"Getting Good Care in the Hospital requires Vigilance" - page 2
From the Pittsburgh Post Gazette Getting good care in the hospital requires vigilance Healthwise Tuesday, January 14, 2003 By Virginia Linn, Post-Gazette Staff Writer... Read More
Jan 21, '03WHEEEWWWW!!!! I just e-mailed Ms. Linn and really got into it. I took her through the typical issues nurses deal with every day, everything I have to do with 13 patients, WHY I had 13 patients.( the ratio supposed tobe 1:8 but if we lose one patient we lose a nurse and the other nurses have to pick up the extra pts), the extra "side jobs" we were assigned, like washing floors and walls in dirty utility rooms, testing equipment, moving furniture, and so on.....I told her that I have changed peoples lives and have had my life changed, and that none of us deserve to be approached with hostility or suspicion right from the get-go. Damn, I sure do feel better! KEEP SENDING HER MAIL. We need to be pro-active and stop being viewed as whiners.
Jan 22, '03Why does everyone blame the nurses for sloppy housekeeping? The time has passed when nurses responsibility was to keep the room clean, IMHO. That's not to say I won't take out a full bag of trash, but it is infrequent. My priorities are not to empty wastebaskets.
AND !! I observe, nearly daily, in patients rooms.....someone (either patient or family member) tosses a kleenex, a paper towel, a paper cup at the waste basket. It misses and falls on floor. An hour later (eight hours later), the trash is still on the floor, in the vicinity of the wastebasket. Although now, it includes hamburger bags, wrappings, large soda cups, coke cans. THESE PEOPLE WILL SIT AND VISIT 3 HOURS AND NOT PICK UP THE TRASH, AND PLACE IT IN THE WASTEBASKET. IT IS '''MY JOB''' IN THEIR VIEW. WELL, 'SCUSE ME,
BUT I AM NOT THE ''HOTEL MAID''. YOU CAN CALL THE GOVERNOR IF YOU WANT TO, I am not cleaning up your slovenly room.
Jan 22, '03I sent this reporter an e-mail. I don't know how to copy something, so I'll just have to paraphrase what I wrote.
I told her that nurses are not responsible for a lot of what she outlined as problems; there is a difference between nurses, RT's, housekeeping, etc.
I advised her that nurses have been warning about declining care in hospitals for years, and the public basically turned a deaf ear to these warnings...now they are reaping the consequences of ignoring us.
Briefly touched on nursing shortage v. shortage of nurses willing to put up with subpar working conditions.
Concluded with comments about putting pts & families in an adversarial relationship with nursing staff. Also noted that call bell might not be answered promptly b/c nurse has 8 other call bells to answer "promptly."
I'll be interested to see if she answers any of our e-mails.
Jan 22, '03Wow you guys!!! What thoughtful and eloquent responses. I'm so impressed by your quick action.
The more I see articles like this and the more I listen or "watch" rather what everyone here says to one another the more I understand that the public has no idea what nurses do or what their role is in health care and that there is a nursing shortage but is driven by hospitals. And it's not just via low wages, etc. I truly believe that most hospitals only see a "bottom line" and if they can get away with having two less nurses on duty to save a buck they will even though it increases stress for the staff and decreases patient care.
Jan 22, '03I read with great interest, Colleen10's article. I had similar experiences here on Staten Island, when my mother was admitted with fx femur.
It's difficult to determine whether the nurses were overworked, or didn't want to leave the soap-opera conversation they were having with each other.
I believe we have to hold Administration accountable for the shortcomings. It seems that Administration is only interested in cutting costs, and have no idea of what it takes to run a desent hospital or ward. Administrators are business oriented, and will look at a budget on paper and make their decisions based on a piece of paper. They are not expected to have any human qualities to be Administrators.
What happened to Medical Personnel running hospitals as was the case in the past?????
Let's take a realist look at the situation and call for reform.
Jan 22, '03Dear Ms. Linn,
I compliment you on your recent article on how to get the best care during your hospital stay. I understand you have gotten a lot of replies from RN' s unhappy with the way nursing was perceived. I think the article was, for the most part, accurate. I am an RN, and also have had my mother in the hospital for extended stays. The care she received was absolutely unacceptable, but I also had the privilege of knowing what was happening on the nursing side, and I'd like to share that with you.
At that hospital the nurses were assigned between 8-12 patients, some requiring complete care. When I look at my mother's needs, she could probably have used 2 hours minimum for assistance with washing, eating, and physical assessment. . I believe in the American Journal of Nursing they found that for each hour of direct care there is 30-60 minutes of documentation required. My mother was one of the "light" patients, some of the women on that ward needed twice as much assistance, and did not have a family member to help with small requests. So, in a perfect world, nurses on that floor would have been assigned only 4 patients apiece- as opposed to 8-12.
Nurses on that floor, and in about 80% of the units around the country worked through coffee and lunch breaks. We saw them eating at the desk while charting, and interrupting their lunch to answer call bells. They remained relatively pleasant, but often became testy when asked for more Kleenex, or water, or even a bedpan, or a wash. Patients have a right to expect those items, but the nursing staff has been told to "manage their time" and "prioritize patient needs". So, some of those items were waiting for the next time the nurse made it in the room, or were neglected altogether. More patients were incontinent, and no one got a daily bath, so that meds could be given safely, and treatments administered.
Ancillary staff has been cut in many facilities, with the thought by administration that the nurse can take care of the many small requests while she is in the room with the patient. After all each item "only takes a minute". But with 10 patients, each requiring a 2 minute intervention every couple hours, each nurse has just used about 15% of her time, or about 2 hours of a 12 hour shift. You can imagine how that would be frustrating for a nurse with meds that are late, or an emergency going on in the next room, or the family of a dying patient to support. Unfortunately, no matter what that nurse decides to do, one of his/her patients has the perception that they have been neglected. Nurses spend every shifts knowing someone in pain and ill needs help and is waiting. No one disputes that the patients deserve prompt, unhurried, gentle care, but right now it seems impossible. The frustration of working in that environment can be credited for the large amount of nurses that choose to move on, making the situation even worse.
Emergencies are a part of working in a hospital, and it is reasonable to think that care of other patients will not suffer when they occur. Let's agree that daily about 10% of people currently admitted will have a problem that requires prompt intervention. First, the nurse must be there to identify the problem before it becomes life threatening- much more difficult with today's more intense patient load. Crisis work takes at least an hour for the intervention and then the (sigh) documentation. Most of the time two nurses are tied up until tings are back under control. An experienced nurse counsels grieving and angry families, coordinates care between all the other hospital departments, assesses and intervenes in medical emergencies, and is a safety net for residents and interns. These jobs cannot be delayed to a later time or done in slipshod fashion, and for that time the other patients in a nurses' assignment wait, no matter what their needs. If two patients are suddenly ill at once the entire floor's staff can be caught up in the crisis but luckily that doesn't occur often.
Each nurse can expect at least one admission during his her shift. It easily takes an hour to welcome and settle the patient, and carry out all the treatments that must be done immediately. Adding all this up, if we take an hour for an emergency, and another hour for the admission, plus and equal amount of time for documentation, we are down to 8 hours left from a 12 hour shift to care for the rest of his/her patient load.
Each patient now gets an hour for basic care. Keep in mind that documentation needs to be done, so decrease that to about 45min of direct nurse contact per patient. Remember, I estimated my mother needed at least 2h- but according to my calculations she can expect only half of that. Does she deserve more? Absolutely. As a daughter and a nurse I am caught between what is needed and what is possible.
Nurses argue that people should expect and get the highest quality care. That is why most of us went into the profession, and where we get our satisfaction. When I go home I love feeling that I was able to treat someone to the same care and attention I would give to a family member. Unfortunately, doing something special has become a quick hair wash, an extra warm blanket, getting pain meds to them within 15min, or a back rub. All those things should be routine, not special extras. That's why nurses ar giving up and going to other professions. The public should be aware of what to expect in a hospital setting, and if they want more they need to join us in lobbying for change.
Jan 22, '03canoehead, your letter is excellent! Thanks for saying what we nurses know, but aren't always able to put in to words.
Jan 23, '03canoe, your letter is awesome and was right on target ....couldnt agree with ya more.....
Jan 23, '03My letter to Ms. Linn is not the most articulate. I am TIRED, as are we all.
But, I did include some links to some great articles on the crisis.
Here are some links that I feel are invaluable in understanding the true causes of the crises in nursing and patient care:
Here are two links to a show about the current nursing situation as described on the PBS program "Frontline"
Here is a link to a very important article which was recently published in RevolutioN Magazine, a nursing journal.
Here is a link to a book written by some of the most respected nursing leaders of today:
I am sending you these links because I am a nurse.
Nurses, and therefore patients, are in a desperate situation. Our only hope is that the media and the public will finally wake up and hear us.
Christina C., RN "
Jan 23, '03gee... she irritated me in that article...
heres my few cents....
(its long...but I'm mad)
I am a Licensed Practical Nurse in the boroughs of New York. I am licensed to work by the state, I studied in an accredited school of nursing, and passed the NCLEX-PN (state board exam for practical nursing). I have worked in both inpatient hospital and long term care settings. My scope of practice is that of a nurse, I work with the Registered Nurse to help give as complete care to my patients as possible.
I only list my education, so you may know where I stand.
I was directed to your January 19, 2003 article, Getting Good Care in the Hospital Requires Vigilance, on a popular website frequented by nurses-- AllNurses.com . I've read your article, and appreciate your side of the story. To be a patient is not one of the better things in life to be, I do agree. Unfortunately, you list what is going on wrong, but, you do not list causes as to why it may be happening, and imply that it is the nurses fault.
As a nurse; as a compassionate individual, I would love to personally give each patient as much care as I physically could, in a perfect environment, with no other distractions. Unfortunately, as is life, it's never that perfect.
I will use a busy Inpatient Rehabilitation Unit, 3P-11:30PM shift as the basis of most of my examples, as it is often as close to an 'average' perfect environment as you will ever find. I ask you to keep note of the TIME references here... it might prove interesting.
Please note, the unit holds 65 beds, there are five nurses (usually divided into 3 LPN's and 2 RN's, Staffing may Vary), and 4-5 non licensed assistive personnel. The patients contain every sort of patient, may it be Orthopedic (second day post op knee and hip replacements, externally set broken bones, second day post op surgical patients, often with drains still in place, Ventilator patients, Patients with Dementia, Patients with Traumatic Brain Injury, patients with respiratory disorders, patients who are dying who do not wish hospice in the hope that they will heal, Fresh Stroke patients, Cardiac Patients, as well as any other disease process where there is a hope of getting well enough to leave.)
On an average day, imagining that there are 8 empty beds, dropping the census to 55, that would be 11 patients per nurse and aide. A verbal report takes place at the start of the shift, it is usually finished by 3:30P as long as the day shift nurse has completed her duties, and nothing else is going on. As soon as report is finished, the patients are met, and assessed. 'Hello, my name is Barbara, I'll be your nurse for today. How are you doing today?' is usually met with a request for pain medications, as they have just returned from their time in the rehab gym. So, I figure, we're going to use 2 minutes each patient to meet and have a very Brief assessment (IE a once over, the patient is breathing, theres no emergency at this moment). Every time I need pain medications, I must go from the patient room to the mini floor pharmacy area (The medicine carts are being refilled by the pharmacy from 3P-4P), Check the medication administration record for the medication. Then, I must go to the nurses station, and remove the medications from a computerized narcotic box. Essentially, you need a personal code, and a password to retrieve medications. Then, the meds must go to the appropriate patient. On a good day, with no distraction, I can accomplish this in 5 minutes each time. Also, I'd like to introduce the concept of documentation. For every minute of patient care, there is approx. 1 minute of documentation that must occur, but it often gets crammed into the extra seconds we can glean from time to time.
So far, counting 5 requests for pain medication, 25 minutes. to assess my patients, 22 minutes, a total of 47 minutes.
It is now 4:17 PM, dinner trays are being set up by dietary staff. Invariably, lets say, 98% of the trays are delivered correctly... that's a 2% degree of error, or .. approx. 1 tray is not correct. Trays will be passed at 4:20-4:30
At this time, assuming each nurse has 4 diabetic patients, the nurse must check their blood sugars. The Machine itself takes 30 seconds, the explanation of what the nurse is doing as well as performing the procedure takes approx 1 min, 30 seconds, then explanation of the reading figure, another minute each giving us a total of 3 minutes each, again, barring distraction. 12 minutes gone. Oh wait... I forgot one thing.... there are only 2 machines to assess blood sugar readings on the ENTIRE UNIT. Being on the side of hopefulness, lets say, we are the second nurse to get the machine, and that each machine has batteries. 12 minutes waiting and charting time (no time is wasted idly standing, there are not enough chairs, we can not sit.), then the 12 minutes for our checks. Now, due to our lack of equipment, and time constraints, our diabetic patients have their trays, and their blood sugars have not been tested yet.
Ok, now, it is 4:41P. Diabetic medications such as insulin and oral medication is passed (you should not give a sugar lowering agent without checking the patients blood sugar, doing so can be dangerous) assuming that you have to give all 4 patients medications, at 1 minute each, that puts us at 4:45P (again, barring all distraction)
The List for the admissions is being assembled on the floors white board. It will not be final until 5PM. In hoping for a 'perfect assignment' lets say each nurse gets 2 admissions, and, begins starting the paperwork. This takes approx 5 minutes each for basically verifying which patient is going where, assembling all the paperwork (a rehab admission is approx 25 pages long, 10 of them are devoted specifically to nursing).
4:50, calls for report on these patients begins, at approx 5 minutes a piece in report itself, and 2 minutes of waiting (and charting) on hold, 14 minutes gone. It is now, 5:04P
Allowing the "hour rule' (medications must be passed between 1 hr before time, and 1 hr post time its due.. eg, 6PM med meds are typically given between 5 and 7) you now begin your First Medpass. 11 patients, at 5 minutes each, (setting up meds, explaining meds, and administering meds). 55 minutes. Guaranteed, at this time, you will get requests for bedpans, the bathroom, tissues, water, et al. It is often passed to the aide, who, at this time is assisting patients into pyjamas, passive motion machines (for new knee replacement patients), brushing dentures, and helping with bathroom runs. Assuming that there are 5 more requests for medicine related items, at an extra 5 minutes each, 25 more minutes. It is now 6:20.
The admissions now typically arrive. They typically are unfed, medical orders are typically received with the patients. It takes approximately,20 minutes for the late food trays to arrive, Settling the patients, transferring them to the rehab beds, and taking care of any immediate concerns (pain management, comfort, bowel and bladder needs, cataloging clothing and personal items brought in ) takes approx 30 minutes EACH. It takes approx 20 minutes for them to eat. This leaves us at approx. 6:50 for the first patient to be done, and ready to be formally admitted. The 10 pages of the , with about 2 minutes of explanation and getting the required signatures per page, it is 20 minutes, barring the patient or family has questions, or issues such as inability to read English, Spanish, Russian, or Cantonese, inability to see, inability to sign (many new stroke patients cannot sign due to weakness) or dementia type confusion. With a Very Rapid skin check and physical assessment (we need to know if there is any skin breakdown, and when it occurred) we can assume it will be approximately 7:10P at the time the bedside portion of the first admission is completed, and returned to the unit clerk to be entered into the computer. Assuming that the other patient is sitting ready, their assessment and admission can begin at this time, and can be finished by approximately 7:30P (remember, this is just the admission paperwork, not the standard floor paperwork).
Remembering the 1hr rule again, 8PM and hour of sleep medications are now passed from 7:30-9:00 ( remember, now we have 13 patients, at 5 minutes each or 65 minutes, plus an extra few minutes each for medication requests.)
9P, now, the admissions are formally completed, all values and medications are entered into the form, as well as patient status. Assuming 15 minutes each it is now 9:30PM.
Dressing Changes are done now, assuming that in your 13 patient there are 7 dressing changes, at 7 minutes each (explaining, setting up, and doing) would be 49 minutes. It is now 10:19.
We now have 1 hour and 40 minutes of the shift left. We did not take dinner, or go to the bathroom, and, yet, it was a perfect night-- I mean, nobody asked for anything.... nothing like tissues, or their garbage bags to be changed...
10PM Blood sugars, and medications... assuming that we have 5 diabetic patients, and 5 Ten PM medications, 5 minutes each.... 50 more minutes gone, 50 minutes left until the next shift comes in...(and we pray that they come in with no call outs... )
10:10PM... Now, we document, including Flowsheets on each patient (1 minute each, we;re moving fast) Notes (one each, it takes 2 minutes for a unique and pertinent note) and odd requests (the occasional sleeping pill and pain med, lets assume 2, at 5 minutes each) lets add that up.... 49 minutes.
10:59P-- Bathroom period, over at 11:00
11:00-11:30P report to night shift.
Wow, Ms, Linn-- a perfect night, I mean, we allotted a minute for a bathroom break.
now, imagine we toss in an emergency situation-- add an hour anywhere during the shift, and allot an extra hour to catch up on the documentation afterwards...
now, imagine that you have no relief, odds are that you are mandated, as in FORCED to tack an extra 8 hours to the end of your shift.
So, drawing from this example.... how do we get more, and better care to our family members, or worse... to ourselves?
Here are some ideas...
1) Have a family member or friend around who can help the patient with things such as tissues, ice and water.
2) Please remember to say 'Please' and 'thank you' to the nurses, after all, we are people too.
3) If something is wrong-- eg a full garbage can, or a mess somewhere, please direct the complaint to the nurse or aide... we will let maintence or housekeeping know... but, as nurses, we often don't have the time to take out the garbage, or change the beds.
4) Please make use of your surveys.... hopefully, management will get the picture and hire more nurses to get things done....
5) Lobby to government. Insist that we need more nurses and more aides.
Tell me, Ms. Linn, if you had a job, nay, a Career, where you are educated and tested, specialized in your field, Would you tolerate no break periods, no meals, and a chance that you will not be able to go home at the end of your shift? Would you tolerate Short Staffing?
We nurses do..... why? I hear you ask.... its because we CARE to do the best job we possibly can in the conditions we are faced with.
May the Goddess help us if all the nurses were to stop working one day.... It'd be a very bad day indeed...
Thank you for your time,
Ms. B. Casuso, LPN
--- Barbara Casuso
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