Obstacles to providing care - page 2
What obstacles occur during your work day that make it difficult for you to care for your patients? I am grateful for any comments you have. I am not a nurse, but will be doing research on ... Read More
Feb 18, '00Thanks everyone for their great posts. It has been most interesting and informative. Tara, could you say more about your unit being procedure driven and the different expectations for male versus female nurses. What do you mean by procedures? What are some examples of different expectations?
Also, I am curious that hardly anyone mentioned difficulties in dispensing medicine to their patients. I am thinking of only studying the "obstacles" that arise from the medicine dispensing because there are soooo many obstacles it might be too big to try to study everything that makes it hard for nurses to provide care to their patients. Would it be too "small" to study just medicine related delays?
Thanks again and I am in admiration of all you dedicated, supportive nurses! You are truly inspiring.
Feb 18, '00Regarding medicine dispensing. I rarely have trouble getting meds. But if I don't have something. I bring it up with pharmacy and within 5-10 minutes I have it.
We have a medication dispenser...It holds all our medications...that we use most frequently...including I.V.'s and narcotics.
We have a pharmacist on our unit. He puts medication orders in the computer. And pharmacy sends the medication through our tube system(medication we don't have in the medication suspensor). We have a tube system throughout the hospital. So we send our labs...medications through it.
The old hospital I worked at. We had a pharmacist for days (on the floor). Otherwise...on off shift. We had no pharmacist. A transporter came around every hour...to pick up new dr. order. And the transporter dropped off our medications. It was a very slow system. And if we had an emergency occuring...and a STAT order came through. One of the nurses had to go downstairs to pharmacy to pick up the STATS.
Feb 19, '00Some of these have already been said...but I feel the need to vent
-Calling up nurse after nurse (in vain) hoping they might come in and work the following shift because staffing is low
-Listening to long winded reports that make you late getting stated on your work
-have work handed over to you from the previous shift. My faviorte is that they still need a u/a on a pt...yet there isn't a specimen cup in the room!!)
-having to call a nurse at home because you don't know it they gave the 6pm coumadin because it wasn't signed off and you don't want to overdose them
-Pt family members asking a multitute of questions, then being approached an hour later by another family member asking the same questions
-Poor Dr handwriting
-Strange orders that need clafification. I once had an order that read: Insulin 5 NPH 30 units SQ ...the man's FS was 46!
-pt's that have both medical and surgical team coverage. we wind up with alot of conflicting orders..too many cooks...
-Dr's not responding to pages...we have one that refuses to answer pagers before 9am
-Parmacy not delivering meds, denying they ever received the orders, refaxing the orders at least two times.
-Drs ordering non formulary meds
-Drs not filling out conset forms for blood transfusions 9required at of hospital)
-Restraint policies intended for nurses who only have one patient
-Inappropriate admissions (i work on a med/surg floor) that you have to transfer to another floor immediately upont their arrival from ER
-Finding out a patient with a roomate needs to be on isolation (for MRSA, VRE, etc). This is especially tough when beds are tight in the hospital. would be nice if all pt's had private rooms.
-working with lpn staff...rn has to give their iv push meds ect, and they can't take admissions
-roaming the halls looking for someone to help you pull up a pt in bed ...cna's have a way of disappearing sometimes
-lack of supplies...we once ran out of emesis basins in our hospital
-we don't have a tubing system on our floor, so we have to walk labs samples over to the lab ourselves...samething with meds if you need them from pharm, and they don't have another run for two hours
-no transport personell..have to take pt's to radiology for x-rays, or pick them up from pacu
-nursing staff has to clean rooms on the days we don't have a housekeeper
-have to go be escorted by hospital security to get a food tray for a pt if they wish to eat after the cafeteria has closed. would it really be that difficult to have extra food available on the floor for pt's?
-faulty computer systems
-finding mistakes (big or small)..then having to correct them.
-should i continue?
-home care or ambo arangements not made for a person who is to be discharged....this one takes up a great deal of your time.
-i could go on forever...
Feb 21, '00Can't say i can add much to the obstacle list, everything's covered! I work nights at a prison, so i'm sure things are done a bit differently. My biggest complaint is short staffing. Another complaint is the officers. I work nights, my job consists of labs, passing a few meds (at 12am and 4 am), checking out chest pain and SOB complaints (which are mostly just to get to see a nurse, rarely are the ligit complaints), filiing, chart reviews, triaging sick call request for day and evening shifts, and investigating and answering complaint forms.
We are usually covered up in paper work and right in the middle of it the officers come to us complaining of heartburn, headaches, sinus infections, etc. We are to give them OTC meds as needed. Every night it's the same thing, 4 or 5 officers (usually the same ones) complaining and wanting something for their complaints. They can see we are busy, but yet we are expected to stop what we're doing and care for them. Even when we go to lunch, they sit with us at the table telling us what's their latest illness, and requesting something. Our breaks are different, and sometimes we've had to leave our break go to the infirmary and get what they need, then go back to lunch. We get so tired of caring for the officers. Actually they are more demanding than the inmates!!
Feb 29, '00Did you know that a med nurse is expected to be able to medicate a patient every 4 min, and TaPs is expected to take no more than 15 min a round?
I once counted the care I was expected to do in one shift, and the acceptable time limit for each (as a manager I was given a ratio list) and it came to exactly 7 hours and 50 min if my hall was full. I was NOT payed for the lunch break I never got, and although we worked with very capable CNAs we were expected to do a inch by inch, measure every dermal abnormality, on anywhere between 4 and 9 patients an evening. Then there were the Tube feedings we had to turn off to give dilantin, and our DON decided that since evening shift had NOTHING to do all night, we could give all daily meds and supliments.
I would get a patients treatment done to their sacrum, gluteal folds, feet and the CNA would come to me 1 hour later telling me that the patient was full of BM, or she had washed the patient and the dressings were all wet, or off.
Our admission from the Psych facility has a psychotic break exactly 48 hours after getting to us because they forgot to tell us that they were on some SSRI
An agency supervisor comes on and acts like we are all stupid, or (in the oposite extream) decides to go out to dinner for an hour.
an agency nurse is angry with you because she does not want a different assignment for the second half of her double shift, and you later find her 5pm accucheck levels in the MAR compleatre with how much insulin was given and where it was injected, apical rates for the digoxins ordered for 5pm, and q 2 hour resperatory treatments signed out for the entire shift
LTC resident is cheyne stoking and they are a full code (or worse yet you come on shift and they are stone cold).
Or your patient you sent to the ER for Diabetic ulcers is being readmitted after 5 weeks in the hospital, but their BG is 594, transfer sheet says Diagnosis: Diabetic Ulcer Managment, but there are NO insulin orders, and the nurse who discharged the resident tells you flat out that the patient was NOT a diabetic, that the diagnosis was a misprint (this is a resident I had taken care of for 4 months, she WAS a diabetic) Family members comming in and telling residents NOT to take a medication, because it was bad for them, or bringing a diabetic a 12 piece family meal from KFC, because their sugar was off and we were "refusing" to feed them.
Activeties department having a cookie club and not monitoring the diabetics who joined.
Administration telling us to stop being upset because a resident hit another one of us hard enough to bring an actual injury. They were confused and there was nothing we could do anyway, because they could not be transfered to another facility because the other facilities would not accept them (even the geripsych center). and mussent forget they have rights
Having a resident on only authorized and supervised visits because a visitor brought him a bottle of narcotics and he tried to OD (and then changed his mind) but days is to busy to set up supervision and evening shift just lets him do what he wants.
Being told that we have a clean air plicy about cigaretts but noncompliant and confused residents smoke anywhere they want, because it is their right (both of the MAJOR offenders have O2 running, but its ok, they signed a waivier) <==Dripping sarcasm.
having a staffing shortage so bad we are expected to not complain to the agency nurse who writes orders in the MAR but not in the order sheet,
or the one who has a resident with a 52 BG and since it is 40 min until the ACTUAL time the accucheck can be done, PLIES the resident with sugared OJ then retakes it so she can just document that it was 74,
or the CNA who tells a resident that even though she knows the resident is supposed to be gotten up out of bed before the end of the shift, the nurse forgot to write it on her assignment sheet so she is NOT going to do it.
having a resident who vomits up their tube feeding every night, and dietician says that she wants to INCREASE the rate because he is loosing weight.
Housekeeping complaining because nursing didn't empty the trash bins before they got here, or that we are using to many paper towels,
Or doing an education on a diabetic/dialysis resident the foods he should avoid, and when you get to proscessed meats and sour kraut they say "but I had 2 hotdogs with mustard and sour kraut for dinner, but I ate my carrot raisin cole slaw, thats better for me right?"
or another resident smelling of ketones refusing to allow her sugar to be checked until she is give a double dose of her narcotics.
being told that your 119 bed facility is adequatly staffed with 5 people as long as one of them is an RN for night shift, but other shifts are staffed by CNAs per resident.
Going to a managers meeting at 8 am, after 3 nights on, still running a fever even though you started Abt yesterday, and the next time anyone talks to you about it your told that you need to adjust your attitude, and stop being defensive about expectations being put on your staff.
Then there is the Pharmacy whos STAT policy says they will get us ANY med with in 2 hours, if the Dr orders it stat, but it takes 2-3 days for admission orders, unless they go in Monday morning.
Passive agressive Drs who refuse to send Pharmacy a hard copy of a Narc script but have given a verbal order for the drug to be given, so the patient is left waiting, and waiting
or worse yet you call for an order to cover the resident being sent out 911 for a bad head wound, and the Dr says "and what happens when I DON'T give the order to send her out"
or sending a resident to the ER because resperatory treatments are only effective for 20 min before the wheezing and rhonchae are back, and the ER tells the family "if the nursing home had just given her a treatment she would have been fine" and when the same patient goes into CHF tell the family that we should have sent her out sooner (same ER)
I guess the bigget impediment to nursing is the burnout from being beaten down repeatedly
just remember "Beatings will continue until moral improves"
Mar 11, '00Oldtimer and Beano just about sums up my feelings as well. I have been a nurse for about 30 years, so I can certainly relate to all of those issues identified. Now that we know the problems, how do we resolve them? I have been a staff nurse, charge nurse, team leader and now in an upper management position. Doesn't matter what the times are, the problems remain the sasme. We discuss issues, and propose answers, but many of them are not realistic goals. I agree that "upper management" has the higher degrees, theories on how to make things work, finance woes of FTE's, etc., but they have lost contact with what is going on at the bedside. I don't know what the answer is, but I can certainly understand why nurses are leaving the profession. If I had it to do over again, I would have stayed in the factory and been retired with a nice pension by now. Oh well - my first thought was helping mankind......wish I had the time to do that. So sad the direction that nursing is going today, and no real mouthpiece to change things.
Mar 13, '00All the above plus not being totally able to be the kind of nurse I really wanted to be because of all this. I want the time to really care, to really share. This has been a disappoint me for me personally. I became a nurse to help patients not only to get better but to feel better too.
Mar 14, '00This is too much. Not one of you have mentioned JCAHO, Medicare and the Feds and their regs. They are one of the reasons for duplicate charting, excessive restraint rules, and the massive amounts of paper work. They, who are years away from the bedside, are on a crusade to "IMPROVE" patient care ..... by throwing up most of the very obsticles you have mentioned. In short, until they stop messing in nursing and medicine and let us get back to the patient, nothing is going to change, except more regulations, more paperwork and more unrealistic goals.
Apr 13, '00Originally posted by Anita_novice:
What obstacles occur during your work day that make it difficult for you to care for your patients?
I am grateful for any comments you have. I am not a nurse, but will be doing research on "nurses as problem solvers". I needed to know what things occur during your work day that are "problems" that you have to deal with (like can't read prescription, etc.)
Thanks so much -
Apr 15, '00Originally posted by Tara:
Everyone is correct. I feel the same way. I can also add it is most frustrating to work for a facillity that doesn't follow there own policies. Having to listen to doctors complain about the nurses on the floor. I work in a procedural based area. The most frustating is the different expectations applied to female vs male nurses.
Apr 15, '00Greetings!
beano and ecb: did we work at the same hospital in a different decade. You were describing my last place of hospital employment so well, it brought a shivvvvvvver
to my spine.
Anita_novice: was your interest about medication admin r/t the medication study about bar coding the med, the pt's armband, and the nurse in order to decrease/prevent medication errors?
Seems as if focusing on the "forest" (medication issues) without looking at the "trees" (see the above postings) is short-sighted.
Apr 15, '00Been a nurse for 29 years, and have worked just about everywhere. I can not add one thing to the dialogue that "beano" and "oldtimer" didn't already say. Good luck with your question - it must be a hot topic.
Apr 20, '00AMEN TO ALL THE ABOVE REPLIES SO TRUE.
The paperwork is atrocious and though chartingby exception is catching on,the institution i work at now insists on narrative on several of the things that are already on flowsheets such as there is a spot to check that the iv is secure and site is okay but then yu have to chart the same thing in the narrative why?
The computer systems are unfriendly to put it mildly--and instead of everything being available in one system we have one system for orders and another for scheduling and another for labs so we have to log off one and log in to another to get info.
Then there is the ancillary services issue--the housekeepers can't clean the room until you have stripped it. If there isn't a housekeeper then guess who gets to clean--the last institution i worked at the housekeepers weren't allowed to touch the monitors at all so we had to find a dust mop to clean off the top of the monitors. why?
As for Tara's comment about different expectations for male and female nurses----boy is she right. The last institution i worked for did!!!!!! Unfortunate but true.
The female nurses were expected to be more thorough in patient care, more flexible in respect to schedule changes, more accountable for everything, quieter, more polite, more respectful. should i go on.
The male nurse were always having excuses made for them--they could tell the raunhiest jokes within patient hearing and never have a thing said to them--a female nurse making a mild off color comment at the desk that the patients could not hear was reprimanded.
when asked why the difference, the unit manager's response was "boys will be boys" attitude was also directed to noisy behavior, work not done, anger, irresponsible behavior, not coming to work after being on call because they were tired but female nurses were penalized if they didn't work their regularly scheduled shifts
after being on call. I could go on and on. The double standard is alive and well and living in several hospitals. This is part of the reason i left my last employer and my new one seems to be a lot better in equal expectations for male and female nurses. I'm not saying that all hospitals have different standards for male and female nusrses but that some do and it's sad. at the last institution i worked at the female nurses had been complaining about the conditon we received the patients from OR for years--things like the patients arriving in PACU with blood and betadine all over them and their patient gowns, the gowns soaked with irrigation solution and God knows what else, on a cart with another patient's name on it, no ID band the list goes on--we were repeatedly told that the OR
staff was too busy to worry about the little things. A new male nurse went and compained to the manager and the next day there was a
comittee set up between the OR staff and the PACU staff to investigate this problem and do something about it. One time i approached the manager about getting OT and
the social worker to see a female doctor's axiallary node dissection patients preop because she was sending so many of them home post op and those two departments were frequently gone by the time the patient was a wake enough to talk with them. It was a patient care issue and made sense to me. The unit manager went off about being tired of spoon feeding doctors and she should take care of it from her office etc. Two days later i got in trouble with the same manager because i didn't have a male physician's billing forms available on the unit for him. This was a female manager.