.  Luckily the ones I knew were fired. Crazy Connies crush up paracetamol tablets, mix them with tap water, and inject their brew into IV bags.  They sport a massive behive and love to wear an old fashioned nurse's cap, white dress, and white stockings.  She talks to her dead dog all night long. Out loud. She never bothers with drug charts, if a patient is asking for pain medication she just hands them whatever it is she is carrying around  in her handbag.  She walks up and down the ward talking to herself, while blaming herself for her boyfriends death in a car accident because "another dude liked me and put a voodoo curse on Rocky to get him out of the way". I do hope that all Connie's get the help that they need and stay the hell away from nursing.  The truly scary thing is that I have run into more than one of these types.

Pervie Peter.....typical perverted male staff nurse (am I being offensive?  Good.  Now let's continue). Todd from Scrubs has got nothing on Staff Nurse Peter..  He lears at you with a sickening grin. Constantly.  He constantly tries to look down your tunic top, admits it, and laughs about it.  And when you go into the office to do some charting he follows you in and sits way too close.  They will not give this guy a nursing student to mentor under any circumstances.  He rates the quality of the hospital staff by cup size and their "hotness".  He speculates about what kind of knickers the female docs wear.  He finds out where you live.  And one night when you are on the sofa with your husband watching a movie you look at your window to see Peter with his face pressed up against the glass staring at you.  And this is how he interacts with us older middle aged look like hell females.  You should see what he puts the younger members of staff through.  Hospital management does nothing about Peter types who harass his coworkers.  Until he starts on the young female relative of a patient.  Then all hell breaks lose and we never see Peter again. 

Old Fashioned Alice. ....  Alice trained when Christ was a babe in arms and she let's everyone know it when she gives her reasons for refusing to retire. She was brought up on the moors of yorkshire and has an accent to go with it.  Her jowels are the size of a small country and she is either huge or extremely tiny.  She is so old that agency HCA's didn't realise that she was a nurse and told her to "get back to the bed and ring the bell for help".   

Here are some classic Alice-isms: "In our'n day we didn't use gloves, we had shit all over our hands and went from one patient to another and I see no reason to change"  In our'n day we smoked at the nurses station, it gave the place an air of sophistication".  "In our'n day we didn't have any of this fancy shmancy life saving stuff and it was better and so are coal fires". "What is the point of infection control and IV antibiotics, we didn't ave none of th'at nonsense in our'n day".  "I'm making a cuppa for the relatives, and then I'll deal with the bleeder, that's how it was done in our'n day". Coming on duty after Alice's shift blows chunks because you have half of her workload that she ignored to pick up as well as your own.  No meds have been given, notes are being burned to heat the fire that Alice thinks we need for heating the ward and patients are deteriorating before your very eyes.  But their beds have perfect hospital corners and they have all had a cuppa and a fag. Even the ones on 02 have a fag.  Alice doesn't believe that 02 is flammable because "we didn't worry about that shit in our'n day".  Oh, and she thinks that modern nurse training is pants and tells mentally ill patients to "BEHAVE".

Should have stayed an HCA Shirley........Shirley had been an HCA from her late 20's until her mid forties.  She thought she knew more than the nurses.  She thought she ran the ward.  She loved to crack jokes at the nurses expense:  "Nurses don't change lightbulbs silly, they just document that they did".  She repeatedly slagged off the nurses for not doing all the basic care.  She didn't do it either, of course.  When one nurse had 5 critical patients during a drug round for 30 of them, Shirley would tell the patients "I am the one who does all the real work around here because I am an old fashioned 'nurse'".  Then Shirley would go out for a 2 hour fag break and leave the Nurse with 5 critical patients to answer all the call bells alone for 30 people .  Then one day Shirley decided to go to nursing school.  Despite loads of reservations from her mentors she somehow passed.  She nearly didn't and it took her 4 years to do so.  She graduates and gets a job on her old ward. 

But she cannot handle the nurse workload and makes more drug errors in one day than I have seen in  a lifetime.  She is in tears from the stress.  She just avoids the really sick patients because she is so lost with it all, and goes about still working as an HCA, ignoring critical problems while her colleague does her job for her.  She is great at bed bathing  and gossiping but has no executive function whatsoever. Constant constant communication errors and fuck ups. Then she goes off sick with stress, resigns (or got sacked), and now works at Primark.  Sweet fucking come uppance. I love it.

Happy New Year Everyone!  Be a better nurse than the ones on this post!