Unit is Total Chaos

  1. Dear Nurse Beth,

    I currently work for a privately owned community hospital at a combined ICU of 26 beds.

    JCO came by on December 2017 and we were told that we failed their audit due to charting.

    JCO returned on May, and we failed again due to the same exact reason. Now, the unit is struggling to keep an intensivist MD and they keep sending us out of towners who sometimes call a "mayday" and leave b/c they're afraid to lose their MD license. Basically the unit is a total chaos, we are charting on three different areas. We have the computer system that doesn't communicate with the monitors (hr, rr, bp, spo2, Cvc/art line, balloon pump machine, ccrt machine, etc), so we have to manually validate q15 min or more often depending on MD orders.

    We also have a hourly flow-sheet where we have to write down every single monitoring vital from the monitor (which has already been validated on the computer chart), plus drip rates on prescribed metric system and ml/hr conversions hourly, plus we also have to document our assessment findings on this flow sheet (even though we've already documented on the computer system). Then, each drip has a perspective paper log that we're supposed to do as well. That's because our computer system doesn't communicate with the pumps, or the medication profiles system.

    Then, we have a separate area in the computer system for intake and output where we manually total out the intake and the output because nothing crosses over unless it's entered by the RN.


    The charge nurse's duties include auditing Foley's, central lines, medication compliance, ventilator management, plus all the mentioned charting, hourly per shift.

    The temp-director informed us that we are now responsible for auditing each-other in a written two page document that may take up to 2 hours to complete. This is in addition to all the paper and computer charting we're already doing. Staff is calling in sick on a daily basis, RNs are also leaving at least one per month. Everyone is constantly coming in late and staying up to two hours after their shift to meet the charting requirements.

    Staff is at each other's necks, I've been threatened by another RN of getting punched in the mouth over a computer while I was trying to catch up with my charting after my shift.

    I'm worried about my license, and most importantly I'm worried about my patients safety! We're up to our necks with triple charting, it's killing us. Everyone is on edge, we don't even have a secretary, no nursing techs, we don't even have the basic supplies most of the time like flushes, IV tubing, printers don't work, only a few computers can print. And, AOS gives us <30 min to transfer out a patient who has an assigned room, regardless of my other patient's condition. We have a two patient assignment, but lately with all these staff call ins we've been tripled.

    It's a nightmare because I'm under contract and it doesn't expire until Jan of 2019! What should I do?
    I feel like calling out safe harbor every single shift!
    Most of my medications are not at the unit, the narcotics are in a locked box inside a locked box for which we have to get a key for, the key is sometimes at the pixies at the total opposite side of the unit. Then we have 15min to return the key, and scan the medication at the bedside that's if the scanner and computer at the bedside even works!

    It's a nightmare! I'm losing sleep, I've been having patients that have critical symptoms that the previous nurses have missed. I'm starting to feel chest pains, my anxiety it's at an all time high, I can't hardly sleep the night before my shift, I've developed anorexia nervousa and I've lost about 15lbs in the past 2 months. Every morning before my shift I feel nauseous and throw up everything, even water! I'm a single mom, new nurse barely 22 months in practice. Any advice from you would be greatly appreciated. I'm beyond tears, I feel like I'm in a panic state all the time. On my days off I review content regarding critical care. It's the only thing that helps to lessen my anxiety.
    Thanks for your time!

    Dear Panicked,

    Some of the things you list are serious and some are common aggravations. In many units not all computers link to a printer, the narc keys are in the Pyxis, meds have not been delivered by Pharmacy, and not all devices interface. If you worked previously in a unit where infusion pumps interfaced to the computer, it's hard to go backwards.

    Some of this is "reality shock", but it sounds like most of the pressure you are experiencing is due to the failed JC surveys combined with lack of nursing leadership. They are frantically operating out of fear and and that never works well. With revolving intensivists, temporary nursing leaders, high turnover, no help and lack of supplies, you are operating in chaos.

    The biggest concern is your health. Your body is talking to you. If it's impossible for you to cope in this unit, you have to get out. See a doctor as soon as you can and use the Employee Assistance program for counseling if they have one. Short-term counseling helps with reality-checking and finding some short-term coping mechanisms.

    Breaking a contract can have ramifications, but this is costing you your health and putting your practice at risk. Whatever decision you make, your health has to come first.

    Best wishes,

    Nurse Beth
    Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!
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    About Nurse Beth, MSN, RN

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    8 Comments

  3. by   Pixie.RN
    Just as an aside, true anorexia nervosa is not what you described, OP. You sound like your anxiety is making you vomit, which of course causes weight loss but does not involve the compulsions and issues associated with anorexia nervosa. Just wanted to point that out before you claim a disorder that you might not mean to claim!

    Best of luck, OP. That place sounds like a mess.
  4. by   JayHanig
    Nothing validates my decision to retire early more than the OP's story. After sitting on the sidelines since 2010, I've finally decided to let my licence expire with my birthday next month. Can you believe the NC BON wants $30 to retire my license? Good luck collecting that.

    Better I owe them the rest of my life than do them out of it!
  5. by   rnpatrick
    What does your contract company say? Have you created a paper trail of your concerns. Citing safe harbor I know of only one state that has that. I have used that. It gives you protections while you await peer review. But, if the committee is stacked with "pets" could be tough. You should compile journal articles and standards that back your concerns. If the peer review does not go your way and you suspect bad faith you can appeal to CNO and then directly to state board of nursing.Craft a letter to state board of nursing to get an opinion about your concerns. You can do an initial outreach as theoretical not identifying facility. Have you written ACCN? They have good standards.

    Get everying together and write so you show you are exercising your duty to report. Back concerns with EBP. Good luck!
  6. by   Roz, RN
    I, too am looking forward to early retirement. In the nearly 40 years that I have practiced, I have seen tons of change. Most of it has not been for the better. We are mandated to use our old paper charting system for trauma patients, even though there is a template for traumas in our EMR. Same for conscious sedation. If we don't copy everything from the paper chart into the EMR, we get dinged by medical records for not documenting. I spend more time charting now than I ever did with paper records! 2.5 years and I'm done!
  7. by   Sugarbear55
    After 41 years in nursing, the last 15 years in Home Health, I too have retired, not because of patient care , but because of the ever increasing computer documentation. The computer charting requirements placed me in the position that I stay in my home office area until the wee hours of the morning charting just to stay current. This is at the expense of and neglect of my family. New staff usually do not stay past their probationary period. I see the current computer demands to be the downfall of quality patient care.
  8. by   riggy3
    The information you provide indicates a hospital in a transition from paper to computer documentation working in a situation almost from 1990. The inspection teams should fail the hospital. That is really not a direct reflection on the bedside nurse. The administration adding more layers of paper to make up for the poor interface of computers today just gives the inspectors big flashing lights to find... Seems to me there were Federal funding available to update computer systems as well as increased Medicare payment percentages for the care given . This computer transition bonus funding was a motivator at the hospital I worked. When the Electronic Media of Epic interfaced across the systems charting stress did decrease after the learning curve of computer use settled . The transition in the 600 bed hospital did not happen overnight it was worked in over a period of 3 to 5 years. The instant fix will take money and time. Plenty of consultants are available out in the field to help with the transition.* **
    You mention a coworker threatening you over the use of a computer. That makes me believe there are inadequate numbers of computer work stations. Much of the problems you are experiencing are directly related to equipment funding.*
    The Pyxis system appears obsolete. The narcotic storage in a separate look box is from way back in time in my practice 1978 . The older Pyxis systems I worked with had drawers that open for commonly used medications. Morphine 4 mg in one drawer compartment for instance Pyxis would generate a screen to get it. The software used an integrated log, dose, time, date, patient name, who took out the narcotic and to have a waste amount witness if only 2 mg* was used for instance . We did a manual count of the amount of cartridges remaining in each drawer entering this in Pyxis. The pharmacy could possibly rearrange the drug storage even using the current system.*

    Does this hospital use any kind of shared governance? Getting the staff involved in design of charting be it paper or computer will go a long way. There is plenty to be done at your hospital not just the ICU by getting staff buy-in and support from nursing administration improvements could happen fast.*

    You mentioned being under contract. Makes me ask what really is the penalty if you leave? The hospital system I worked they had a contract time for attendance to critical care class or if they paid toward continued college credit. Those under contract were to pay back if they left before satisfying contracts. Dependent on the amount of stress this hospital system has caused you paying them might be the best solution for you.**

    One other point I will make you mention you are in the career 22 months. Over my time I noticed the novice nurses between one to two years seem to develop difficulty with the reality dealing with actual stress in an ICU.* We did have support groups as part of our mentor-ship programs finding the sharing* in groups of 6 or 8 from other nursing departments also helped to reduce stress you mentioned. The other hospital units are also experiencing stress Med /Surg, Peds, L& D, ICU when we had them share. Many times I saw this stress you mention is not unique to the ICU.
    * You did mention the ICU has a high staff transition. Are these long term nurses or from the group of novice nurses as well?*
    Nursing leadership has some work to do .
    Best wishes*
  9. by   MrsK62
    There is usually a clause in a contract which states you can leave after giving 30 days' notice, clean. You certainly can't go on like this for the next five or six months. Give notice and let them find someone else.
  10. by   beekee
    Have you been there at least 1 year? You may qualify for FMLA. Check your contract to see if it says anything about FMLA. Speak with your PCP about your mental health to see if it would be appropriate to take some time off via FMLA to address your health issues.

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