How Does Your Job Keep You From Giving Good Patient Care?

nrsang97, BSN, RN · Nov 13, 2008

Nurses frequently tell me that there is just too much work to do. I agree. Here’s your chance to speak up about it. Take the poll and let us know if there are ways you can be more efficient about what you do.
Then tell us. Don’t generalize, be specific about what tasks you do all day that could easily be deleted without any harmful impact on the patient.
Of course, if you have just enough work and your working conditions are just fine, and you always get out on time, you can write a line too, just to rub it in the faces of the rest of us poor slobs.
In my case, our unit is set up so that we are supposed to chart and give report in the hallway. This kills my feet. I could work more efficiently if I did not have to stand for so many hours. I finally figured out that it’s designed that way because the patients want to see someone standing. Otherwise, they feel that no one is really “working.” (I have no idea why the nurse is considered “not working” while sitting but the unit secretary is. Input is appreciated on that.)
Redundant charting is another holdup. Why must I chart the same thing in 3 different places? How does taking me away from the patient, actually benefit the patient?

I totally agree with the being on your feet and others thinking you are working, but sit down and you suddenly aren't doing anything important.

Also how many times do I need to chart that I gave a med, checked restraints, and interventions. We have excel care and no one reads it but the nurses, (computerized care plans), but we have to do them. Waste of time, but I do them.

Another thing is I wish the docs would communicate with each other. We had a pt go bad and neurosurg resident called off to stat CT and to OR. ICU resident was not notified by RN or neurosurg resident, and the RN heard it from the intensivest. Why should the RN have to call the ICU resident, Why can't the docs communicate with eachother?

Too many patients and not enough staff. Just too much to do to give all the care the patients need sometimes.

nursejohio, ASN, RN · Nov 13, 2008

In L&D we have to chart our meds on mom eMAR. Fine, but we also have to put meds (steroids, narcs and such) on the delivery summary, so the nursery folks can see it all. I understand the rationale, but we'd save so much time if they could just pick a single place for us to chart our stuff. We have *computerized* charting, 2 separate computer systems, both of which we're required to print multiple stuff from, causing us to waste even more time because our printers are junk and seem to always be jammed or offline. For a social service consult, we have to print a form from each system, enter the order on one system AND call to leave a message with the office.

OH! And now, only med orders pharmacy has processed come up under the pt in pyxis. Great, until we have a 8cm SROM multip come in! Having to do all the steps for an override to get to pitocin only takes up time the nurse doesn't have. That would be perfectly acceptable, beneficial even, on a different type of unit. But until they put cytotec, methergine and hemabate on the 'standing order' med list, the override thing is a hemorrhage waiting to happen!

Pediatric Critical Care Columnist · Nov 13, 2008

OMG, redundant paperwork is the bane of my existence. We have "goal sheets" for all of our CQI indicators that we're supposed to fill out every single shift. We have microbiology flowsheets that we have to document all cultures on then when the results are printed we're supposed to transcribe them onto the flowsheet. Busy work for sure when you have a patient you pan-culture twice a day. We're also supposed to transcribe our routine lab values onto the flowsheet when we get the printouts, even though the unit secretary prints lab flowsheet every morning and afternoon. We're supposed to document all our meds on the MAR (and have them checked and cosigned by another nurse) and in our nursing notes, and some nurses even put them on the flowsheet. We're supposed to document that we drew a blood gas and then record the results on the flowsheet. (I don't know how I could have results to put on the flowsheet if I didn't draw the blood...) We're required to write a narrative note minimum of q2h in addition to documenting any changes or interventions in that time period; record VS, I and O, and vent settings q1h; perform and document head to toe assessments minimum q4h and all of it on paper. While keeping our paper Kardex up to date in case a resident needs to know what our feeds are running at. Oh, and all those printouts I mentioned? The unit secretary brings them to the bedside, sometimes one at a time, and the nurse is expected to file them in the chart. Then with our Berlin heart patients and CRRT atients, all the information documented on that paperwork is supposed to be duplicated on the flowsheet and nursing assessment. Plus we have a very detailed wound care form that is to be filled out whenever we change a dressing. (Do I have time to read all the preceding ones to assess the evolution of the wound? No.) It's insane.

On day shifts we do rounds twice. That means that we have to drop what we're doing and give a detailed head to toe report to the intensivist on each of our patients then deal with all the new orders generated by this practice. (Our intensivists like to involve themselves in peeing contests and so many of the orders written in morning rounds will be modified on evening rounds.)

Then there's the continual rearranging of the furniture... We move at least half our patients from one bedspace to another everyday for sometimes rather esoteric reasons, and since we're an ICU those moves involve four people. I draw the line at putting the kids on a transport monitor to move them from one end of the unit to the other. If they can't go unmonitored for 10 minutes, then maybe we shouldn't be moving them! We have one patient who has been on the unit for coming up to a year (most of his life) and he has been moved from one room to another at least a dozen times. He's been on CRRT for amlost forever and moving him isn't a picnic, even if we don't talk about all the junk his parents have crammed into his room. Did I also mention that we're supposed to take him for walks off the unit whenever his circuit is changed??? Don't foget to take a spare epi infusion syringe in case something happens to the one that's running... Christmas is coming so you just have to know we'll have to take him to see the tree in the courtyard! Maybe Mom will insist on playing in the snow too.

tj92114 · Nov 13, 2008

I work for and LTAC Hospital, we have 3 floors and approximately 20 patients for each floor, with only 1 CNA per floor! This means that I have to stop passing meds,stop doing any kind of patient care, or any of the mounds of paperwork and charting that is required and help the CNA with cleaning, and repostioning the patients, because neither one of us can do it by ourselves. This is putting the patients at risk, because they are not being watched by enough personnel, my chances of making an error are greater, going back and forth doing my job and the cna's job at the same time. One patient was crashing, and luckly was found by housekeeping, who called a code. Oh and by the way the cna's are being offered a $25.00 bonus if they are willing to take the floor by themselves!!!

Reigen · Nov 14, 2008

At my hospital, I was told that there are interpreters (for several languages) on at all times...I am lucky if there is one, so I can't communicate with some of the patients. Trying to locate a translator is another time consumming factor, that makes it difficult to do my job.

NOTHING is convieniently located-- ONE IV tray so you have to individually get everything you need. Each item is located in one of three areas, so you must go to each area to get a different piece of needed items to start an IV.

Equipment is located in several "storage areas" that you end up hunting for, resorting to calling Cental Supply AKA SPD only to have equipment left outside the room or not delivered in a timely manner.

Since we no longer can have items left on the counter outside of the patient's rooms, the delivered items are "confiscated" by the charge nurse and are taken away if the items are left on the counter. Since I am not informed items have been delivered, I usually have to have another piece of equipment sent from SPD, and then watch very closely for arrival. I really do NOT have the time to be standing by the room waiting for some equipments arrival.

There is also the medication system a "Pyxsis" only on this floor there are two of them at different places on the floor, and many times you have to go to each one to get medications.

While that shouldn't seem to be a problem, most of the time it's for one medication clear down the hall to the other end to get just that one medication.

If you have to call pharmacy for a missing medication, you are never told "here is the missing medication", it's just placed into the Pyxsis by pharmacy staff.

You have to keep returning to check (both Pyxsis) if the medication has indeed been delivered.

Stat medications can take over an hour at times to be delivered. With the high acuity of patients on this floor, I do not really have the time to keep checking for a medication delivery.

The hospital now also requires the RNs to transcribe all orders, (Unit Secretary is not qualified to enter orders as I was told when asked why), which now makes me have to stop doing patient care and do the secretary's work in order to carry out the Physician's orders for care. With 6 to 10 patients with several orders, and a new addmission, or a discharge this is even MORE time away from my assigned patients.

This is very time consuming with only 2 computers to place orders so that other departments. ie: Lab, Dietary, X-ray, Housekeeping, Social Services etc., get notified of orders that affect their departments.

These same computers are the ones the nurses use during a working shift to do patient discharge instructions, electronic charting and other patient care items (admisson assessment/charting). These are also the ones that the Charge Nurse uses to do bed count, room changes etc.

Having to do the work of other persons ie ward clerk, etc., locating equipment, supplies, mediications, all lead to jepordizing my assigned patients.

WHEW! sorry long post.

lindarn · Nov 14, 2008

Will someone kindly tell me why nurses accept jumping through hoops just to accomplish routine patient care? Does administration get their jollies from watching the nursing staff attempt to do the impossible? Does administration have to go through these impediments to accomplish what ever it is they do to command the six figure salaries that they earn?

In short, why do nurses put up with the degrading things that nurses do just to take care of their patients? I am not asking this to be a wise @$$. I am baffled that we put up with it. Are any of you organized? I would start with you union rep, and make it know in no uncertain terms, that certain things need to be streatlined in order for you to do a good job. Get together and come up with ways to combine many of the above duties that you have, and other ways to streamline you work. No one should have to overcome so many obstacles to accomplish patient care. You can be sure that administration does not have to go through all of that to do their job. JMHO and my NY $0.02.

Libdarn, RN, BSN, CCRN

Spokane, Washington

UM Review RN, ASN, RN · Nov 14, 2008

Will someone kindly tell me why nurses accept jumping through hoops just to accomplish routine patient care? Does administration get their jollies from watching the nursing staff attempt to do the impossible? Does administration have to go through these impediments to accomplish what ever it is they do to command the six figure salaries that they earn?
In short, why do nurses put up with the degrading things that nurses do just to take care of their patients? I am not asking this to be a wise @$$. I am baffled that we put up with it. Are any of you organized? I would start with you union rep, and make it know in no uncertain terms, that certain things need to be streatlined in order for you to do a good job. Get together and come up with ways to combine many of the above duties that you have, and other ways to streamline you work. No one should have to overcome so many obstacles to accomplish patient care. You can be sure that administration does not have to go through all of that to do their job. JMHO and my NY $0.02.
Libdarn, RN, BSN, CCRN
Spokane, Washington

So does that mean that you're still working at the bedside, putting your job on the line every day by telling Admin all this?

I'm just not willing to go that far. I'll probably leave bedside nursing rather than make waves because I'm not willing to sacrifice my family's financial future flailing at windmills.

StNeotser, ASN, RN · Nov 14, 2008

Because nobody bands together to all say that they are tired of doing jobs other departments should be doing or asking why we need to chart something in three different places.

People say they'll stand behind you and eventually it ends up in two or three going to management about a said problem and you look like the troublemaker/whiner. Charge nurses do not always support the floor nurses.

One thing we have all banded together this year with was the way they did the holiday scheduling. It's a first.

StNeotser, ASN, RN · Nov 14, 2008

In my case, our unit is set up so that we are supposed to chart and give report in the hallway. This kills my feet. I could work more efficiently if I did not have to stand for so many hours. I finally figured out that it's designed that way because the patients want to see someone standing. Otherwise, they feel that no one is really "working." (I have no idea why the nurse is considered "not working" while sitting but the unit secretary is. Input is appreciated on that.)

This is really awful and over many years could be very detrimental to your health. Where I work we have some computer screens set at about shoulder height (for me, I'm short) on the walls. They are for charting ADLs, the CNA's and nurses use them for meal intakes, outputs and so on. After about three minutes of it my arms get terribly tired. The reason why they're in the hallways - so the public and patients don't think we're doing nothing if we're sitting down. I don't really care what they think. They also violate HIPAA requirements but they haven't been taken down.

As to time wasting activities - charting something in three different places for another departments convenience. I'd like that to stop. Locating supplies is a time waste. Supposedly central supply is meant to do this but I know I can for example bring two boxes of ABD pads down one day and the next day they're gone and nobody from central supply has brought anymore so I traipse up to central supply to get more.

Another thing, when dietary deliver meal trays, if they've "forgotten" something that's it. Don't even try getting one of them to go back and get a sachet of salad dressing or pat of butter. That apparently is nursings job.

Pediatric Critical Care Columnist · Nov 14, 2008

Will someone kindly tell me why nurses accept jumping through hoops just to accomplish routine patient care? Does administration get their jollies from watching the nursing staff attempt to do the impossible? Does administration have to go through these impediments to accomplish what ever it is they do to command the six figure salaries that they earn?

Of course they don't. That's why they left the bedside, to get away from the physical and emotional stress and the workload. Oh, and the shift work.

On Monday our unit had, according to our patient care manager, the worst day in 18 years. It was as bad as she described, but she doesn't realize that a lot of our shifts are just like Monday, but they don't usually have any impact on her. She and our charge nurse had a high-level meeting with administration in the hallway by our nursing desk that lasted nearly an hour while the rest of us scurried around like ants at a picnic trying to get things done. Then the admins faded away, the charge nurse took an assignment and the manager took charge. To her, that's a bad day... Admin meanwhile suggested we just do the best we can... but we are NOT canceling surgeries.

In short, why do nurses put up with the degrading things that nurses do just to take care of their patients? I am not asking this to be a wise @$$. I am baffled that we put up with it. Are any of you organized? I would start with you union rep, and make it know in no uncertain terms, that certain things need to be streatlined in order for you to do a good job. Get together and come up with ways to combine many of the above duties that you have, and other ways to streamline you work.

We ARE organized and I AM the ward rep. Our union has a Professional Responsibility Complaint process for those times when staffing and workload are out of control, but the end result of submitting one is a series of vis-a-vis meetings with management, deflection of blame onto the originator of the complaint ("How many times did you call the manager at home and tell her about the difficulties you were experiencing?" Hello, the problems had already been identified before the manager went home!! What did she think was going to happen, it would magically just sort itself out?), retaliation toward the initiator and even more resistance to taking that route.

We also have a Hazard Assessment process that includes physical, chemical, biological and psychological hazards in the workplace. Things on the psychological hazards list include things like violence, harassment, bullying, abuse, workload, noise, shift work, management style, role conflict or uncertainty, lack of control over work process, and lack of respect. See above for examples! Our unit had a hazard assessment done in July, but the reoprt didn't include any of those psychological hazards. It did identify the physical ones and gave concrete measures to reduce them, but no timeline. Four months later none of htem have been followed up on... because we're expanding into the unit across the hall when they move into their new space. That was supposed to be next week, but now has been pushed back to maybe June of next year. Meantime they're not oging to do anything because we're expanding our space and they'll do it all then...

No one should have to overcome so many obstacles to accomplish patient care. You can be sure that administration does not have to go through all of that to do their job. JMHO and my NY $0.02.

You're absolutely right. No one should. But most of us do because we need that paycheck.

Because nobody bands together to all say that they are tired of doing jobs other departments should be doing or asking why we need to chart something in three different places.
People say they'll stand behind you and eventually it ends up in two or three going to management about a said problem and you look like the troublemaker/whiner. Charge nurses do not always support the floor nurses.
One thing we have all banded together this year with was the way they did the holiday scheduling. It's a first.

Good for you that you were successful.

Tomorrow I am chairing a meeting with frontline staff, management and the union to adress some of our most troublesome issues. I feel like I should wear my flameproof underwear, because I'm going to be in the line of fire from every direction. I also feel like I should be updating my resume because I know the process is doomed before we even start, and that I will have to admit defeat and move on. But to what?

I love my cat! · Nov 14, 2008

I agree with redundant charting. Also, in our PACU, every med has to be put in a lock box. So, every time I need something, I have to run around to the lock box, open it, get the med, administer the med, then run back and put it in the lock box. So, trying to get a post-op patients pain and nausea under control means 10-20 trips per patient to the lock box. TOTAL waste of time.

I personally feel that other NURSES prevent good patient care. Meaning, the Nurses that come in early and start working off the clock, skip their breaks and lunches and then at the end of the shift, clock out and continue to work.

So basically, on an 8 our shift they've done over 9 hours of work. The higher-ups look at this (pretending not to know what these Nurses are doing...what a joke) and then have the nerve to tell Nurses that arrive on time, take their breaks and/or lunches and leave when their shift is over, that they are incompetent. What happens?

The Nurses that do need a break or a bite to eat start taking short-cuts with everything in order to get the work done because Nurse SuperMartyr has set the "high" standards for everyone else and now Management expects it.. I've seen this happen at several places.

It's weird, but I have noticed that many Nurses really, really need their egos stroked by Management all of the time. They love the attention more than they love what is right and fair for everyone...and that includes the patients.

How Does Your Job Keep You From Giving Good Patient Care?

Does your job actually hinder you from giving good patient care?