The Bad Old Days

[SharonH, RN]

I was reading nurscees's thread and some of the comments about nurse-patient ratios and I started remembering:

Back in 1991, I started my nursing career at Thomason Hospital in El Paso, Tx on the pediatrics floor. We also had adult orthopedic patients overflow on this floor. My shift was 7p-7A. This was a 45 bed floor and we routinely took 15 patients each. We were always full. On a good night, we had four nurses which means that 3 of us had "only" 11 patients while one of us had 12 patients. Those were considered "good" nights and they were rare. There was absolutely no IV team and we had to draw our own admission labs as well as blood cultures on the adults for some reason. We were also responsible for signing off our own charts. Naturally, I had anywhere from 10-12 hours overtime every paycheck because I had to stay late to finish charting, etc. Nurses who couldn't get it all done were excoriated. (guess which category I was in?) One of my coworkers who was actually one of the sweetest, nicest nurses I have ever known told me that they used to provide care to ventilated patients on the floor back in her first days in nursing.

When I moved back to GA, I switched to med-surg. On 3-11 shift, we had 12 patients each but there was an IV team who did everything including giving prn and routine meds. The charge nurse signed off all the orders and made all the phone calls to the docs. I thought I was working at a resort. But in a short period of time, this became harder and harder. The IV team began to be phased out. Staffing ratios were decreased but the patients began to be harder to take care of. We started to provide care that used to be done exclusively in the units.

When I finally left a couple of years ago, we were down to 1:5 ratio on day shift but I was working harder than ever. Patients were sicker, family and doctors were more demanding, and the hospital actually employed nurses whose only job was to walk around and making sure we were spouting our "scripts" and evaluate our customer service abilities. Our nurse manager routinely made comments about how she couldn't understand why we couldn't get our work done when we were taking care of fewer patients. This observation was meant to induce shame and guilt in us nurses. It didn't work on me.

What were your first days in nursing like? Do you remember those days with nostalgic fondness or a relief that its over? Are things better for you or worse?

[June55Baby]

I graduated in 1977 and went to work on a 36 bed Med/Surg floor in a brand new hospital with all the latest equipment. Well, the hospital had been around since the early 1900's, but the building was built in 1976 and the equipment was new.

I worked day shift 6:45 am - 3:15 pm, rotated to nights 10:45 pm - 7:15 am and only got 1 weekeknd off each month.

We had team nursing where 1 RN (me), 1 LPN, and 1 Aide cared for 12 patients on days and 1 RN (me), 1 LPN, and 1 Aide cared for all 36 patients at night. This was before the days of managed care and DRGs were just coming about. If you had "good insurance", you could stay in the hospital until your MD wrote a discharge order and some patients did just that, staying weeks when they could have been at home. Needless to say our acuity (was that even a word in 1977) was very low. Patients were admitted 2 or 3 days prior to a protoscopy, upper GI, lower GI, or other GI/GB test for "prep" and stayed for days afterward to get the test results. A cardiac cath resulted in at least 7 day stay and surgery well 10 days at least!

We had no IV Team, no Code Team, no other team - we WERE the team. We did all the AM care (most patients got bed baths) as a team and had to 'Heat Up" all meals in a microwave oven and pass to patients.

I did all IV's, IV Meds and treatments the LPN could not do. We had no IV pumps, I counted gtts to assure the correct flow of the IV and calcualted I&O and fluid counts to give to the next shift. Most every patient had an IV. We used "butterflys"; angiocaths were just coming about and cost too much to use for everybody.

The LPN did PO meds and treatments the Aide could not do.

The Aide did all vital signs except BPs.(They were not allowed to take BPs) The thermometers were glass and mercury and each patient had their own (We no longer had to clean with alcohol between each patient). We took pulse with our fingers on the patient's radial artery and respirations by watching the chest rise and fall. We had the old mercury BP cuffs we had to roll from room to room.

The LPN and I "split" the hall for documentation (black ink for days, green ink for evenings, and red ink for nights) and I gave report on our team.

I was responsible for signing off all our orders and counting narcotics. There was no such thing as Unit Dose, Pyxis or Accudose. We gave sliding scale insulin accorrding to urine sugar tests. The LPN did the test and I gave the insulin.

I could go on and on, but I look back on those as good days! I had time to spend with my patients and I had a great team to work with.

[mattsmom81]

June55baby, your early nursing experience in the 70's could be mine...and I also look at it as the 'good old days' and look back fondly. We weren't burning out, stressing out, and we DID have time with our patients...much more quality time than I do now. I enjoyed nursing back then, not so much today.

Our acuity was lower and I try to think hard about why that was. Were problems treated earlier before huge complications set in? Did doctors in their clinics spend more time with patients...'heading off at the pass' potential problems? Were patients allowed to come into the hospital 'for a rest' and a little TLC (I used to always have one or two housewives in with this)and did this actually prevent disease?

I can't help but wonder how much our high stress lifestyles today plus the HUGE changes in patient care since DRG's and managed care actually lead to the high acuity and complex patients we see on today's medsurg units.

[rnmi2004]

Our acuity was lower and I try to think hard about why that was. Were problems treated earlier before huge complications set in? Did doctors in their clinics spend more time with patients...'heading off at the pass' potential problems? Were patients allowed to come into the hospital 'for a rest' and a little TLC (I used to always have one or two housewives in with this)and did this actually prevent disease?

I can't help but wonder how much our high stress lifestyles today plus the HUGE changes in patient care since DRG's and managed care actually lead to the high acuity and complex patients we see on today's medsurg units.

That's a great question--where are all these higher acuity patients on M/S floors coming from? In the "good old days," would they have been in the ICU's? I'm wondering what staffing was like in the critical care units compared to the general floors.

[NurseFirst]

That's a great question--where are all these higher acuity patients on M/S floors coming from? In the "good old days," would they have been in the ICU's? I'm wondering what staffing was like in the critical care units compared to the general floors.

ICUs came into being in the late 60s, if I recall correctly. Other CCUs came along later.

Higher acuity pts came from the fact that pts don't get into the hospital in the first place without being sicker, and go home sooner. If it can be done outpt, it can be. (I was just looking at something where they were doing an hysterectomy with a new procedure that could be done outpt!!!). If it can be done with home health care rather than the hospital, it will be.

NurseFirst

[DidiRN]

I think the newer drugs and the technology has expanded so much that personally I've seen people who would have never made it to the ER go home. I'm amazed at how long chronically ill people are surviving these days.

One thing I've noticed in my area the past year or so, is how many older morbidly obese are surviving longer. I've seen 400 plus lbs in their 50,60, and even 70's come in. That's something I don't recall. But then again, I haven't recalled many younger ones of that weight coming in either.

Back in the old days, even though we had more patients, it seemed to me in my area that people were much more satisfied with their care and had more trust in their nurses and docs than I see now. Alot of them wouldn't even be in the hospital or even overnight nowadays, they would have been done as an outpatient. The very ill we see now just didn't survive. I don't remember seeing as many errors as I do now. Alot more older nurses who have worked there for a long time. Much more job satisfaction. The care was in general good. It's so sad how things have become; not in terms that people are surviving longer of course, but everything else. I've been saying for a while that I personally believe these are signs the entire system is falling apart.

[apaisRN, RN, CRNA]

My impression is that the sick floor patients would have been in the unit, and the unit patients would be dead. We can preserve life a long time these days, sometimes to no one's benefit.

We had a really spacy house sup one evening a couple years ago. My floor was swamped and understaffed. So this gal, who hadn't been a bedside nurse in I don't know how many years, came to help us out. We expected her to take vitals or give IV meds for the LPNs. Nope, she offered to pass the drinks trolley. As a new nurse I was puzzled. What drink trolley? Someone explained it to me and I couldn't believe that a practicing nurse still thought we had time to be flight attendants!

[June55Baby]

Our acuity was lower and I try to think hard about why that was. Were problems treated earlier before huge complications set in? Did doctors in their clinics spend more time with patients...'heading off at the pass' potential problems? Were patients allowed to come into the hospital 'for a rest' and a little TLC (I used to always have one or two housewives in with this)and did this actually prevent disease?

I can't help but wonder how much our high stress lifestyles today plus the HUGE changes in patient care since DRG's and managed care actually lead to the high acuity and complex patients we see on today's medsurg units.

These are good thoughts. If we offered more "rest" and TLC, would it be preventative? I don't know.

I remember when my twins girls were born in 1978 I stayed in the hospital for 13 days... My OB said she was keeping me a couple of weeks because she didn't want me to be driving back and forth to visit them in ICU (about 14 miles - 1 way). That was not uncommon nor looked upon as poor management. In fact, it was good practice!

But as others have said, we are saving patients who didn't have a chance in 1977. Technological advances have soared and many of those patients we cared for in the ICU in 1977 are now receiving care on the general units. While those we offered rest and TLC to in 1977 are at home and usually not receiving care at all. Maybe that's why sales of drugs for depression and anxiety have risen dramatically. But did we even have anything for depression and anxiety back then other than Elavil or Valium??

[sblanchet]

I graduated in 1981. Nothing annoys me more than listening to "old timers" bragging to today's new grads that when they started they took 60 patients by themselves, cooked all the patients' meals, did all the laundry, walked ten miles to work uphill both ways, etc. I remember having a hall of 26 patients on evenings with myself two Lpn's and one aide. Most of the patients weren't even sick! Those were the days when people could be admitted for a barium enema, an arthrogram, a check-up, or whatever else. Patients were kept in the hospital extra days to accommodate families who didn't feel like picking up Grandma on Tuesday so could she please stay until Friday? Most if not all of the patients on the medical oncology unit where I work would have been in intensive care when I started. I hope new grads do not pay attention to this kind of nonsense. They face very difficult, very sick patients. It also amazes me the way the hospital lobby has been so successful at thwarting efforts to have nurse/patient ratios written into law. Day care centers operate under such mandates, so why not hospitals, too?

[medsurgnurse, RN]

I am on a floor with excellent ratios(LDRP) , but I keep wondering of the stuff JCAHO thinks up is supposed to keep us AWAY from patient care. Truly, I don't understand how one can do nursing care with all the extra crap we have to fill out, ask, etc. It's rarely vial to the patient's well-being.

I remember reading one RN say that they had to do a nutritional screening in ER. I mean, you go in for a sprained ankle and someone interviews you about your eating habits! And if any problems were noted they had to be refered to a dietician form the ER. Ridiculous. Preventive health care is wonderful but ER is not the place for it. I remember when I did ER, we had to do a pain scale, on a separate 20 question type page. writing it in our notes apparently wasn't good enough. And we also had to a patient education form about what was taught to the patient, again writing it in our notes was not good enough.

[laurasc]

What were your first days in nursing like? Do you remember those days with nostalgic fondness or a relief that its over? Are things better for you or worse?

I graduated in 1985 and started on a General Surgery floor that specialized in gastric bypasses. (in those days it was a nasty procedure unlike now) It was a 31 bed floor, we worked 7:30AM to 7:30PM and staffing consisted of usually 4 RNs and 1 RNA. (nursing assistant, in other words she didn't do meds) We averaged 7 to 8 patients each and we practiced "Primary Nursing" meaning that we were responsible for all aspects of the patient care. We were assigned a patient when he/she was admitted and we were responsible for the care plans, for co-ordinating with the various services available. On the floor we did all the care including AM care, all the meds, ivs, procedures, etc, etc, etc. On top of that, because the RNA couldn't give meds and care for IVs, we also had to deal with her patients.

That was on days.

On nights we were 2 RNs and 1 RNA. Since the evening started at 7:30 we were responsible for the various preps for surgeries. The most common was tap water enemas to clear...which usually means we had to subject the poor patient to several 1Litre enemas. Depending on the night and what was scheduled the next day, it wasn't uncommon to have multiple enemas and other preps to do not including the meds for our patients and for the RNA's as well.

To say we ran our fannies off was...well, an understatement. :chuckle

It was crazy. I haven't worked in a hospital for nearly 15 years and will never go back either. Partly because of that reason...too much to do and too little time. The other part has to do with "politics" but that's another thread altogether.

Laura

[snowfreeze, BSN, RN]

A big difference is less ancillary assistance, no IV team, fewer if any nursing assistants, no more daylight and evening unit managers, and the managers we have now usually have an assignment too. Secretaries are few and far between and are responsible for more than one unit, when we are lucky to have one. Environmental assistants don't exist anymore, and when was the last time you saw a candy-striper? No security in many sub-acute facilities and none in long term care. No daylight nursing supervisor anymore, that is shared with the DON and ADONs, evenings and nights have only one supervisor for the whole facility and she is expected to fill in for call offs on the units. Off shifts don't have housekeeping anymore so you empty your own trash cans and quick clean a room for that unexpected admission at 2am. The work load is shifted a bit but it is still a heavy work load.

Families are rude and aggressive at times and no one to help you out cuz everyone has their hands full.

I remember when a fresh open heart was 1:1 for at least 24 hours, now you can get a fresh heart from the OR and take a second patient that is 2 days post-op ready to go to stepdown.

Organ donors used to be 1:1 in the ICU, now they are paired with another ready to transfer patient. If the charge nurse is busy with the patients they are assigned to you have to talk on the phone with the lab, the donor service in your state, the family and often the potential receiving facility, plus keep a dead person alive until donors are found to take organs. And possibly transfer your other patient to another unit. Then when donors are located you have to take your patient to the OR and/or assist with cornea extraction at bedside.

The last trauma unit I worked in, the only 1:1 was a kidney transplant that was VERY unstable. Usually a 48 to 72 hour old multiple trauma was kept 1:1 when ever possible because even the most stable crashed during that time.

Specialty flight team was the only job where the patients were all 1:1 because you can't fit more than one patient and the team in a helicopter or lear jet.

[SharonH, RN]

It was crazy. I haven't worked in a hospital for nearly 15 years and will never go back either. Partly because of that reason...too much to do and too little time. The other part has to do with "politics" but that's another thread altogether.

Laura

I totally understand your feelings. I left the bedside only a couple of years ago and sometimes it's hard for me to believe that I won't be going back. Everytime I even think about it... .....