Finding myself negative these days. Can my expectations be too high?

[dorimar, BSN, RN]

I have always been the friendly supportive person at work. I never offered unsolicited advice (and still don’t) and have NEVER imposed myself or my views on someone else’s situation, or tried to show just exactly what and how much knowledge I had, as many nurses do. I have always freely and constructively given advice and information if it was sought from me. I have always had high expectations of my own nursing practice, and I never expected everyone to nurse like I do. For the most part, all of my coworkers gave good care. Some were average and some were exceptional—but all appreciated and respected the exceptional care. I never gave anyone grief in report for not knowing something or not doing something—until recently.

It is lately seeming to me that many ICU nurses these days are giving the absolute minimum allowable. And the allowable minimum seems to be rapidly increasing. Much of the ICU care I see these days is sub-standard—yet it is becoming the standard. Many ICU nurses now don’t seem to understand the importance of prevention and the impact their care (or lack there of) can have. Many ICU nurses today couldn’t tell you their patient’s medical history, or current problems/issues with the patient or plan of care. I’ve gotten report form some nurses who couldn’t even tell me what kind of belly surgery the patient had this stay and when. How does one critically think and work through rapidly developing problems and changes without knowing the patient’s medical history, why they are here (some nurses couldn’t tell you that one either), and other new and current issues/complications/concerns they have going on (like an NSTEMI, or thrombocytopenia, or coagulapathies, renal failure, DVT, PE, new onset afib, etc. etc. etc)? While I think that critical care nursing is so much more than following orders, some don’t even know the orders.

I have learned to turn a blind eye and not say a word. I have doubted myself (am I doing too much? Do I worry about unnecessary stuff?). I have repeatedly told myself that I expect too much. But when I am forced to come out my isolation room to check a triple alarm, only to find the patient’s nurse reading a book right in front of his room and in the face of his monitor that has been emergently ringing for quite some time—I do start to get annoyed. Especially when I have both my patients screens up in my room and KNOW it is not my patient, but stop what I am doing because someone may not be able to get away to check their other patient (we have had some sentinel events related to unanswered alarms)—and still they are ignored. Then I get report from the prior shift and they cannot tell me who the docs are, why a patient is on a particular drip they are responsible for titrating, or any of the patient’s medical history, or where they want the sats, or why is renal on the case, or why is cardiology on the case, did not know they had an MI this stay, or that the new and most important concern is that he may have an ischemic bowel, or do not even stop to question why they had to titrate the patient’s O2 all the way up to 15 LNRM with sats of only at 90% and are happily reporting off on a “stable patient”….. And these same nurses seem to have a disdain for those of us that understand the importance of knowing all that stuff about our patients and acting on it when we should….

It is affecting my care, because I find myself frantically searching through charts to find out information when I come onto crumping patients. And it is becoming the norm, because these nurses are role models to newer nurses and they are being taught to have disdain for those that bust their ass on the job.

Last night I came onto a calmly delivered report by not a new nurse on a supposedly nothing patient (although the report was that she was anxious). The nurse did report to me that her sats kept dipping into the 80’s all day, but I had to look in the room to see she was on a 15LNRM and had to ask her, “She’s been sating like that on a 15LNRM all day”?? Yep! And now she is sating 79% for me—whoopie!!! Also, I find from looking through the chart that she was supposed to be on BIPAP continuously and I ask the nurse and she says—“it was making her anxious” (no call to the doc). The day nurse knew nothing—who was pulmonary, who was cardiology, was she in for pneumonia, CHF, COPD, PE???? –let alone her medical history. So I started my shift frantically searching her chart before I could even figure out where to begin with her. Of course we ended up tubing and lining and paralyzing, etc.etc. And I know that I became rude. And I know that I am becoming negative. And I find myself angry at work so often theses days, because last night’s situation is becoming a common occurrence. And the up-and-coming nurses are learning to practice like these nurses. An actual recent quote from a brand new grad just off orientation in ICU on my unit “Don’t tell me all that stuff! Just tell me what I have to do”!

I know there are those who may flame me for this, but I need to vent. I am tired, and starting to realize that I am the minority at work now days. Is there anyone who understands where I am coming from?

[love-d-OR]

No one is going to flame you, or at least they should'nt. Anyway, I understand where you are coming from, I really do as I have felt that way at times. However, I do have to admit I have had days where I was given bad report and subsequently gave bad report to the uncoming nurse. I was once told by a nurse "oh you don't have to bother about xyz information. I'm back tonight anyways." She was not back, so I ended up giving a scattered report. I have gotten the too often "I don't know why he is on xyz drug" or flat out incorrect infromation. You are not alone. Take heart, unfortunately the level of care will not be the same across the board.

By the way, where was the charge nurse and every other nurse when this woman was sating in the 80's?

[Ruby Vee, BSN]

i've been accused of having too-high expectations from time to time. i don't think that's necessarily a bad thing. i, too have noticed the trend toward minimalism in icu care: mouth care not being done, patients not being turned and the nurse is sitting at the computer shopping on ebay. i suspect that the problem is the rapid turnover in the icus as new grads get an icu job immediately out of school so they can get their minimum two years of icu experience to be accepted into crna school. with a dearth of experienced nurses in the icu, nurses with two years of experience or less are being tapped as preceptors. at two years, nurses are in danger of thinking they know everything without truly understanding how little they actually do know. when they're tapped as preceptors, they cannot pass on a depth and breadth of knowledge that they don't yet possess. also, poor work habits tend to get passed on. if suzy's preceptor has demonstrated a work ethic of sitting in front of an alarming monitor reading a book, suzy isn't going to "get it" when i, as an experienced nurse but not her preceptor try to explain to her why that isn't cool. after all, her preceptor must be a great nurse or he wouldn't be a preceptor, right? the answer might be more travel nurses while permanent staff are hired slowly enough that good preceptors can be found for each orientee.

[cloister]

This very topic is being discussed among our senior staff and educators a lot these days.

Why does it take some of us the full 12 hours to take care of 2 ICU patients when others with less experience are reading a book by 10 p.m.? Why do we have newer staff complaining that they're "bored" wth their assignment? Why the sense of entitlement to the patients with all of the bells and whistles?

I'm not sure how we teach competence and compassion. I understand what it's like to be new and task oriented, because some days it seems like you can't see the patient for the tasks. I don't understand, however, not being curious about learning more or reading the H&P or looking up the meds or reading the progress notes. How do you expect to give expert care if you don't know about your patient's history?

I remember my orientation and how firmly the expectations were laid out by senior staff. I agree that with the influx of so many new RNs that a lot of our culture got lost in the shuffle. It's now up to us as senior staff to regain a culture of nursing excellence in our ICU and move us beyond the minimalist approach that seems to be creeping into our practice.

Not sure how to do that, though. Role modeling doesn't seem to be doing it. Hell, nothing seems to shift some of our folks. Warn them strongly enough and they go screaming harrassment to the union. Some do their two years and leave, but ironically, they're actually some of our best new RNs. I usually hate to see them go.

I think it must be us, as much as I hate to admit it. Had a registry nurse the other night who took an hour break, didn't bathe either of her patients, and managed to label her AM labs incorrectly, necessitating a redraw. I had to remind her to chart notes on her patients at 0300 as she sat reading a book. She decided that she would like to come to work in our unit and made inquiries about traveler positions available here. Why not? We asked very little of her, and she obviously feels no real accountability for her practice. There were no repercussions for the botched lab draw, although it's pretty obvious that she didn't check armbands before labeling the tubes. In some places, that would be grounds for termination. Not with us. We just shrugged it off like it was business as usual. Not good.

I like to think of myself as a nice person, but I think I'm going to have to drop that fantasy and start being a lot more direct with people. As in "When do you plan to bathe your patient?" and "I notice that your patient is still on his back. Let me help you turn them", and "You seem to have some extra time. Could you assist so-and -so with his patient?" As in "They've posted a new hemodynamics class. Have you considered going?" As in, "Have you checked the guidelines of care to see what our practice is?"

I don't know why some nurses seem to think that they have no real responsibility or accountability for their patients or their nursing practice. I know only that I am tired of following these individuals or having them as my colleagues or being their charge nurse. I also know that unless my other colleagues and I speak up and demand better that things won't change. It's up to us.

[GucciRN22]

i'm not a new grad (been out about 14 months and then about 2 months in icu), but i still don't have that "nurse's brain" that holds all this information. it seems like on orientation, i'm writing information down furiously in report and my preceptor hardly has to write anything, yet, when doctors call, family visits, or at the end-of-shift report, he/she seems to recall everything they heard about the pt's history, how they came in, who's consulting, old tests, etc, etc, etc. it amazes me!:bowingpur

even if i do get everything written down, it gets "lost" in the scramble of what becomes my shift! there are those of us who are really trying, but i guess it's just harder for some than others. ain't givin' up though!

[RNperdiem, RN]

I see some of this in places where the senior staff is stretched too thin.

Some units are a patchwork of floaters, agency nurses and new grads. The senior nurses spend a lot of time precepting and being in charge.

I usually get a sketchy report from the floats who picked up their patient from a per diem who is now handing the patient off to me(per diem).

[reisling]

Wow!!!Sounds like you and I work in the same place.. I have given much thought to this subject and the only thing I have been able to figure out is that they have dummied down our nursing schools. I don't think nurses intentionally give bad care, but they have never been taught the basics. Nursing schools today are more interested in teaching research then bedside nursing. That was kind of funny when you wrote about your pt desatting. I have been in your shoes before and the excuse given to me was "she has been like this all day". As if that makes it ok.......We are all doomed because someday these "nurses" will be taking care of you and me.

[bellehill, RN]

Oh, you are preaching to the choir. I have become so frustrated and disillusioned at work with the lack of care being given. Let me give you an example. I walked on the unit to be in charge as a patient was being transported for a stat head CT. I was 30 minutes late due to a snowstorm so I had no idea what was going on. The doctor called to see if the scan was done yet and I informed him it was in progress. He asked me if the patient was receiving their hourly neuro checks...I did not know so I looked at our assignment board, saw they were listed as a Q1h so I said, "yes". As the night went on, this patient was a withdraw for the next day since she had bled and there was nothing the neurosurgeon could do. Now I started looking at the charting to try and figure out what happened and what was going on and I found out we were doing assessments Q2h. I checked the chart and the last order stated Q1h neuro checks. Who changed it to Q2? Apparently nursing did.

We have nursing report sheets we are supposed to update and give report from; the problem is no one ever updates these sheets. After this patient died I decided I would make sure they were updated so when I am in charge I ask everyone on the floor if the report sheets are updated. The other night I had a nurse tell me, "I don't need you to tell me how to do my job". But you know what? Someone has to because a patient died.

It is a frustrating situation but I am not in this job to make friends, I am a patient advocate and sometimes that means standing up to my own peers. You are not alone with your feelings, now if someone can figure out how to fix it...that would be awesome!

[mt33133]

Wow, this is scary stuff!! As a new grad getting ready to begin a 6 month critical care nurse residency program I am shocked by the laziness and attitudes of the nurses described in the situations above!!

For me, I have always imagined my patients as if they were family members. Am I providing the kind of care I would want and expect to be given to my mother, father, sister, grandma, etc? There is a good possibility that each of us will end up in the ICU one day, and we will want the very best care possible in order to improve the odds of us making a recovery. It is a shame that some nurses don't feel the need to provide the very best care possible. The ICU is full of very, very sick patients, and to have such a nonchalent attitude is dangerous!

[cloister]

You bet the patients are sick. And yes, I think all of us need to treat patients (and families) as we'd want our own loved ones treated in that situation. No one in their right mind wakes up in the morning and says, "Wow! Hope I end up in the ICU today!" The stress level for patients and families is sky high, and a little kindness on the part of the nurse goes a long way. Competent care on the part of the nurse goes even further.

Glad to hear that at least one person entering the profession today has received the memo. Good luck to you as you begin your critical care residency!

[ana tomy]

I have been tossing/turning about this very topic..ready to quit. I am on a med/Surg unit that is basically a step down unit to ICU. I have been torn about how to reach these staff that do the minimal and don't seem interested in really knowing what is going on with their pts. Only interest is getting charting done and getting back to desk." Ignorance is Bliss" seems to be their motto. They know that others will pick up the slack because we care. And we will. It's frustrating. Is it worth having good Nursing work ethic anymore. I am stressed and they are not. Just saying...

[trvlngrn22]

Dorimar, like you, I found myself becoming more negative and disappointed in my peers. Labelled as having a bad attitude by those that did not understand my frustration. Then a friend gave me this quote saying that she thought of me when she read it. "A cynic, after all, is a passionate person who does nto want to be disappointed again." (Benjamin Zander). Did it help, no- not really. But I liked that someone who understood me saw that passion in me. It does help to vent as you have here.

I don't know why this is happening either. Nursing basics, answering alarms, common sense, all seem to be declining these days. I did change to travel nursing so that I answer more to myself, am less involved with staff issues, get to leave after I have had my fill.

I might add that I am still looking for the place that I may be comfortable in. With travelling, I have worked at 3 Magnet Hospitals in the last year. Disappointed in the nursing attitude in all of them. Am trying a 4th Magnet Hospital come May, but think the answer is not in the status that the hospital achieves by pushing paperwork. The answer is most likely with the nurses like the ones who have posted here. We need to convey what is acceptable practice and lead by example. It is hard to change a work environment, but I think it can be done. Try to get some like-minded coworkers to help. Good luck.