I have been a med surg nurse for 20 plus years. I worked at the same hospital for 20 of those years. I was terminated because I simply cannot keep up any longer. I have accepted and learned CPOE. med scanning,computerized charting, etc. BUT...I cannot go completely "paperless" and always chart in "real time" . ( just to mention two out of many gripes).
The last year of my employment at this facility that I loved and grew up with, changed administration when 2 new hospitals opened in the area. During that time most of us "older" nurses (highest paid) either mysteriously left or retired early after years of employment, all being replaced by new grads. No offense to new grads, you are very much needed and have been trained in the new ways.
I feel like an old dog being kicked to the curb. I am a good, caring nurse. Spent "too much time with my patients". Forgot twice to document if smoking cessation education was given and no flu and pneumonia vaccine status documented. That won't happen again!
So what if I was trying to keep my patient from coding trying to get a transfer to ICU all by myself while all the docs and charge nurses and supervisors were at their morning meetings and not responding to pages "in a timely manner" sooooo... I didn't chart or give all my meds in that "timely manner" many times and have been doing the same since I was a new nurse. That is fact and I'm sure many of you will agree you've had to do the same.
I guess I just don't know how to be a nurse any longer. Can anyone relate to this?
I don't know what to do. I can't retire (lost most of it in the '90's) and had to live off the rest when I lost my job. Its a dog-eat-dog world out there and new nurses are in demand. I am 53 years old and never thought the career of my dreams would end up this way.
I do start a new job in a LTC facility next week. Maybe this will work out. I'm too old and poor to go back to school now.
My greatest advice to all you new nurses is, hang in there and take good care of me when I need you, and start putting in a lot for your retirement right from the start. I truly have been traumatized to the point I feel incompetent and I know that is not the case.(PTSD)
OK - Full disclosure.. I am definitely a COB (crusty old bat). We're in this pickle because we have allowed the tail to wag the dog.
I am not computer phobic.... heck, I taught myself to program back when personal pcs were just a pipedream. I love all things tech - especially all those lovely "machines that go bing" (tribute to Monty Python's The Meaning of Life).... but somewhere along the way, clinical folks lost influence & clinical systems have been designed by people without any insight as to how patient care actually takes place. We now are expected to modify our patient care work to meet the needs of the documentation system. This is nuts.
If the system was designed more logically, nurses wouldn't be doing manual documentation at all - we'd have mechanisms in place to accurately capture patient interactions, nurses could simply dictate as they performed the work, carefully placed cameras would help capture assessment findings, interventions and such.
Hey, a COB can dream, right? It could happen.... after all, in 1976, no one even dreamed that we'd all be carrying powerful computers capable of wireless communication around in our pockets.
If you're concerned about trends in hospital nursing, you might want to read this recent NYT expose about "bruising workplace" Amazon has created for its white-collar workers:
Similar behavior toward those who work in their warehouses is well-known but has been written off as directed only at low-skilled workers who are easily hired and fired. This is about the brutal treatment of highly skilled professionals.
What's happening is something called metrics. Factory worker metrics—meaning how much they accomplish on the job—has always been easy to measure and the results, brutal working conditions, are well known. The resulting ill-will that created in the auto industry many decades ago is why the UAW regards Ford and GM as their enemies to this day. It'd be terrible to see the same happen with hospital nursing.
But measure the apparent productivity of white collar jobs has been much harder to. You can measure how many people a customer service rep talks with an hour, but how do you measure the productivity of more complex jobs such as management or nursing?
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A friend of mine illustrates what used to be. She was an editor at Microsoft Press. Coming back from vacation, she found over 200 emails in her In-box. Rather than grind away for weeks to catch up, she simply deleted all of them figuring, as she told me that "if it is important, they'll contact me again." That was the mid-1990s. Microsoft had no way to tracking that she'd done that. She was safe.
Amazon in 2015 not only tracks that sort of thing, it does so in real time and in great detail. If an Amazon employee did that, she'd be in a "conference" with her supervisor within a few hours. Amazon not only tracks deleted emails, it tracks and reports how quickly its white-collar staff respond to their emails and even tracks if they're not responding well into the evening by logging on from home. White-collar workers can warned and even fired if they don't keep their scores on these various metrics high.
What you're seeing as hospital nursing becomes more computerized are attempts to introduce metrics into nursing management. Older nurses are right to sense that that data doesn't measure the quality of their work. Some younger nurses are, I fear, being seduced into thinking that doing all the proper data entry is what constitutes good nursing.
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Keep in mind that the change isn't the introduction of something new. It has always been possible for administrators to hassle nurses about small things and make their lives miserable. That dates back to the early days of modern hospital nursing, which I describe on page 78 of a book you can find for free online here:
Be sure to note what's said about "scientific management," a fad of early twentieth-century business that's making a comeback. It's precisely what Amazon is doing and thinking it is being bold and innovative. If you read more on the topic, you'll also find it called Taylorism, after its chief promoter. It's core value is to view workers as tools, stupid and in need of being forced to be more productive. Not a good environment to work in. Charlie Chaplin's 1936 movie, Modern Times, dramatized what it was like. Notice that the boss has screens to watch his workers and subordinates to demand "more speed." That's today's computerized metrics.
The principle has been around for a long time, but it has been held back the difficulty of measuring how productive white-collar workers are. It is that this wealth of new data that computerization makes possible gives far more information to administrators and thus enables them to better hassle their subordinates for failures to do this or that. That is where the danger lies.
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Years ago, when I worked on the teen unit of a major children's hospital, day shift when I worked was horribly overloaded. One of three shifts, we did at least half the work. Nurses endured it in order to have a day shift position.
Stupidly, in the midst of all our other work, the administration expected us to take care of patient baths and linen changes despite the fact that both were more appropriate for evening shift, where the work load was far less demanding.
I coped by a simple expedient. I simply decided that linen changes weren't a day shift task. When I resigned after 10 months on the unit, I even made a point of suggesting in my resignation letter to the director of nursing that baths and linen changes be formally moved to evening shift. Many of our teens were bed-bound after major surgeries and required a lot of care, so not doing linen changes enabled me to give them excellent care.
When I started, no problems arose because the temporary head nurse was one of the sweetest nurses in the hospital. She knew how overworked we were. When the permanent head nurse returned, she was another story. She was ill-tempered and excessive critical, always finding faults. I don't recall her ever praising a one of our overworked nurses.
She was aware that I was rarely doing linen changes, but could only gripe about it from time to time. Why? Because collecting data like that would have been a lot of work. Linen changes were only recorded on nursing notes as a handwritten entry. To document who was and wasn't doing them would have been quite a bit of labor. She'd have to acquire the nursing notes even for discharged patients, read through them line by line, counting what was done when. And since the notes weren't alway clear about the staffing, she'd have to correlate that with staff assignments.
Not so with the new computerized systems. They can (and probably are) being designed to collect all sorts of niggling task data and, with that data readily available to administrators, they can use it as a weapon to threaten and even fire. This discussion illustrates that.
I can't write more here, but I think many of you realize that the most important work a nurse does isn't easily quantified by computerized metrics. Changing bed linens and the like can be a check box that is easily tabulated. Taking the time to calm a frightened child or encourage a depressed older patient isn't something that can be measured and thus isn't a part of these metrics. And often, to do the latter, you must slight the former, passing some niggling task to the next shift or doing it later that some arbitrary time.
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One final note. Computerized metrics is clearly a "coming thing" in nursing administration. You find it everywhere. Elsewhere on this site, I blasted IBM's new nursing apps. They make it easier for administrators to track certain types of nursing activity, I wrote, but they do nothing to help nurses accomplish more in the time they have. If anything, by putting work into clumsily prioritized to-do lists, they slow nurses down. Spending more time accounting for how they spend their time means less time actually working.
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If you know someone who does research in nursing, please encourage them to do an intelligent, fact-driven formal assessments of the value of these changes, measuring their real impact. Administrators are inclined by their very personalities to like these changes. Only by documenting that they come with a major downside will this trend be reversed.
Do watch that Chaplin film. It's funny, but also makes its point brilliantly.
We now are expected to modify our patient care work to meet the needs of the documentation system.
Can't like this enough! I also agree with the poster who stated that nurses are becoming "data scribes." Just because you can collect data doesn't mean you should collect that data. How much of what you are forced to chart is really pertinent to your patient's progress? How much of it is even looked at by anyone other than (perhaps) a researcher somewhere or a lawyer trying to prove there was negligence somewhere? When did nurses lose their power to control their own documentation to data miners and the legal system? I'd even question the adage "not documented, not done." Why did we buy into that? Defensive charting is one thing, but in my opinion nursing takes it WAY over the top. Physicians, therapists, dietitians all chart also, but they do not go to the absurd lengths that nursing does. What are we trying to prove? It reminds me of a bunch of kids: "See, Mommy, we did everything you asked of us--it's all written down right here."
I'm not against new technology, but why can't it be made to fit our requirements? Why does nursing always let someone else tell us what to do and how to do it?
Even COBs can have good ideas. Similar to you, I'd love to see these changes.
1. The iPhone's Siri adapted for patient care. Say, "Reminder, 15 minutes, Take blood pressure in 307." And in 15 minutes Siri would say, "Take blood pressure in 307." That's much faster than typing everything into some so-callled nursing app.
2. Know those little Amazon buttons that will order laundry soap for you? Have a similar set of buttons in each patients's room, perhaps on an easily summoned touch screen. Pushing "Vital Signs" would record that a patient's vital signs were taken, with the data being taken from the appropriate device.
3. When I worked in a hospital, my biggest time waster was finding the nurse I worked with. A five-second communication might take a minute of my time, repeated endless through the shift. A quick, touch-a-button, staff-to-staff communication system donned at the start of a shift would save a lot of time. And it would need to be voice. Texting is way too slow.
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Keep in mind a critical distinction. What nursing administrators need for their work is typically a "getting things done" to-do list with priorities and weeks-later due dates.
That adapts poorly to nursing when tracking a task via a to-do list can take longer than the task itself. Also priorities work poorly with patient care. Getting Mrs. Jones a glass of water may not rank high as a priority, but if she asked at 9 am and still hasn't gotten that glass at 11 am, something has gone dreadfully wrong.
Unfortunately, administrators tend to want to force their work-management schemes onto nursing and, as you note, they're typically the tail wagging the dog.
When I got my first job as an RNLP, I was 22, fresh out of college, with a shiny new BSN. I passed Boards, earned the right to drop the LP, and started on my 36 year (and counting) journey. That was in 1979.
I was a bedside Nurse for 26 years, first in Peds, then MedSurg. I had no desire to go into management-mainly because I didn't like any of the people who were lol. I also had no desire to play the hospital politics game.
I realize most newly minted nurses now would probably consider me a failure, since I "only" wanted to do direct patient care, and they are trying to figure out how to get away from actually touching sick people as quickly as possible.
I know that I would not be able to keep up now, not after being away for 10 years. I wouldn't even want to try. The technology doesn't faze me, I love it. But I'm a dinosaur. That doesn't bother me, because over the last 10 years, I found my niche.
I agree with you on a lot of what you said in the above post, though I used part in the quote. So true that the younger nurses (on average) seem to think climbing the ladder and getting out of Med/Surg is the best and least messy option...or something like that. I never had an interest in climbing either. I just wanted to do my job the best that I could and work with people who thought and worked similarly.
Specializes in Psych, Addictions, SOL (Student of Life).
I have been a med surg nurse for 20 plus years. I worked at the same hospital for 20 of those. I was terminated because I simply cannot keep up any longer. I have accepted and learned CPOE. med scanning,computerized charting, etc. BUT...I cannot go completely "paperless" and always chart in "real time" . ( just to mention two out of many gripes). The last year of my employment at this facility that I loved and grew up with, changed administration when 2 new hospitals opened in the area. During that time most of us "older" nurses (highest paid) either mysteriously left or retired early after years of employment, all being replaced by new grads. No offense to new grads, you are very much needed and have been trained in the new ways. I feel like an old dog being kicked to the curb. I am a good, caring nurse. Spent "too much time with my patients". Forgot twice to document if smoking cessation education was given and no flu and pneumonia vaccine status documented. That won't happen again! So what if I was trying to keep my patient from coding trying to get a transfer to ICU all by myself while all the docs and charge nurses and supervisors were at their morning meetings and not responding to pages "in a timely manner" sooooo... I didn't chart or give all my meds in that "timely manner" many times and have been doing the same since I was a new nurse. That is fact and I'm sure many of you will agree you've had to do the same. I guess I just don't know how to be a nurse any longer. Can anyone relate to this? I don't know what to do. I can't retire (lost most of it in the '90's) and had to live off the rest when I lost my job. Its a dog-eat-dog world out there and new nurses are in demand. I am 53 years old and never thought the career of my dreams would end up this way. I do start a new job in a LTC facility next week. Maybe this will work out. I'm too old and poor to go back to school now. My greatest advice to all you new nurses is, hang in there and take good care of me when I need you, and start putting in a lot for your retirement right from the start. I truly have been traumatized to the point I feel incompetent and I know that is not the case.(PTSD) Please help me guys! I need feedback!
I feel your pain,
Hold on to your boots because LTC is a whole new world in the realm of time management and patient care. It's not uncommon for a nurse to be assigned upwards of 20 patients and yes most of the charting is done on computer on your feet. That being said, I love what I do. I am 52 and back in school to get BSN then MSN in Nursing Education then I plan to leave or seriously cut back on bedside nursing and help teach the new generation of nurses.
I am fortunate that I have options. My husband and I are very frugal. We put a lot of money in the bank, live in the house he grew up in (No Mortgage), drive our cars till the wheels fall off etc...." So we have put away a fair amount of savings. Putting together a nest egg is about living responsibly within your means.
Part of the ACA is a mandate that all health care facilities be paperless by the end 0f 2017? so weather you like it or not - if you are staying at the bedside you will have to become computer charting literate. You'll also have to hone your time management skills. There are lot's of tricks built into most computer charting systems. At my facility I discovered a magic button that automatically prioritizes my med pass so they appear on my screen in the order they are due. I can't tell you how much time this has saved. The key in LTC is to work smarter not harder. I still spend quite a bit of time with patients, new hires and students and for the most part get all my charting done on time, But I chart on my feet as I push my med-cart and carry the "Bat Phone" in my pocket so I can call physicians and take their calls w/o running back to the nurses station.
I promise if I am still in patient care and you come to me you will receive excellent, competent and compassionate care.
I'm not joining the pity party. You needed to move on before this got to the point of termination.
LTC is not the answer for anyone who " can't keep up". There are plenty of opportunities, other than bedside, that will utilize and appreciate your many years of nursing.
Start thinking a little bit outside of THAT box... and go find one.
Specializes in Psych, Addictions, SOL (Student of Life).
LTC is not the answer for anyone who " can't keep up".
You absolutely have that right - LTC nursing is brutal sometimes - contrary to popular belief is not a place for washed up slackers! In todays tech savvy world you have to keep up. The saying goes "Lead Follow or get out of the way.'' I am 52 and have worked hard to stay up-to date with changes in health care. The changes are here to stay - so it's time to "suck it up buttercup" quit complaining, put on your big girl/boy panties and get to work.
Please do not feel this way. You are highly valued but administration does not know your worth! I am older than you :) Anyway, I lost my job and went travel nursing. I was very valued!! Young nurses came to me and asked loads of questions. Even MD's. I have a can do personality (sounds like you do as well) and believe that I can accomplish anything. Am I slower? Of course. But I got rave reviews from my older patients. YOU CAN TRAVEL AND YOU WILL BE VERY WELCOMED. There are many of us out there. Think Florida and Arizona in the cold winter months. The pay is better for travelers and you can choose what assignments to accept. Find a buddy to travel with, if you can. I was very lucky. Nurses always rented me their spare bedrooms so I was able to keep my stipend. It is loads of fun!!!! Contact me if you need more info.
3. When I worked in a hospital, my biggest time waster was finding the nurse I worked with. A five-second communication might take a minute of my time, repeated endless through the shift. A quick, touch-a-button, staff-to-staff communication system donned at the start of a shift would save a lot of time. And it would need to be voice. Texting is way too slow.
This exists already. I've seen it in NICUs. They're worn like necklaces and have a big button in the center that you can tap and directly speak into and/or be called on. I really wish I had this at my job so I could locate people.
It's not computer charting. It's the way your facility's computer charting was set up. Computer charting can make or break you, and it really is facility dependent. I have worked with four different EMRs so far, and they are not created equal. Not even close.
It takes a little bit longer to learn your way around Epic because it is complicated, but once you do, the ease of pulling up labs/consults/radiology images/assessments is amazing. Epic is comprehensive and will help your critical thinking instead of hurt it because every piece of information you could possibly need is accessed within two clicks. Our Epic has a task list that is truly a task list - every medication, every nursing task, every lab that needs to be drawn is in ONE place. It makes coordinating your care so much simpler. You can even look at a work list for every single item you have to do for patient you have. You can group your work list by type of task or by time. Vitals that pull over from machines are sitting in the vitals section in gray - you have to file them, but they are visible before you manually file them. Epic has limited space for characters in the comments, so if you are the first describing a wound, you will probably need to write a note because true detailed documentation is not possible in a field's comments. All of the fields that populate every time you add a new wound are daunting and I see more people likely to skip wounds/bruises altogether unless the wound is clinically significant - i.e. huge 10 inch heparin bruise, large pressure ulcer, surgical incision. Small bruises/scaly places are passed on in report but not charted because of the hassle of charting them. We miss a lot of wounds at this facility.
McKesson is also pretty intuitive. McKesson, as my hospital used it, was great for adding in comments on a certain line. I almost never hit the character limit. You could certainly write a paragraph. It was easier to document wounds in, for me, because they would have a different box for each body part and then you could write unlimited comments. R elbow - bruise, R forearm - skin tear.... I would see every single bump and bruise well-documented with ease. The downside was the ER did not use McKesson at all - it was always a wild guess whether a medication was given downstairs or not. We certainly couldn't access their charting. We just had to hope the report we got was accurate because there was no way to verify it, especially if the nurse that had done the patient care when home, and the nurse that brought the patient up didn't know anything about the patient because it wasn't her patient anyway.
Meditech - So easy I learned it in one shift, which was great because I only had one shift of orientation at that job. I did not have places for comments. It was almost too simple - I felt like I couldn't properly chart my assessment because of how dumbed-down the charting was. Another place where you'd have to write extensive nursing notes to cover the holes in the charting.
And lastly, Cerner - the one I hate the most. Very NOT intuitive at my facility. Med task list... nursing task list... separate things, neither have labs. You have to dig through the orders to find the labs. Labs print through an entirely different computer application, so a good way to find out what labs you have is to open that application, but it only tells you what labs are due a couple of hours in advance. You'd literally have to log on every few hours to see what labs are coming up for each patient. Still less confusing than digging through the orders... especially if you have something like a platelet count ordered q3 days and it was ordered weeks ago... how much counting to do to figure out whether it's the day for a platelet count or not is a pain. Each system is assessed on a different "band" currently - so if you finish charting on neuro, you have to save it before you go to respiratory. Respiratory's most recent column has the current time on it. If you want to chart on respiratory at the same time you charted on neuro, you have to add in a whole new column for the time that you did your neuro assessment as it does not pre-populate. Vitals that are done by machines do not show up in a light gray - you just have to click on a column to get the vitals to pull over. If you took more than one BP an hour, and one BP took at a weird time like 2035, you might have to do a lot of clicking to figure out what time that BP took and get it charted. Faster to just go in the room and look on the monitor to see what time it took than to click around on every column until you find it, by far!
Obviously, no one that cares about patients is in charge of any of these because even the best of them have many flaws. What's really insidious is how much these companies charge and how many of them there are. By the time a company has poured millions or billions of dollars into Cerner, it's hard to even think about switching to Epic, even if it is easier and results in increased patient safety because there is no ambiguity about when labs are due. It's easier to just throw the nurse under a bus for missing a lab than to make an expensive change to an EMR.
If facilities REALLY cared about patients in this country, they'd lobby for one national EMR system. Forget just computer charting - that's not good enough. If every facility had the same EMR and the same standards at comparable levels of care, countless patient lives would be saved because there would be no confusion about learning yet ANOTHER way to chart on the computer. A nurse would only have to learn a system once, which would no doubt contribute to nurses succeeding at their jobs as well.
I think what they do to the older nurses is such b.s. They pick out a few minor mistakes to find an excuse to can them so they can pay an inexperienced new grad less money to makw twice the amount of mistakes that the experienced nurses are making. On my rotation there are a lack of experienced nurses and it shows. It will bite them in the butt in the long run. You don't deserve this and you are not incompetent!!!!!
HouTx, BSN, MSN, EdD
9,051 Posts
OK - Full disclosure.. I am definitely a COB (crusty old bat). We're in this pickle because we have allowed the tail to wag the dog.
I am not computer phobic.... heck, I taught myself to program back when personal pcs were just a pipedream. I love all things tech - especially all those lovely "machines that go bing" (tribute to Monty Python's The Meaning of Life).... but somewhere along the way, clinical folks lost influence & clinical systems have been designed by people without any insight as to how patient care actually takes place. We now are expected to modify our patient care work to meet the needs of the documentation system. This is nuts.
If the system was designed more logically, nurses wouldn't be doing manual documentation at all - we'd have mechanisms in place to accurately capture patient interactions, nurses could simply dictate as they performed the work, carefully placed cameras would help capture assessment findings, interventions and such.
Hey, a COB can dream, right? It could happen.... after all, in 1976, no one even dreamed that we'd all be carrying powerful computers capable of wireless communication around in our pockets.