Patient care measurement tool

[PattonD]

Is it possible to minimally care for a patient?

Can other care be given besides the doctors orders that would improve the patients experience? For example if the nurse has nothing else to do can she sit at bedside and talk or whatever?

Take it a step further, what if there are three nurses on duty and only one patient? Can all three nurses do something for the patient or would it be better to just perform doctors orders and thats it?

I mean, other than opinion, how would one know if one nurse is better than another?

[CritterLover, BSN, RN]

i'm not really sure what you are getting at.

there are plenty of things a nurse can do for a patient without a doctor's order. nursing interventions. sitting and talking is one that may or may not be appropriate. if the patient wants to talk, learn, be educated about their dx, meds, etc, great. or, the patient may be tired and need to sleep. in that case, sitting and talking would not be appropriate.

i'm not sure where you would find three nurses with one patient (maybe an er on a *great* night), but sure, they can all go in, help care for the patient. this kind of thing happens often in ers/icus when a new patient comes in, we "tag team" the patient to get the necessary things done in a timely manner, but it isn't a case of three nurses/only one patient. there are usually other patients in the department, but the one patient is getting everyone's attention at that time. a code would be another example of when more than one nurse will help care for a single patient.

we don't do medical interventions that are not ordered by a doctor (or a mid-level), but there a plenty of non-medical interventions that can be done without an order. sometimes they are appropriate, sometimes they are not. that is one of the places where nursing judgement comes in to play.

i used to work with a nurse in the surgical icu who had her patients up all night turning, coughing, deep breathing, doing their is, getting a bath. by the time day shift got there, they'd be just exhausted. they'd sleep half of the day shift away! i never thought this was very good judgement, but her patients did well.

as far as how to tell if someone is a good nurse, it really is pretty subjective. i guess first, you have to decide what a "good nurse" is. you would be surprsed how varied that definition is going to be from nurse to nurse, even doctor to doctor.

that being said, i was once told be a very wise older nurse that the way to tell if someone s a good nurse or not is to follow them on a regular basis. you will learn if they do their meds/txs/etc, an see how well taken care of their patients are.

is this the kind of thing you are asking???

[caliotter3]

You're asking a lot of interesting questions and covering a lot of territory. CritterLover makes some excellent responses. I think you could find out a lot by experiencing it yourself. Why not get trained as a CNA and take a paid job in a long term care facility? Or for that matter, you can volunteer at different kinds of facilities. People with your sensibilities are needed everywhere.

[PattonD]

I guess what I am getting at is what if someone, patient or staff, claims a nurse is not giving good care but yet all her orders have been done to perfection in a timely manner?

It seems to me there is a lot of bitching & moaning about who is a team player and who is a slacker in the nursing profession. Why so much drama all the time?

Thanks for the tip on becoming a CNA, whatever that is, but the medical field is not where my intrest is. I enjoy topics of human moitivation and performance management. There is always a way to get more performance out of your employees, or at least improve their quality of workplace environment.

[CritterLover, BSN, RN]

i guess what i am getting at is what if someone, patient or staff, claims a nurse is not giving good care but yet all her orders have been done to perfection in a timely manner?

it seems to me there is a lot of bitching & moaning about who is a team player and who is a slacker in the nursing profession. why so much drama all the time?

thanks for the tip on becoming a cna, whatever that is, but the medical field is not where my intrest is. i enjoy topics of human moitivation and performance management. there is always a way to get more performance out of your employees, or at least improve their quality of workplace environment.[/quote]

ok, well, some nurses are simply more efficient than others. much of that comes with experience. if the orders are done in a timely manner, correctly, that is one of the criteria i would use for a "good nurse."

however, there is more to nursing than carrying out orders. we need to educate our patients/families, monitor our patients for changes, assess our patients to see how our interventions (often the "doctors orders") are working. these are all things that we nurses do that arn't usually in the "doctors orders" section of the chart, but are extrememly important anyway.

i highlighted the last section of your reply, because it really bothers me and i feel the need to comment on it.

trying to "get more performance" out of nurses is a dangerous trend i am seeing in healthcare. administration sees what appears to be an idle nurse, and they feel that it isn't acceptable and they must add to that nurse's responsiblities (to get their money's worth?)

one of the most important thing a nurse can do is monitor their patient, and be available should additional interventions be needed.

on a good day, a nurse may have 5 patients. to me, that is very resonable number on a med-surg floor, with an aide that is responsible for, say, 10-15 patients to help with baths/vital signs/ambulation/meals. lets say that the patients are a mix of medical problems -- diabetes, pneumonia, cva. some are confused, some are alert. two may be close to discharge and need quite a bit of teaching, one or two may be new admits/transfers, the other(s) are "holdig steady." if the nurse really does end up having a good day, and nothing goes wrong with her patients, the nurse will haved time to do all meds, treatments, doctor's calls, interventions, assessments, and teaching with time to spare. the nurse may end up looking idle, as though they arn't doing anything. however, it is essential to point out that the nurse is continuously monitoring her patients for changes. this can sometimes look like a nurse who is doing nothing, but it is an essential nursing function. however, the non-nurses in administration often miss this critical point. they see an "idle" nurse, and feel the need to increase the patient load. so now the same nurse has 7 or 8 patients. still do-able, i think, for a well-organized nurse, as long as nothing goes wrong. but it severely limits the nurse's ability to monitor her patients for changes.

lets take the first scenerio again. say the nurse has 5 patients, and her day is going good. then, while monitoring her patients, she begins to get worried about the lol with pneumonia. she seems less alert, the nurse checks an oxygen sat,calls the doc, gets an xray and abg ordered. turns out, that patient is getting worse. maybe she isn't on the right antibiotic after all. cxr shows worsening infiltrate, abg shows declining po2 and increasing pco2. what would happen next depends on how bad those gasses are, what the other vital signs are, and how alert the patietn is. but maybe the patient needs transferred to icu, maybe all that is needed is a change in antibiotics and some increased supplemental oxygen. it doesn't really matter; what matters is that the nurse caught the change in patient condition in a timely manner, and collaborated with the doctor in a timely manner to get the patent appropriate treatment. the patient will have a much improved outcome because of this.

so, in light of this new info, lets take the second scenerio again. the nurse has 7 patients, and while she isn't behind yet, she is probably barely keeping her head above water. she is running up and down the hall trying to get meds to he patients on time, talking with pharmacy about where the "stat" meds are for the new admit, while trying to get the admission paperwork done. when the cna goes around for vs at 1600, she finds the above patient lethrgic, barely breathing. the cna goes and gets the nurse, who goes in to assess the patient. now, the patient needs to be turned every two hours, and the cna has been in there, turning the patient. but a cna isn't the same as a nurse, and though she is good at what she does, she doens't pick up on the subtle changes in the patient's condition as the nurse does in the above scenerio. so the change in condition isn't caught as quickly. once the nurse sees the patient, she knows things arn't looking good. she pages the fast-response team, and an icu nurse/rt combo show up. they call the doctor, get the patient transferred to icu where the patient is intubated and placed on a ventilator. the blood gasses and cxr are still done, and antibiotics are still changed. however, the patient did not receive timely care and interventions. the patient is now on a ventilator, because the respiratory distress was not caught early. instead, it was caught late. and the patient is now at risk for an additional pneumonia (ventilator-associated) plus dvts, plus stresss ulcers, plus skin breakdown, pl.us nutriitonal deficits because she is now ventialted and (most likely) sedated in the icu.

my point is that there are many functions an rn does that arn't obvious. they are subtle. to the untrained eye, the nurse may be "sitting on her butt doing nothing," when in reality, she is monitoring her patients. this is an invaluable function of an rn that is next to impossible to measure. some studies have attempted to measure this, and they correlate lower rn to patient ratios with better outcomes. my above scenerio is an attempt to illustrate this.

do lower patient ratios guarantee a good patient outcome? no. absolutley not.

everyone is going to die someday. there is no way to adjust staffing ratios to make up for that simple fact of life.

surgeons and medical doctors will make mistakes. there is no way that better nurse to patient ratios will fix that, though it will enable the errors to be caught in a more timely manner and give them a better shot at resolution.

okay, i'm going to try to get off my soapbox now. i will leave you with this: one of the most critical, most valuable functions of a nurse is the ability to monitor the patient so that necessary new interventions can be done in a timely manner when indicated. and, to be available when these interventons need to be done. this is going to mean that, at times, it will seem as though a nurse has "nothing to do." they are not being paid to do "nothing" during these times. giving a nurse so many patients and additional duties that this can no longer be done is dangerous.

[PattonD]

That was a GREAT explanation critter! I had no idea.

So when performance is measured, a nurses downtime would be a great asset. The nurse constantly running up and down the halls would actually receive a lower score if I were to set up a measurement system, knowing now what you have enlightened us (me) on.

[CritterLover, BSN, RN]

that was a great explanation critter! i had no idea.

so when performance is measured, a nurses downtime would be a great asset. the nurse constantly running up and down the halls would actually receive a lower score if i were to set up a measurement system, knowing now what you have enlightened us (me) on.

with regards to patient safety and well-being, yes.

however, it really isn't looked at that way, which is a tragedy in so many ways. there is so much a nurse does that defies measurement.

thank you for understanding.

[PattonD]

Yes I understand. Maintenance is the same way. If maintenance is always standing around with no work to do it means everything is running smooth and they have been keeping up with their PM work. Management sees workers congregating and wants to downsize the maintenance dept. Then there isn't enough manpower to do any PMs and a few years down the road everything falls apart.

It is a nightmare to be constantly pulled away from one project to attend to another emergency. NOTHING ever gets completed properly.