Socialized Medicine/Nursing

[PPL]

Hi everyone. I am especially interested in how nurses are treated in the UK and Canada. I feel the US is moving more and more toward socialism, more taxes, more regulations, more government infringement into private lives and private property. That said, I want to know if the nurses in UK and Canada are generally unhappy and are coming to the US, and if they are or aren't happy, why not? I know they are heavily taxed, so what are they actually able to take home of their saleries? I've heard that accessing the health care in those countries can be a nightmare and forget about it unless it's a dire emergency. I've been an RN since 1982 and there seems to be a move toward more and more regulation/documentation/cover your ass/make it look great on paper, and it's getting harder and harder to actually do quality nursing. So, unless the situation is better in the UK and Canada, why are we moving more toward a socialized system here in the US? Please, I welcome all comments.

[bunky, BSN, RN]

The other thing that I want Snickers to describe is the paperwork involved with an admission, and exactly what the nursing care plan entails on an admit, and the data base. See, the thing that I am getting at here is that while staffing may seem just as short there as it is here, the overall focus of the work is far different because the paperwork here that is CYA is insane. The standards of care guidlelines no matter what the prognosis is are unreasonable. This is what I am hoping that Snickers can shed some light on to illustrate what I am saying.

Say HI to the "REAL BUNKY" for me!

[LRM]

WOW, bunky & PPL you want to know a lot. My paper work experience is limited to EN work (=LPN)& student RN but we don't seem to have anywhere near the documentation you are describing in the states (abit scary!)

On admission each pts nursing history needs to be completed (not full physical assessment, this has been done in ER or by resident MO).

Nurses may decide to document allergies, medical & surgical Hx and basic obs, ect, & anything else that may impact on the pt's admission. The admission notes are brief. Most day-to-day documentation is completed on nursing care plan, planned & signed each shift by allocated RN & changed as needed (normally the plan continues the same from day-to-day dependent on the pt & is adjusted accordingly, eg: DAY 1: obs post-op, DAY 2: obs 4/24, DAY 3: obs TDS, this is adjusted by RNs evaluation, eg: afebrile, eating/drinking well, no Sx infection).

Documentation in charts DOES NOT need to repeat what was done for or with the pt throughout the shift as the care plan is a legal doc & this is sufficient.

Computer pt allocation is completed by each RN for their pt load & must correspond to care plan (for auditing) eg: if a point is given for pt education, then it must be written briefly on care plan what ed. was given for (meds, disease process, procedure).

At least one chart entry (clinical notes)must be written per pt per 24 hr period (normally day shift as more happens) Obviously, extra notes are written if pt condition changes (eg : analgesic give, effect etc, meds changed)

All other members of health care team use same clinical notes, so nurses, drs(residents, registrars, surgeons) plus therapists(physio, speech, occupational, dietician) all document together (gives a continuim & each can easily read what the other has written) Don't need to write "dr ordered..., or physio attended to pt.. as the drs & physiotherapists will document their visits in clinical notes for all to read.

D/C notes are normally brief (meds given , apt times) however if a pt is going to have community nursing (eg: wound changes, hygeine assistance) or transfering to a nursing home/different hospital, more thorough D/C notes would be written for effective communication (cares required, mobility, community needs/problems)

Basiclly I have found the documentation at ward level to be minimal, repetition is discouraged & waffle is frowned upon. Clear, precise, relevant notes are required, with nursing care plans forming the bulk of day-to-day paper work (this is usually only one page)along with med sheets & fluid charts.

Some hospitals are using and working towards introducing Clincal Pathways for their care plans, nurses have mixed reaction to these, more paper work involved if care diverges from pathway, some need abit more refining out here. And each surgeon seems to have their "own" preferences (eg: times for R/O sutures can vary, pre-op preps vary, etc.)which throws the pathway out the window, some consitency needs to be worked out.

Hope this info throws some light onto our 'socialised' system, does this sound similar to Canada bunky?

[leem]

Originally posted by bunky:

As for attitudes about death and dying? I wonder about this all the time. I wonder if it isn't more of a cultural thing, at least in the region and the culture I am working with. It seems that the people who were well off and saw the doctor regularly during their life don't wind up with g-tubes, and their families seem to accept their imminent death without trying to prolong their suffering. Maybe it is lack of knowledge that makes some so unwilling to say no heroics and it may even be partly influenced by guilt at not having had their relative seen by a doctor regularly. It is something that I see all the time and often wonder about. And you do have a mini socialized system here already in the military and it seems to be working alright there.

[This message has been edited by bunky (edited June 15, 2000).]

Hi Bunky,

Just a few things. The well off don't let their "loved" ones pass on more quickly because they are better educated. Its really more of a practical matter. Money. Who gets it. Them... or the doctors. Clearly, you have seen who wins that argument. As for the poor, get real. It is not stupity or guilt. It is that their value system may tend to lean more towards life -- and not its monetary valuation. Incidently, a "G"or "J" tube is not the end of the world, nor should it be the reason to end a life. As far as military medicine goes, clearly you have not experienced the "joy". I have, and thank you, but no thanks. It is a system where, in reality, the patient has essentially no rights, and medical personnel have very little accountability.

Lee

[LRM]

Got to agree with you Lee about the military system, yes it is a socialist system but you are right that the pt has little control & there is a reduction in accountability (worked as civilian in army hospital & it was like being a fly on the wall, very interesting!)

Also, why are we stereotyping the rich & poor, do ALL rich people let their loved ones die & ALL poor people try every avenue to prolong life? Come on guys, we can do better than that, judgemental & stereotypical statements are unethical practices.

[snickers]

hey Bunky....

I now work in a critical care area, however I've spent the last hundred years working on the floor. i talked to nurses who work on the floor, just to make sure that I had the patient numbers right. On the general medical floor on a night shift there is one rn with licensed practical nurses for 13 patients.On the internal medicine unit, there are 3rns and i lpn. The patients on this unit are renal, with ongoing hemo and peritoneal dialysis. It also includes cardiac patients, chemo telemetry(10),There is a charge nurse on both these units from 7-3, each of whom have no patient load. They deal with all the docs concerns, get all outdated meds re ordered and generally keep the docs up to snuff. On a daily basis there are Quinton catheter, tenckoff insertions, renal biopsies occurring on the floor with the floor nurses assisting. The internal medicine unit is 26 beds.The nurses are responsible for the telemetry,although they are out on the floor, not at the station monitoring.On the night shift there is an rn who is in charge

and also has an 8 patient load.(We get 1:25/hour for i.c.)!!!

In terms of charting,there are flow sheets with various system assessment. A head to toe assessment is done on all patients on admission, each 12 hour shift and prn.The cardiac patients require daily and prn vitals that are done by the rn and then charted by the lpns.

The renal patients are mostly bid lying and standing b/p.s...or lying sitting.They are also all daily weights...many bed scale.

In terms of the lab work. Nurses don't do any lab draws on the floors here.It is all done by lab techs. They are phoned for stats, or computerized req's for ongoing. There are also unit clerks on the units from 07-2100, who do all the lab reqs, booking of tests etc, which they transribe onto the kardex.

CBGM"s are done by the lpns and transribed onto the diabetis record by them. Anyone on tpn is qid cbgm(glucometer)

In terms of transribing new orders...the unit clerks do all of that, on the hours they work, after they are gone...then its up to the nurses. The sicker a pt, is on a night shift, the more orders are gotten and then transcribed and then co-signed by another rn.

All the patients have a primary care doc (gp) on the internal medicine unit all patients are referred to an internist, depending on what their speciality is .gps don't generally write orders , just comment in the progress notes. There can sometimes be 4-5 docs involved in the same patient.

Mars....pharmacy generated computerized mars that are sent up on Thursday night (around 2230), Nurese on night shifts check and cosign all the mars. If anything is amiss it is the nurses job to fax memos to pharmacy with the correct info.

meal breaks....Most of us work 12 hour shifts. We are entitled to2 half hour meals breaks and 3- 15 minutes coffeebreaks in that time. One of our coffee breaks is supposed to come after our supper break it's too late by then, so we take a1/2 hour coffee break instead, if we miss a meal break, then we put in for over time(double time) we can't claim for missed cooffee breaks, so if we miss a coffee, we add the 15 minutes to our next break.All breaks are supposed to be taken away from the floor, if one has to stay because of inadequate staffing, then it is not considered a break.

Benefits...We have medical benefits...going to a doc, or any of my family going, does not cost me any money(the employer pays that, we also have extended benefits that cover a large majorityof what isn't covered by medical....physio, medications, anything above and beyond we are covered80% for extended benefits, we have dental coveragefor the family, it covers 100% of basic plan(cleaning hygienistsetc., 60% forcrowns and bridges,dentures and 50% for ortodontia up to a maximum of 1850$, there is no limit on the preceding three.

Inderal costs 14.95, for 100 pills,,,that is claimed back at 80 percent.

Eyeglasses arecovered under the extended benefit package. Children under the age of 16 can see an optometrist q12 monthly,(its covered under medical and q24 months for adults). These benefits are all paid by the employer to any FT employee after 3 months.I think that casuals , once they work 700 hours, and if they have had to pay out any money for these services, then they are reinbursed. Don't forget that when I refer to the employer I mean the government(Provincial), I believe each employees full benefit package is worth about 400 dollars/per employee/ per month.We also have 2 pension plans that we pay into as well, When we retire. the hospital matches the money we have contributed.

Anyway, I think I've answered about half the questions you asked ...I will finish with the next post.

sj.

[bunky, BSN, RN]

OK LRM, you are right. We are making what sound like stereotypical statements but I want to clarify that no where did I say "stupid"! There is a HUGE difference between being stupid and having a lack of knowledge! My point in talking about it was that KNOWLEDGE IS POWER! In terms of knowledge, the layperson person gains knowledge concerning their health through their physician! If a person can't afford to go to the doctor then they lack that knowledge until they have to get a crash course in it! If someone is well aware of their disease condition in the beginning, the treatments and prognosis, they are in a better position to make informed choices in their care and have realistic expectations of their care! Generally speaking, people who can not afford health insurance do NOT seek care until their symptoms are severe because of the cost! This is not their fault, nor is it fair. Study after study on the effects of poverty and health says I am right on this, so I DO stand behind my statement on it. Many times it is a choice between going and having something checked out, or buying groceries. In a socialized medical system this decision between buying food and paying rent over seeing a doctor isn't an issue! Sometimes when it comes to end stage illnesses, it may even be lack of the knowledge that they CAN say NO! As a nurse I am not allowed to stand behind a doctor who is suggesting surgery and shake my head emphatically and make throat slitting motions behind his back! And my idea about G-tube insertion is this: In an end stage illness patient who is unresponsive, thus no longer able to eat, I feel that had loved ones been informed and prepared for this eventuality all along (as is what occurs with ROUTINE CARE BY A PHYSICIAN,) the decisions made would be paliative ones. I am not talking about temporary peg tube placement in a person who is expected to gain back a reasonable quality of life through rehab! I am talking about people who are actively dying! I don't feel that the decision to "lean more toward life" as it was so romantically, and dramatically, put is an INFORMED decision in these circumstances! And I see this a lot!

As for the military system in this country. I have a little bit of knowledge from experience with it, (American loved one misdiagnosed and treated for a serious,non- existant illness until second opinion obtained)and realize that there ARE definate problems, but I also live in a military town with 5 military bases. Two of the military hospitals here have outstanding records and are used by civilians. One is a world renowned burn center, and one is a first class trauma unit, so there are some positive sides to this! I merely pointed out the military idea as an example of socialized medicine existing here. I am well aware of the unaccountability of certain physicians in this system, but what can you expect from a military that once paid $600 a piece for toilet seats! LOL

Now, Ms. Snickers, thank you for all the answers thus far. Do you consider your benefits to be good by comparison to others in your community? From the sounds of it your staffing is about the same as here, and I am going to wait until you are done before I give you a comparison on protocols here and charting etc. I think you are going to be quite surprised.

[This message has been edited by bunky (edited June 27, 2000).]

[snickers]

and now the rest of the story......

g-tube feeders....not too many generally, maybe one or two a month. Quite a few keofeed tubes though, ,checking residuals q4-6h and charting of same.

corpses....nurses spend a lot of time getting "no code orders " on elderly non functioning patients..

The majority of family members treat nurses well, the ones who are unreasonable and complain a lot...I refer them to administration, to vent their concerns. The emerg nurses put up with a lot of s--t and abuse,with the frequent flyers,.The patients generally treat the nurses well...I sometimes have to remind people that the hospital is not a hotel....

The paperwork required with an admission is a three page (doublesided) admission database.It involves a head to toe assessment,weight, height, vitals. The 2nd page is a "have you ever had" list of diseases, previous surgeries(relevant to this admission).

The 3rd sheet is mainly a social questionaire..(previous capabilities before admission, in an attempt to address the elderly situation...whether or not they use any community resources or hospital resources., basically so when they are discharged they are plugged in to the system and hopefully their admissions are not so frequent.The whole thing from start to finish generally takes,20-30 minutes,

No, the place where I work doesn't try to simulate icu units on a 1st aid budget.

It is a social system, whatever surgeries that need to be done,are done,Whatever care needs to be done is done.We have no idea as to the cost of procedures,because it is all covered under medicare.Some procedures are beginning not to be covered and people are beginning to have to pay out of pocket ie: plastic surgery that is wanted,not medically required.We receive monthly lists of what supplies costs, just a fyi thing, but the patients are not billed individually for all those things, Hence it seems that nurses place little monetary value on the supplies we use...we use what needs to be used.

When we have pts. that are from outside of Canada, and they want a breakdown of their medical costs(for their insurance companies,) it never ceases to amaze me as to how much things really do cost.

I've never worked outside of Canada, so I have no basis for comparison to the American system.I do know that if people don't have medical coverage(most do), then the application is somehow back dated, so that the admission and treatment is covered under medicare,the social workers handle that. We are starting to see more

docs balk at providing care, if the person doesn't have medical coverage, however, no-.one can legally be refused here, because it is a "universal system".

What we are experiencing is, huge waiting lists for all types of surgeries, and that is Canada wide. Many of the acute care beds in B.C. are being taken up by elderly patients awaiting placement in long term care places. But there are no long term beds, or extended care beds being built, hence the acute care system is bogged down with"alternate level care patients".The patient population in many extended care and long term care places is changing.It used to be mainly the elderly, now, many beds are being taken up by young head injured people,(blown out their brains on drugs, or mva's,,,with that, an increase in aggressive and violent behaviour that nurses must contend with. Emergency department hallways are lined up with people on stretchers awaiting care, there just aren't enough beds(because of the elderly taking up the acute care beds.!

So anywayPPL and Bunky, hope Ive answered your questions....

Good luck to ya all.

sj.

[snickers]

Yup, I make good money and have a great benefit package......FOR A WOMAN!!!!!!!!!!!

Plumbers make 35 dollars an hour, mllworkers at the pulpmills make 35.00 an hour. Electricians make about 45.00 dollars an hour.The other thing I just found out, is that long term care aides make 20 bucks/hr and lpn.s make21bucks an hour. I make26.50 and have all the responsibility.However, that is a union issue that will hopefully be addressed in our next contract.Don't forget Bunky...we have nursing unions in all the provinces in Canada.

Look forward to hearing from you soon.

sj.

[bunky, BSN, RN]

Thank you snickers for your answers. Now I will do a partial comparison as I have to get to bed, and I am sure that PPL may have a thing or two to add to this. In CVICU where I worked last week, each patient was assessed and flow sheet filled out at 7,11,3 round the clock, full head to toe, and EKG's. Vitals are done continuosly and recorded q2 by protocol and PRN changes as well as a narrative entry in the nurses notes Q2 and PRN changes. Stat labs are drawn by the nurses, and there are a lot of them. On the surgical unit where I normally work, we do head to toe flow sheet assessments q8, are expected to chart a blurb with them on the narrative, as well as chart on them q2 and PRN changes. On our flow sheets we are expected to sign or initial things like that we turned them every two hours, did ROM with them q2, we checked there IV site every 4, IV tubing changed (protocol is q3d and they are to be labeled on the tubing so why we have to put it on the flow sheet is but another mystery to me) as well as all the rest like visitors present, spec sent to lab, use of infection control measures etc. We even have to check off q8 that plan of care was discussed with the patient and their reaction to it. Our vitals are done q4, and we draw all stat labs, as well as getting out our trusty glucometer and testing blood sugars, usually AC and HS, and give regular insulin by sliding scale if needed according to the sugar. If a diabetic is NPO we do it q6h, and I'd guestimate that 95% get this kind of glucose monitoring even if they are only on oral hypoglycemics. On any given day, we have at least 8-10 diabetics out of average 24 patients. We on nights, have computer printed MARS sent up by pharmacy EVERY SINGLE NIGHT, and every night we must go through them all and check them and put the old ones in the chart, and the new ones in the MAR book. With our new staffing grid, which we are not allowed to see, we were to be given 2 RN's and an nurses aide for 23 patients the other night but the supervisor felt bad and gave us three RN's with no nurses aide. Every night we are expected to evaluate the care plan and add to it. We do all of our own vitals on nights. We get maybe one DNR every few weeks, no matter what condition these patients are in. We have at least 2 G-tube feeders on the floor a shift, we have more nursing home residents and with medical problems than we do surgical patients. We are still expected to chart as though they are all acute surgical. On day shift in particular we almost NEVER take our breaks, receive no compensation for not taking them, because THEN you'd get in s--t for it although there is no offer that those giving you s--t will cover your patients for you. If you claimed it on your hours you'd be spoken to about poor time management skills. THEY know you aren't getting to take your breaks! So long as you don't complain about it, then everyone just accepts that it's too busy and no one bats an eyelash. The admit forms sound similar but in addition to yours, here they get us to screen for such things as sleep apnea, and TB! We must also complete a pt education record and keep up with it during their entire stay. Each patient has a new nurses note and flow sheet attached every day to be used for the one day only and filed in the chart. We are expected to do daily weights for pt's with g-tubes and for cardiac patients (although why a CHF who is not a DNR is on a surgical floor with no tele capacity is a mystery to me). We see a lot of TPN on the floor too. Oh and each nurse notes all the orders on each of their patients using a unit secretary, but when even a complicated surgical patient has 4 and 5 doctors consulting and writing orders it is hard to keep up. Oh on nights we go through every chart to look for anything not done. Which means going through the computer to check out lab slips if they didn't save them. I have come in on nights at 11 and found orders written for stat things at 6 PM not done! I find orders from day shift 7-3 written at like 8am not noted by the RN. It's not their fault! They are too busy and I am being sincere. This is but a partial list of what it is to work on the floor here. I am sure that PPL can add her own. Can you see the differences? Can you see why I think we have the right idea in Canada? So much of our charting is CYA work that takes us away from the patients.

[PPL, BSN, RN]

Well, with everything I am reading, I've decided that MAYBE it would be OK to be a nurse in Canada, but I don't know if I'd want to be a patient! Based on everything Snickers has told us, it sounds like they have less bull---t paperwork for sure, but it doesn't sound like needs are getting met, unless it's an emergency; what with huge waiting lists, people lined up in the halls, etc. She certainly is making more money then I am, and the benefits sound good, but how much of that $26.50/hr is she taking home? Are the patients on waiting lists for surgery/procedures because there are fewer docs(docs fleeing the situation), or because the money is just not available to treat anything but "life and limb" as she so aptly put it earlier? Leem and LRM make mention of lack of patient control/rights, but here in the states, it seems like patients have all the rights, and don't mind telling us so! I, like every other nurse, have been taught to be patient advocates, but at what point do we advocate for ourselves? I have never been in a union, like Snickers is, but I believe that whenever you have heavy government involvement, you'll have unions. I feel helpless to change the nurse's situation here in the states, because I feel that any time you have some fat bureaucrat(read management)sitting on the throne, insulated from having to do the job in the trench, and in fact, receiving a fat paycheck for decreasing the numbers in the trench; the situation will continue, and may in fact, get worse! I see our situation here as being VERY MUCH bureaucratic, even without a "universal" system, so I am hard pressed to believe that the government could and/or would enhance the system, by taking it over. And so, like LRM has said, we just have to do what we can to make our little patch livable, by sticking to our ethics and values, but the problem being of course, that in the present climate, it's becoming nearly impossible to do it! Hey, maybe we should start Vol II of this subject, this topic has become so long, but I am getting an education, which I thank you all for that!

[LRM]

What a lot of info to absorb. I agree with bunky that socioeconomic status & health are directly related (the poorer one is the worse their health) with education & knowledge identified as the main variables. And in a system where accesibility to health care is available for everyone (rich or poor) health prevention measures are instigated & knowledge is disseminated more readily. Now bunky I never said poor people were 'stupid'.

PPL, I did say in the military that the members often don't have much control over their health care but this is different in the oz public health, socialised system (totally different culture). We have a full pt rights bill that allows pts to seek second opinions & refuse Tx. There is no option for selecting dr (this is where private has advantage)but many of the drs are first class in the public system, yes the hospitals are all teaching hospitals but pts are allowed to question Tx & dr's. opinions.

As far as pt advocating, yes it is a priority here too. One can advocate in both the public & private system. In terms of advocating for ourselves, do you mean wages or staff nos?. Aren't both also advocating for the pt, adequate staff nos are needed for safety & reasonable wages are needed to encourage nurses to enter work force & encourage them to further their education & enhance their knowledge base thus knowing they will be sufficiently renumerated.

Unions here in oz are looking at striking soon as we have been waiting for >6 mths for the government to meet & discuss pay increases (Queensland hospitals). No nurses like taking this action but staff satisfaction also needs to be a priority. Nursing is no longer solely a 'vocation' where a person enters this profession because "they wanted to care for people". Caring alone does not pay the bills & we all have a life outside our jobs & if not then we MUST make one.

By the way, I have never been a big union supporter but since doing my degree my eyes have been open to many sociological issues that I didn't really have an opinion on before. I still think unions should not have control & manipulate the system for their own benefits (then the fat cats in the unions sit back & dictate, no different to capitalism) however, they do have strengths & when used for the right purposes (pt safety or in eduaction, student benefits by increasing teacher nos & decreasing class sizes)they facilitate a more equitable distribution of resources & allow a voice for the people.

[snickers]

PPL:

You've mentioned a couple of times in your posts about we in Canada being heavily taxed, hence I thought you'd be interested in seeing a breakdown of a typical paycheque I receive and the subsequent breakdown of deductions...... for 7 shifts

gross pay was 2376.57 net pay....1282.21 total deductions 1094.26.

Income tax...........672.01

Canada Pension...90.55

Unemployment Insurance....57.04

Superannuation....128.28

Canada Savings Bonds84.82

Union dues.....41.74

R.N.A.B.C......14.92

year to date, gross earnings have been 27,667.31 & takehome....15,175.27 total deductions 12492.04. So,,what do you think? Any basis for comparison?

oh yeah,we also accumulate sick time (maximum 1100 hours at the rate of 7.5 hours a month, aswell as holiday time.(230 hours this year.)