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Is it like this everywhere now?

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by Forest2 Forest2 (Member)

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Look medicine, despite what anyone may wish to believe, is a business in the USA, not a calling. As such there is the great economic principle that I like to describe to point out why we (doctors, NPs, RNs, CNAs, etc.) are so screwed. It is called the project management triangle. There are 3 sides that consists of quality, cost, and time. The manager/employer can manipulate any one of the 3 sides to obtain whatever goal they are trying to achieve, but changing one constraint requires changes in the other 2 to remain a whole product. So in theory if you require something of high quality in a short amount of time, the cost to make it will have to increase. If you want a low cost with a good quality the time to produce it will have to increase.    But here’s the thing about medicine Medicare and Insurance companies set the cost for most medical services, not the providers. The quality is also mandated to a great extent by the law. So 2 sides of the triangle are set by outside entities, thus the only thing institutions can manipulate to maintain a profit is the amount of time we are allowed to preform the services. And thus you have the stupid, unattainable expectations we do today.

 

 

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On 6/11/2019 at 1:31 PM, Forest2 said:

Patients AND nurses die from clicks.  I wonder what it is like to work in a less advanced county that is not so sickly complicated.  I wonder when the peak of nursing was?  1960's?, anybody? I am a bit envious of nurses who retired in say, 1980.

I don't know when the peak was, but I graduated in 1991 and I loved it for 15 years. It started gradually becoming more intolerable where I work after about 2006 or so. I have to say, though, as bad as it is - where I work is far better than a lot of other places like the corporate owned hospitals. (I work at a smallish nonprofit community hospital).

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SmilingBluEyes has 20 years experience.

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On 6/11/2019 at 3:14 PM, OUxPhys said:

Ive heard stories like that from older nurses at my previous job. They said the patients weren't as sick and there wasn't all the redundant charting. They also had the weekender program and they had better shift diffs.

The "older" nurses are right. Patients are sicker, older, more obese, needing increased  lifting/shifting,  and require more resources that sadly,  are not sufficient---- than ever before.  Double and triple charting is much more frequent.  The adage, "death by a thousand clicks" is more than an adage, it's for real. Admin focuses on minutiae rather than  on real issues and needs of a complex patient population and pinching pennies costing dollars later.

 

It's getting worse and the Baby Boom generation is just getting started.  Give it about 10 or 15 years, and the population we care for will be ever more complex.  All while nurses, too, are getting older and more tired of the BS.

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MunoRN has 10 years experience as a RN and specializes in Critical Care.

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On ‎6‎/‎11‎/‎2019 at 1:31 PM, Forest2 said:

Patients AND nurses die from clicks.  I wonder what it is like to work in a less advanced county that is not so sickly complicated.  I wonder when the peak of nursing was?  1960's?, anybody? I am a bit envious of nurses who retired in say, 1980.

I'd pinpoint when it all went to *** as being 2008 or thereabouts.  

Prior to that, nursing management followed the same basic standards as other fields that required intensive management of time demands, this was done with 'time-studies'.  The basic idea was that if you x-number of things that absolutely had to get done, then as a manager you could only expect that to get done if thorough and exhaustive time-studies showed that enough time was being provided to complete these objectives.  This required compiling exactly how long various tasks took in various circumstances.  If you wanted to add a task that takes 10 minutes, then you had to find 10 minutes of tasks to cut.  Otherwise, it would be considered ridiculous to expect 9 hours of work to be done in 8 hours.

Prior to 2000 or so, this was done with staff with stopwatches and clipboards.  Then it started to transition to electronic real-time tracking, this was originally a big selling point to transitioning to EMRs.  This was a device I used at one facility: https://www.rapidmodeling.com/time-study-software

At some point around 2008 nursing managers as a whole abandoned the idea of time-studies, which opened the flood gates to adding more and more tasks without any thought as to how much workload nurses now had.  So now we're in the position of doing 12 hours worth of work in 8 hours and yet getting told we should have done 16 hours worth of work.

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Glycerine82 has 3 years experience as a LPN and specializes in Subacute rehab, geriatric.

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On 5/26/2019 at 6:44 AM, panurse9999 said:

 We spend more time checking boxes to generate revenue, than we spend at the bedside,

THIS.  

This is by far what I hate.  I can be absolutely over-loaded with a med pass, treatments, addressing labs, addressing acute issues, etc. and then to top it all off I have a boat load of documenting that NO ONE ACTUALLY NEEDS. The doctor doesn't look at it, my colleagues don't look at it, it's literally for nothing. Well, not nothing.  It's for insurance. 

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On 6/16/2019 at 11:34 AM, SmilingBluEyes said:

The "older" nurses are right. Patients are sicker, older, more obese, needing increased  lifting/shifting,  and require more resources that sadly,  are not sufficient---- than ever before.  Double and triple charting is much more frequent.  The adage, "death by a thousand clicks" is more than an adage, it's for real. Admin focuses on minutiae rather than  on real issues and needs of a complex patient population and pinching pennies costing dollars later.

 

It's getting worse and the Baby Boom generation is just getting started.  Give it about 10 or 15 years, and the population we care for will be ever more complex.  All while nurses, too, are getting older and more tired of the BS.

The kind of care dealt out in hospitals now is scary.  We didn't care for people in the 1980's like they do today.  We actually provided real care and attention back then( I am generalizing so don't get all out of sorts).  Now it is all about money and the perception of care.  A popularity contest.

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TitaniumPlates has 15 years experience and specializes in ED.

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On 6/16/2019 at 4:24 PM, MunoRN said:

I'd pinpoint when it all went to *** as being 2008 or thereabouts.  

Prior to that, nursing management followed the same basic standards as other fields that required intensive management of time demands, this was done with 'time-studies'.  The basic idea was that if you x-number of things that absolutely had to get done, then as a manager you could only expect that to get done if thorough and exhaustive time-studies showed that enough time was being provided to complete these objectives.  This required compiling exactly how long various tasks took in various circumstances.  If you wanted to add a task that takes 10 minutes, then you had to find 10 minutes of tasks to cut.  Otherwise, it would be considered ridiculous to expect 9 hours of work to be done in 8 hours.

Prior to 2000 or so, this was done with staff with stopwatches and clipboards.  Then it started to transition to electronic real-time tracking, this was originally a big selling point to transitioning to EMRs.  This was a device I used at one facility: https://www.rapidmodeling.com/time-study-software

At some point around 2008 nursing managers as a whole abandoned the idea of time-studies, which opened the flood gates to adding more and more tasks without any thought as to how much workload nurses now had.  So now we're in the position of doing 12 hours worth of work in 8 hours and yet getting told we should have done 16 hours worth of work.

Agreed.  The EMRs are also "glorified cash registers". 

We're being tasked, along with physicians and technologists---to bill for the hospital for every "recoverable" charge.

So we aren't just doing nursing---we're doing billing. It's why there have to be certain things done at completely irrational intervals---such as "hourly rounding", "hourly VS" (when not an ICU patient) and such---because those items qualify the patient for ICU charging.

I have heard my pals in ICU talk about how the patients meet zero criteria for being in that unit---and the doctor's admit it---because the patient has great insurance and they can bill at a higher rate for those stays.

I've discharged in record time---patients on capped insurance, such as Medicare or the uninsured. I mean---patients that I worried wouldn't make it to their car. But we admit routinely---patients that "need watching" because nobody can quite figure out the origin of their 12 year long belly ache, with an ETOH and narcotic addiction---but superlative insurance coverage.

I'm done being a cashier. If I wanted to do that, I'd go work for 7-11 and have some time for my family---and 7-11 is actually safer than being  a nurse!!!

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OUxPhys has 4 years experience as a BSN, RN and specializes in Cardiology.

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10 minutes ago, TitaniumPlates said:

Agreed.  The EMRs are also "glorified cash registers". 

We're being tasked, along with physicians and technologists---to bill for the hospital for every "recoverable" charge.

So we aren't just doing nursing---we're doing billing. It's why there have to be certain things done at completely irrational intervals---such as "hourly rounding", "hourly VS" (when not an ICU patient) and such---because those items qualify the patient for ICU charging.

I have heard my pals in ICU talk about how the patients meet zero criteria for being in that unit---and the doctor's admit it---because the patient has great insurance and they can bill at a higher rate for those stays.

I've discharged in record time---patients on capped insurance, such as Medicare or the uninsured. I mean---patients that I worried wouldn't make it to their car. But we admit routinely---patients that "need watching" because nobody can quite figure out the origin of their 12 year long belly ache, with an ETOH and narcotic addiction---but superlative insurance coverage.

I'm done being a cashier. If I wanted to do that, I'd go work for 7-11 and have some time for my family---and 7-11 is actually safer than being  a nurse!!!

I worked at a place that would nickel and dime patients for everything. If they needed anything we would have to look them up in the system, find what we needed and press the button underneath it. I refused to do this, just took it out as “floor stock”.

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TitaniumPlates has 15 years experience and specializes in ED.

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^^^This.

Unfortunately, when it came down to brass tacks and I would do stuff like that---taking items out of the omnicell and not pressing the button---we would get nastygrams that really just threatened us with layoffs or firings.

A place I worked had a "free stock" room---NS/LR and primary tubing (in an ER the size of mine, you use those items like---drum roll---water!)---and THOSE things were placed into the omnicell and you had to pull them under the patient's name! 

In EPIC, we were told that we had to "start and finish" a litre of NS....or they wouldn't get paid. We were told we had to document every single step of d/c-ing an IV, including discharge information of what to do  if the site started to bleed. I did that verbally every time anyway---but we had to write an actual NOTE to say that we did this "education"---or, according to them, they would not be paid for the IV at all.

I have no idea what the truth is behind some of these claims--whether it's someone shoving their work onto us--I know that once some of my compatriots got into the "back office"---all they did was study and do their work for their Master's or DNP---and sent out memos to staff that portions of their work was now to be performed by us.

So---OP----YES. It is like this "everywhere" now. It's a business and it's one of the last bastions of profit for stockholders---medical supplies, medical procedures/imaging (I used to have an ER doc that would order an "abdomen series" on EVERY SINGLE PATIENT, no matter what the chief complaint was. This is $1200 worth of imaging that the radiology group could separately bill for.), and all of the trappings.

I still laugh at the memos that come down that we "have 3 flushes per patient" or "no more rainbow pulls you must wait for actual orders to pull blood"---in an emergent situation which can be anything in the ER, anytime---that is ludicrous. It finally got to the point that we were forced to put together "kits" that were only allowed to be in the room when a patient was in the bed. Nothing else could be in the room. At all. The claim was that bedside carts are full of infectious diseases and that the patients "routinely  steal needles"....there was never any evidence of either claim.

I do what I want now. I pull a rainbow and waste the remainder if I don't need it. I grab all of my supplies each hour or so and put them in my fanny pack that I now use on shift. I hoard flushes in my cargo pockets and make noise when I walk. I stick bottles of glucostrips in my pockets, along with bottles of insulin (we were told that they must be multiuse vials and can only be drawn up in the med room and returned to the pyxis. Nope.)  I have stashes everywhere in the unit that make it easier for me to not have to go and spend 15 minutes + 2000 steps each time I miss an IV.

I think what the main problem really is---is that some nurses actually try to accomplish these things without any workaround. I get following rules. It DOES NOT make me a Bad Nurse because I hoard flushes.

All done with these hoops.

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OUxPhys has 4 years experience as a BSN, RN and specializes in Cardiology.

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11 minutes ago, TitaniumPlates said:

^^^This.

Unfortunately, when it came down to brass tacks and I would do stuff like that---taking items out of the omnicell and not pressing the button---we would get nastygrams that really just threatened us with layoffs or firings.

A place I worked had a "free stock" room---NS/LR and primary tubing (in an ER the size of mine, you use those items like---drum roll---water!)---and THOSE things were placed into the omnicell and you had to pull them under the patient's name! 

In EPIC, we were told that we had to "start and finish" a litre of NS....or they wouldn't get paid. We were told we had to document every single step of d/c-ing an IV, including discharge information of what to do  if the site started to bleed. I did that verbally every time anyway---but we had to write an actual NOTE to say that we did this "education"---or, according to them, they would not be paid for the IV at all.

I have no idea what the truth is behind some of these claims--whether it's someone shoving their work onto us--I know that once some of my compatriots got into the "back office"---all they did was study and do their work for their Master's or DNP---and sent out memos to staff that portions of their work was now to be performed by us.

So---OP----YES. It is like this "everywhere" now. It's a business and it's one of the last bastions of profit for stockholders---medical supplies, medical procedures/imaging (I used to have an ER doc that would order an "abdomen series" on EVERY SINGLE PATIENT, no matter what the chief complaint was. This is $1200 worth of imaging that the radiology group could separately bill for.), and all of the trappings.

I still laugh at the memos that come down that we "have 3 flushes per patient" or "no more rainbow pulls you must wait for actual orders to pull blood"---in an emergent situation which can be anything in the ER, anytime---that is ludicrous. It finally got to the point that we were forced to put together "kits" that were only allowed to be in the room when a patient was in the bed. Nothing else could be in the room. At all. The claim was that bedside carts are full of infectious diseases and that the patients "routinely  steal needles"....there was never any evidence of either claim.

I do what I want now. I pull a rainbow and waste the remainder if I don't need it. I grab all of my supplies each hour or so and put them in my fanny pack that I now use on shift. I hoard flushes in my cargo pockets and make noise when I walk. I stick bottles of glucostrips in my pockets, along with bottles of insulin (we were told that they must be multiuse vials and can only be drawn up in the med room and returned to the pyxis. Nope.)  I have stashes everywhere in the unit that make it easier for me to not have to go and spend 15 minutes + 2000 steps each time I miss an IV.

I think what the main problem really is---is that some nurses actually try to accomplish these things without any workaround. I get following rules. It DOES NOT make me a Bad Nurse because I hoard flushes.

All done with these hoops.

We would get nastygrams every few months as well basically saying it “effects our reimbursement” blah blah blah. It sounds like our med room/utility room was set up the exact same! EVERYTHING was in the omnicell except for medications. It was ridiculous. 

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So much craziness, like KY jelly locked up in the accudose.  Like I'm going to steal this stuff??!!  You get to the point, you don't have time for that nonsense, just open the thing and grab what you need.  I am not wasting supplies or time, I get what I need.  

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