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dream'n, BSN, RN 12,941 Views

Joined: Aug 28, '06; Posts: 985 (58% Liked) ; Likes: 2,901

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  • Apr 16

    Errors arise from the absolute panic nurses are in trying to get everything done. Often units have no secretary, and there are one to two techs for an entire tele or med-surg floor, and one of them may have to be a sitter....ICU is lucky to have techs, even when taking 2-3 patients, frequently with multiple admissions & transfers, answering phones, dealing with families & visitors, + passing meds, turning and suctioning patients + giving other basic nursing care, and God forbid if you have someone who is trying to circle the drain. Rapids, code blues, outrageous charting requirements, and if you've drawn the short straw, charge duties so you can deal with patient assignments and staffing issues. It's way too much everyday.

    Change has to come from the top. All this is upper management squeezing the life out of the supervisors and unit managers to have bare bones staffing, regardless of staff feedback and the negative patient care effects. Somehow, CEO's are going to have to actually start believing that on the ground hands on care makes a difference in patient outcomes, and they are going to have to actually want good care for the patients, at least want it enough that they are willing to pay a little more to get it. As we can see, for now, they are not. We all hear about "patient care is our first priority" at the orientations or occasional pow wows, but we know it's just bs, because if they actually believed "Patients are #1" or whatever, they wouldn't leave one tech and 5 nurses for 30 patients. That's sh*t care and everybody knows it. If one patient goes bad it's a disaster. Pt outcomes and satisfaction suffer terribly because we just need "another set of hands" to help us. No one is lazy; we just want to be enabled to give proper nursing care to all our patients if we bust it for our entire 8 or 12 hour shift.

    Anyhow, because of staffing, instead of practicing Nursing Excellence, we are more often than not practicing Seat of Your Pants Nursing, mainly putting out fires and barely keeping the head above the water. That means rush-rush-rush, & by necessity nearly ignoring some patients while dealing with the other needier ones, with very little time for double checking, reassessments, and thinking things through, and hence the perfect storm for errors. Then when someone makes an error that we get dinged for, everyone swoops in so this "never happens again." What happens then? Instead of looking at the root cause and giving the floor more HELP, they add more processes, checklists, and paperwork to an already overwhelmed nursing staff.

    Now management is coming back in with that ridiculous and insulting "huddling" crap they had going years ago. Yeah, we are woefully and potentially dangerously understaffed, but we are supposed to just huddle, and if we work together as a team, then we can get through it.... Like it's just us not working as a team or putting our heads together that's the problem. Scripting, huddling...my head is going to explode. A long and meandering answer, but in a nutshell, in looking at error prevention, it's generally all about staffing.

  • Apr 16

    Kristi,

    This is not directed at you personally, but at the whole "safety" bubble: Some of this is getting exceedingly disingenuous at this point.

    I understand why frontline staff must be involved in solutions, and we want to be, but you know as well as I do that the first 30 "holes in the swiss cheese" are things that bedside RNs can't fix, and what's worse, we are very likely to be vilified for caring too much about them or calling any attention whatsoever to them. So then, all of this becomes a bit of a game where we're playing by ourselves.

    These nearly 20-yr-old reports and terrible (actually awful) analogies about how many people we're killing have ceased to be useful in this conversation except as attempts to make those with the least power in our organizations suffer with ongoing guilt - while those who shouldn't be able to sleep at night continue to shirk responsibility.

    "We" are not sociopaths out killing jet planes full of people.

    If you want to help patients (and nurses), the only way is to get real. Nurses and Safety teams have been coming up with mostly asinine (and some good) suggestions the whole time our profession has been being taken over by business people and their hired cheerleaders, who make up whatever facts are needed to suit their cause. And as far as I can see, the "cause" is to appear to be doing something about safety. It's very useful for the public to believe that uncaring, undereducated, poorly-prioritizing RNs and callous, money-hungry jerkwad physicians are the cause of safety issues. Well, we have made a ton of strides and now it is time for others to step up to the plate.

    Sorry. I know your work is important but this conversation needs to change in a big way.

    What am I going to do about it???? > Spread the word about this damaging, devaluing and demoralizing farce.

  • Apr 16

    Ratios! Overloaded nurses are more likely to make mistakes.

  • Apr 16

    Quote from chare
    To those of you saying that you would only give medications drawn by another during an emergency situation, what makes this different? If your concern is that the medication wasn't properly prepared, don't you think that the increased stress and anxiety during an emergency is going to greatly increase the probability that an error will occur?
    I can't believe I have to explain this.

    It's a benefit to harm ratio. All hands on deck for a true emergency where speed may be the difference between life and death. In those situations, we take verbal orders without protesting--even if it's against policy and procedure--or just anticipate what needs to be done and do it.

    In situations where there is no emergency and no real reason to bypass safety checks, the benefit to harm ratio shifts.

  • Apr 9

    Quote from cardiacfreak
    I called a cardio-thoracic surgeon one night for a patient's PAIN 10/10 (he was the only doctor on the case). He wasn't happy and told me "Well, Cardiacfreak, DON'T ASK HIM IF HE'S HAVING PAIN!"

    He may just have a point. LOL
    You know...this might be the answer. In elementary school nursing you never ask a question that has an end to it. Does your head hurt? Are you hungry? Dose your hair hurt? You can even ask them if their name is Daffy Duck and most of them will say, "yes." So you ask open ended questions like, "what's bothering you," "why are you here in my clinic," and you'll get the real reason.

    Keeping this in mind...do you think "most" (of course there are exceptions to everything) patients would NOT tell you if they were hurting to the degree that they thought needed attention? So why not let them volunteer the information instead of giving them a free pass to say yes they are experiencing pain, 10 out of 10 of course.

    Just a thought.

  • Apr 9

    Quote from Oldmahubbard
    I am a Psych NP, worked as an RN back in the dark ages. But I vividly recall asking about pain, back in the day and some patients would absolutely deny it. But 5 minutes later, they would be talking about this ache, or that discomfort, or various other similar descriptors.

    This was long enough ago that only cancer patients got narcotics. But it wasn't really that long ago. Strange.
    I believe we've gone to the opposite extreme due to the whole JCAHO mandate; trying to legislate interventions versus allowing health care professionals do individual in depth personal patient assessments.

  • Apr 9

    Quote from meanmaryjean
    "a bad system in which we set unreasonable expectations"

    hherrn hit the nail directly on the head!

    When the expectation is "no pain ever/ pain is always bad and should always be avoided at all costs" - then you CREATE this massive problem.
    Yes.

    And CMS' involvement and culpability in the situation is more than the sum of the facts they presented about their involvement.

    For example:

    During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

    1 Never
    2 Sometimes
    3 Usually
    4 Always
    Sure, it sounds pretty bad to think that a hospital (or nurse, physician) didn't "do everything they could to help you with your pain."

    But when there is a preconceived idea (or a knowingly dishonest understanding) by patients of what "everything" should or does involve, combined with the undeniable fact that patients' ideas of "everything" may very well involve non-therapeutic, medically-incorrect, unethical interventions, well then now you have a problem.

    Add in the idea that the only acceptable answer we seek to receive on these questionnaires (as we have all heard a million times) is "always."

    So the question is one that puts healthcare providers between a rock and a hard place. CMS knows this. Well, their utilitarian "ends-justify-the-means" approach to saving a few dollars on care that has already been provided in good faith was never a secret, and has now officially backfired spectacularly.

  • Apr 9

    "a bad system in which we set unreasonable expectations"

    hherrn hit the nail directly on the head!

    When the expectation is "no pain ever/ pain is always bad and should always be avoided at all costs" - then you CREATE this massive problem.

  • Apr 9

    Quote from verene
    I'm not sure how the pain scale contributes to addiction. While patients could certainly use more education around pain and the use of the pain scale. It does allow a metric to show improvement or lack of improvement in a pain rating. If rattled off quickly and given with out any reference points, yes it is meaningless, but this is where active listening, patient education and clinical judgement come in.

    ....

    I whole heartedly agree that opioid addiction and abuse is a problem in this country, that we don't do a good job of managing pain or education patients about it, and that addiction is a serious issued. I just don't think you can conflate the existence of the pain scale to causal factor of opioid overdose deaths.
    verene,

    You make legitimate points about some of the underpinnings of addition and about how we can better assess pain.

    That the pain scale single-handedly causes opioid overdose deaths wasn't the claim made in the title of this post, the opening lines, nor in the blog post referenced.

    There are many, many relevant factors - each playing a little part in the progression of this problem. Of course there is nothing inherently wrong with the pain scale as a basic tool. There's nothing wrong with understanding that pain can't be solely objectively measured and so we must listen carefully to what patients say their pain is to them. There's nothing wrong with remembering that pain is important and we shouldn't forget to assess it, just as we wouldn't forget to assess vital signs.

    Perhaps you didn't ride along on the original swing of the pendulum - but at some point a lot of individuals and entities signed on to the idea that "0-10 pain scale" plus "the pain is what the patient says it is" plus "pain is the 5th vital sign" should be understood to mean that making any observations whatsoever, amounted to judging patients and not believing them.

    I will spare you the details of how this played out in a large urban teaching hospital and how it absolutely did contribute to the situation in which we now find ourselves.

    My opinion and experience has been that

    0-10 + the pain is what the patient says it is + it is also a "vital sign" = nothing short of a disasterous way of thinking and has brought harm to our patients over time. Moreover, although I can grant that the original intentions were good and ethical, in reality, effectively banning the reasonable use of objective data about a patient's pain was never an honest or ethical way to interact with patients about their pain or their reason for seeking care.

    If rattled off quickly and given with out any reference points, yes it is meaningless, but this is where active listening, patient education and clinical judgement come in.
    This statement is....well, it's offensive because it assumes that the only problem there ever was with pain scales was the person administering them. It implies that if they are reviewed in a calm and pleasant manner (as opposed to "rattled off") while making good eye contact +/- an appropriate "look of concern" and a sympathetic tone of voice and then being ready to carefully listen to what the patient says about their pain, then everyone will use the pain scale to give a reasonable rating of their physical pain and there will be no problems! And, that is simply not how all of this has played out over time.

  • Apr 9

    Well it looks like CMS is trying to cover their tracks in role that HCAHPS plays....

    https://www.qualityreportingcenter.c..._vFINAL508.pdf

  • Apr 9

    Yes, nurses occasionally talk bad about patients. Patients talk bad about nurses, too. Nurses talk bad about other nurses. Elephants make fun of zebras. Blah, blah, blah. It's not something I'd concern myself with- especially as a student. People are people and do step out of line from time to time. You will do it too, although maybe in a different manner.

  • Apr 3

    Nurse Bruno: "Are you sure you can't go to the bathroom on your own?"
    Patient: "No, I need to have one of the female nurses change my diaper each time."
    Nurse Bruno: "How about I just insert this 22f catheter in you so you don't need to bother your nurse?"
    Patient: "On second thought, I can walk to the bathroom myself."

  • Apr 3

    I think, Emergent, that you're dealing with a patient who has a sexual fetish about wearing diapers and all the accompanying accoutrement that goes with it.

  • Apr 2

    Quote from TriciaJ
    He has a right to be as loony as he wants. You have a responsibility to provide care for him. Period. Do not take anyone's stupid stuff personally. Even if he means it to be. If he's being cared for in a nursing home, he is already struggling with powerlessness. Many people don't handle it well. Fantasizing that he has the power to send you to a concentration camp is as good as it gets for him.

    I once had a patient threaten to tell my husband on me; "You know what you done". Uh huh. Yeah, whatever.
    I both agree and disagree with you. (How confusing is that!). Yes, I do have a responsibility to provide for this patient, ( I don't believe I stated the gender of this patient). However; the tide is turning in nursing to recognize that nurses are no longer required to be beat up, spit at, physically abused and verbally abused.

    Anti Semitic remarks are not acceptable in any realm.

    This patient is completely oriented and knows exactly what was being said.

    Consider if you will this situation in reverse and this patient had shared with me their own Jewish heritage and I had said, I'm going to send you to the Concentration Camps". I would be fired that day.

    I think it's time that patients are held accountable for their actions.

    Being sick isn't an excuse for being rascist.

    Several hospitals in my area are employing "Patient Behavior Contracts" that clearly state a patient cannot be verbally abusive or racist. We have a large population of foreign doctors here who have to put up with horrible statements on a routine basis.

    It's time for a change.

  • Mar 26

    We have a saying where I work that goes "There's a right way, and then there's the _______ ________ Medical Center's way!".

    When a coworker complains of the way something is done, then makes and appropriate suggestion, I reply with, "Stop making sense!"

    Rooty Payne, my work brother in arms, has a couple:
    "It's only (8 or 12) hours."
    "I don't run the train, I only shovel the coal."

    Got any?


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