nurse call response times in Ontario hospitals

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Hello, all. To introduce myself, I am not a nurse; rather, I am the son of an elderly patient - my father - currently in hospital in Mississauga, ON. In fact, I am writing this from his bedside.

My father, 84, is suffering from renal failure and also has severe dementia and has been plagued with both for many years now. My mother, 77, has cared for him at home all this time. It has been a very rough road for a very long time, but with tremendous care from my mother and his doctor, he has - sadly in a very real way - persevered. That said, his doctor explained that should he ever need to go to the hospital again, there would not be much he could do, going so far as to recommend getting a DNR form registered. We agreed as a family and my mother has done so.

He is now in hospital since last Tuesday as he had experienced a severe increase in fatigue to the point where couldn't walk. The ER doctors explained that his creatinine level was 500 - very high. What we thought was just a rash from diapers turns out to shingles. They confirmed everything we had already established about not treating him any further and that we are looking a palliative situation. They were quite compassionate and we all prepared for the end. We were told we would be admitted and they would do everything possible to keep him comfortable. In a way, this was very much a relief as my mother was at the end of her rope and unable to care for him any more. That's when things went south.

Without getting into too many sordid details, the net result is that the care we have received since being admitted feels woefully inadequate. We have been in the hospital a few times before, so we understand the disjointed nature of the doctor-nurse-hospital relationship, but this round has been the worst.

First, we were never advised that the shingles outbreak would warrant isolation. The first night nurse saw the chart and went into a frenzy installing a HEPA filter in the room and getting everyone into gowns and masks.

The next day, this man who has no gas in the tank still has the werewithal to want to relieve himself in the bathroom. We - my mother, brother, and myself - don't know what to do, so we try and get him there using a comode chair. We're successful a couple of times, but one time not. Mess on the floor. Nurse calls are usually answered immediatly, but no one actually shows up for several minutes - usually well over 10 or 15 - while my dad is sitting in, and staring at, his own feces. Nurses walk into the room asking us what supplies we have. Gowns, masks, diapers - nothing's ready.

Later that day, after talking to a palliative care doctor and going through this conversation again, we were transferred to a negative pressure room. Again, supplies are constantly lacking. At one point, again after a bathroom call, I see the nurse running around looking for a fresh night gown and bed pad. No bed pad - using another night gown instead. Wait times have gone through the roof. Usually 30 minutes or more now.

My father has been issued sedatives to sleep at night so he doesn't try to get up on his own. My mother being my mother, is sleeping with him in his room every night. First room had a spot to lay down, new room does not - we brought in our own cot. Nevertheless, last night, my mom did not notice my had had gotten himself up and halfway to the bathroom. Thankfully she got to him just in time to catch his fall. No time to ring the nurse. After she finally situated him so she could call, it took more minutes than I would expect to respond - 5 or more, as I understand. What would have happened had she not been here? He's behind double doors as it is, then stuck in the bathroom to boot with no comprehesion that he's even in a hospital. When my mother raised the notion of a bed alarm, they told her there were none available. I may well spend the night tonight for fear of another fall.

As for nurse compassion, it's up and down, but mostly down. We've had really great and compassionate nurses at times - they are angels that make a world of difference. We haven't really had that this time, and most just don't care at all. We had one nurse who I guess just assumed my dad was deaf because he's old and literally yelled at him while he's half out of it. It startled the hell out of him and he yelled back at her. It's a revolving door of nurses here - usually no more than 2 days in a row with the same nurse and we are always starting from scratch trying to explain the situation and my dad's needs.

All this is to say nothing of the unbelievable lack of cleanliness throughout the public areas of the hospital - gobs of dust everywhere, blood on the walls in the bathroom (something I immediately brought to someone's attention, only to find it cleaned over 24 hours later), and on and on. This whole situation is feeling a little sureal. But I digress.

I apologise - too many sordid details after all!

Back to my primary question. Compassion and supply issues aside, what can/should I expect for nurse response times in a hospital in Ontario? Should it matter if the patient is in isolation? I intend to bring the whole situation up with patient relations - at the suggestion of one of the doctors, and I know I can't change the world overnight, but I would at least like to get an idea of what I should be expecting. If nothing else, to ease my and my family's own minds.

Any insight is appreciated and if you have bothered to read this far, my gratitude for allowing me a chance to vent a little.

I think that so many of us would completely agree with you - nurses cant do it all, and unfortunately they are sometimes expected to. Important things end up being put off because there simply is no way to manage it all. Unfortunately, when this happens, its the patients and families who lose most. :(

Amen! I realize the OP is upset and looking for answers, perhaps even someone to blame for the frustration the OP feels... that is a natural emotional reaction to what the OP is going through. However, what the OP is encountering is a complex systems issue... not specifically a Nursing issue. So, it is not accurate nor productive to point the finger at Nurses to blame for this situation because believe me, there isn't a single Nurse who wouldn't love to be able to give more to every single one of their patients... it's just not a realistic expectation. The health of the care-giver, (i.e. Nurses) is not seen as important as the health of the care-receiver -- this is the flaw with the Ontario healthcare system. We are worked to the core, with oftentimes inadequate supplies and little support until we have little left to give. The rate of burnout, compassion fatigue and the misery index among Nurses is at an all time high. At the end of the day Nurses are human, and humans wear down over time in conditions like this. Having said that, I am NOT saying that it is ok... I am saying Nurses are not the reason for all of these issues the OP is encountering. The healthcare delivery system is flawed and its making its front-line workers sick, and patients like the OP's father are suffering for it... and for that I am truly saddened.

I'd love to mainly focus on my patients and not have to spend time on things like, sorting and rationing linens, for instance. Unfortunately, there's usually no one else to take care of these things because of "budget cuts". So, this duty gets added onto the ever growing list of non-nursing duties we Nurses are expected to do. So, if the Nurse doesn't pay attention (to both meds and linens... everything else), she/he will end up with a dozen incontinent patients with no bed sheets, no towels to bed bathe them, etc etc and more angry patients and angry, upset families who are mad at Nurses for things that are out of the Nurses control but Nurses are expected to fix... and I understand why they're angry at us Nurses because Nurses are the only ones who are ever around.

Patient's and they're families should not have to deal with all this nonsense. It's just sad all around.

I also work in Canada and I am sorry about what you are going through. 30 minute wait is a bit too much I think.. In BC we work very understaffed as well (I have 5 patients with barely any care aids/psw) on the floor, but when one of us goes on break, the other nurse has to answer the call bells. It is our duty. Regarding the linen, our patient families just ask any one of us in the front and take as much as they can.. It's ok to, even with the patients, as long as they ask.

With the call bell, the lack of bed alarms and the break issue bring it up to the person in charge. With isolation, they are trying to do the best to make sure the other patients are safe as well and it is not to compensate the comfort of your husband.. Hope you can find better support. Being in a palliative hospice setting or a bigger hospital with a palliative unit might be the best option for you family. A regular medical unit is by no means the right place for a pallative patient to be and stay comfortably. It is more catered to other patients and especially with dementia, hospice can make the workload of a unit extremely hard to cope for nurses especially when they are short. You need to be in a better adequately staffed place to suit your needs. Ask to meet with the social worker to get sorted on placement asap

It depends on where a person is but unlike the USA, there are almost no cna working in a unit and where I am, we take care of 4-5 patients each with only 1 caregiver/CNA/nursing assistant for the entire floor of 30-40 patients..I barely have time to sit for 5 minutes when I work a day shift. The other issue is that a RN might be working with LPN who cannot give any IV meds, in that case the RN has to give meds to not only her 5 patient assignment but also 2-3 of the LPN's patient, and if the LPN's patient goes sour the RN has to switch the patient with one of her easier assignments as well. I worked in both Canada and the USA and graduated from the USA but the workload in Canadian nursing is very high and also to the point of being ridiculous... I do try to answer all and my other nurse's call bells when they're on break and with the continuous incontinent pad changes, boosting people up and feed patients at the same time my meds always are behind fairly quick... but 15 minutes really go fast when you have so many patients needing help at the same time.. I always feel guilty for asking family members to wait because I have a lot of pressing issues to deal with at that moment.

I agree with you, there are circumstances where it's not appropriate but it also depends on stage of dementia. Also, I'm not defending that specific question.. I am talking about gauging questions. You'd be surprised... OK but let's exercise some common sense here, questions like this one are used as gauging questions. They are not asked specifically for the purpose of ascertaining whether a dementia patient literally knows what year it is.

For example, questions like this are often used when an elderly patient with Dementia is suspected to have a UTI so and R&M/C&S can be done to confirm and initiate appropriate treatment as this pt population does not always present with "classic" symptoms of UTI. Delirium is oftentimes the most common symptom of UTI in this pt population. Symptoms of delirium can range from agitation and restlessness to hallucinations or delusions. Asking gauging questions, or closed-ended question, and a variety of other communication techniques helps us to differentiate "dementia symptoms" from "symptoms of infection" etc...

While this is true, asking patients if they know who they are or where they are, when they have a history of not knowing (which was the OP's specific complaint), is not going to assist in the assessment of a UTI. Assessment of restlessness, agitation, behavior changes, grimacing when voiding (if unable to communicate pain), cloudy foul-smelling urine, etc are better indicators in this particular client type.

In the absence of any of these associated symptoms, disorientation to time and place will only confirm the existing diagnosis of end-stage dementia.

We need to stop thinking of patients as algorithms and checkbox items. This is where nursing judgment comes in.

While this is true, asking patients if they know who they are or where they are, when they have a history of not knowing (which was the OP's specific complaint), is not going to assist in the assessment of a UTI. Assessment of restlessness, agitation, behavior changes, grimacing when voiding (if unable to communicate pain), cloudy foul-smelling urine, etc are better indicators in this particular client type.

In the absence of any of these associated symptoms, disorientation to time and place will only confirm the existing diagnosis of end-stage dementia.

We need to stop thinking of patients as algorithms and checkbox items. This is where nursing judgment comes in.

Does the OPs father have end-stage dementia? If I missed that detail then the fault's on me. Sorry.

Also, it was meant as a generalized example to save me from having to overflow with details. I'm not speaking specifically of UTIs, clearly my attempts to add explanation have only added miscommunication as I didn't realize it would be taken literally. And NO I do not think of patients "as algorithms and checkbox items" (I've noticed you've flung that at a bunch of nurses who have commented on this forum) thank you very much ;). I am familiar with associated symptoms, I was not born yesterday. Your comments to me and to others have bordered on condescending, but i'll find entertainment in it - thanks!

This is a dead horse now.

Does the OPs father have end-stage dementia? If I missed that detail then the fault's on me. Sorry.

Also, it was meant as a generalized example to save me from having to overflow with details. I'm not speaking specifically of UTIs, clearly my attempts to add explanation have only added miscommunication as I didn't realize it would be taken literally. And NO I do not think of patients "as algorithms and checkbox items" (I've noticed you've flung that at a bunch of nurses who have commented on this forum) thank you very much ;). I am familiar with associated symptoms, I was not born yesterday. Your comments to me and to others have bordered on condescending, but i'll find entertainment in it - thanks!

This is a dead horse now.

You're right, I'm sorry. I participated in beating a dead horse. Apologies.

Specializes in PCCN.

I just want to say, I think op was genuinly wondering why things were the way they were, as far as how thing run in an acute care hospital.

And he and his family are embarking on that journey , which he has never been on , and looking for guidance.

I understand wanting to know the whys if I was in that situation too- many people dont know the why's of isolation, the whys of advanced dementia, and the process of not treating anymore.

It is our job to educate. I imagine after that, then I could understand the frustration of repeating ourselves.

Sorry OP wishing you ease on this journey.

also, interesting that it sounds like things in Canada are very similar to things in US as far as staffing being taken away, etc.I always thought things were better "up there"

Hello all again, and again, thank you for the continued interest and input.

As an update, I must say that our nursing situation specifically has improved over the last couple of days. I have to give some credit to the insight and support from this thread for allowing me to vent, receive some sympathy and support, and also for giving me a better appreciation for what is going on outside my door.

There are other factors, too, not the least of which is that the immediate fears from the first couple of days have subsided and we are all a little clearer of mind. My dad has also settled into a groove of a sort. I'm sure being on a sedative (Haldol (sp?)) is helping there. I am taking the night shift now and my mom has spent the last two nights at home.

With this more calm state, I am making more of an effort to connect with our nurses to make sure my dad's condition is known, explain why someone's here all the time, and that the only calls would likely just be bathroom calls. Plus just simple stuff like exchanging names and offering to get a coffee.

All that means that our perspective is now a little more balanced and our needs not quite so immediate. Still, the nursing care itself is markedly better. The staff of the last couple of days are just generally more calm and compassionate and nurse calls are being responded to within minutes since last night.

Further to some of the more recent comments made, I was actually thinking about a few of those points myself today. Most prominently is the appropriateness of where we are right now given his condition. The suggestions of palliative and hospice care are very relevant, but we have been advised that they cannot direct us anywhere until they get a better handle on where he's headed. A blood sample was taken this morning, but no results yet. The isolation is strictly a consequence of the shingles. There simply is no specialized care - that I'm aware of - for dementia patients. So, the fact remains that he has just enough strength to get up and thinks he can walk to the bathroom. Doesn't know he can't, let alone that he's in a hospital. And so we are here by his side at the hospital for the time being. This speaks in part to our feeling at the mercy of the system. Note that we have only had the one visit from the palliative doctor on day 1 and 1 visit from the new renal doctor on Sat. when she took over the rotation. I did ask the nurse this morning if she knew whether we could expect a visit. All she could tell me is that a visit is in the file, but no specifics as to when. Perhaps we need to start being more proactive with the powers that be - CCAC, etc. It must be noted though that we are not new to the machine. My mom has been trying to navigate this system for years, dealing with CCAC (for the non-Ontario readers, that is the Community Care Access Centre), other hospital stays, and the like. This is the nature of public health care - there is not much control.

On the matters of his placement and current support needs, the nature of this situation - i.e. that he will absolutely fall if not constantly monitored (or heavily sedated) - still appears to not be understood, or at least appreciated. This I still don't get, particularly given that he is in isolation. As happy as I am for the improved care these last couple of days, there still has been absolutly no acknowledgement of our role here. (Save for the tech who came to take blood today; she was super gentle, compassionate, and spoke to both my dad and me, acknowledging the importance of our being here.) I still feel like no one, other than that tech, understands why we are here. For all of the overload being referred to here, I would have expected that our presence would be welcome.

Nevertheless, getting back to the original topic, if I may be so presumptuous as to offer the perspective of a lay person, I think the nurse response time issue can be boiled down to a few key points, with the concepts of communication and compassion pertaining throughout.

- setting expectations: I think this is very important right up front at the time of admission; what is clear from this discussion is that response times will vary by hospital, ward, and even by shift, as well as why you are calling; giving a new patient (and their caregivers) an outline of what to expect will go a long way to aleviating stress and frustration; I don't think a nurse necessarily needs to take on this task, but I think someone should - even a brochure would help, albeit a little cold; this is also a 2-way street where patients and/or their families can lay out circumstances - such as in our case - that may require special attention

- help us help you: as in our case, nurses can advise us as to how best we can help you help the patient; this is case-by-case, of course, but if the caregivers are willing and able as we are, then by all means, tell me where I can hunt for supplies so you don't have to; I know this is not always an option and perhaps we are atypical in this regard, but when it is here, take advantage of it; on this point, is there a liability line that needs to be considered? particularly as it pertains to, say, helping my dad to the bathroom? it should be noted that as his son, it is taking a bit to wrap my head around seeing his "junk" and dealing with diapers; understanding that and trying to show me how it's done might help cut down on bathroom calls, but is it legally appropriate in the hospital? still, during the first couple of days when we were waiting anywhere from 30 to 60 minutes, it becomes a trial-by-poopy-fire situation

- fix the system: no easy answers here, but if we here in Ontario are going to make nurses the core of support for all things hospital related, taking "it" from patients, doctors, auditors, administrators, etc., then they need more non-nursing support, plain and simple; otherwise, things need to be restructured dramatically, but I will leave that to smarter people than me

Well, there you go. Someone oughta fire off this thread to the Ontario Health Minister and call the media. We can watch them ignore it all.

Thanks all again for the continued input. Perhaps together we can make things a little better here and there.

Specializes in Acute Care, Rehab, Palliative.

I generally try to discourage family members from toileting the patient themselves. Knowing how to safely transfer is important and I would rather that trained staff do it. Also you have to recognize that eventually getting him up will no longer be a safe option and changing his brief after he is incontinent will be better.

It would be difficult for anyone to give you a hard and fast timeline for having a bell answered . If it takes some time that is because we are busy.

Fixing the system would be great. It's not a lack of funding. It's that the huge salaries of the LHIN and hospital managers eats it up.

Specializes in Educator.

Thank you for your well thought out response. I agree with loriangel14 that there is a liability issue when family is involved with toileting but I completely understand your dilemma. Do I wait for the nurse and then the messy consequences if they don't respond in time? But on the other hand you risk injury to the patient and/or yourself if you are not careful.

You have witnessed some of the dirty secrets of healthcare, I wish there was an easy fix but we all know that is not the case.

Thank you for your well thought out response. I agree with loriangel14 that there is a liability issue when family is involved with toileting but I completely understand your dilemma. Do I wait for the nurse and then the messy consequences if they don't respond in time? But on the other hand you risk injury to the patient and/or yourself if you are not careful.

You have witnessed some of the dirty secrets of healthcare, I wish there was an easy fix but we all know that is not the case.

I AGREE 100%. It is a total patient safety and liability issue. We have had a few patients experience falls, and serious fall-related injuries (ex. hip fracture, concussion) because, although "well intentioned" (even after rigorous education/family conferences), their respective family members were trying to be involved in the patient's care in ways that were NOT appropriate (this was always done while the nurse was not available, tending to another patient). Those same families always tried to blame the Nurses rather than taking accountability for their responsibilities. We Nurses see so many messy things, and often have to try to "clean up messes (incld. pt injuries caused by non-compliance/family)" because of family dynamics... but we're always treated like "the patsy".

Specializes in Acute Care, Rehab, Palliative.

Yes and the OP has to realize that getting the patient up eventually isn't the best option.

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