bren3299

Not to put a damper on the mood BUT regarding the not changing IV sites on the prescribed "expiration date"- Actually, more and more research is supporting leaving healthy IV sites in longer...no standard change date but rather using a validated phlebitis rating scale to assess the patient's site and use this assessment to decide whether to resite the IV rather than an expiration date. Many factors dictate how long an IV site can remain healthy, not time alone. I believe this practice is based more on tradition than evidence and results in wasted resources and time. Of course the issue becomes the fact that hospital policy is what it is...but perhaps it needs to be changed rather than that healthy IV site...My WHY has to do with precisely this... WHY are we wasting our precious time doing useless tasks- -bowel sounds on patients with absolutely NO bowel issues or symptoms (evidence shows they are a useless assessment, basically-esp. on a person devoid of distension or other symptoms) -blood glucose checks that nurses blindly keep checking...even though the pt has had normal results everytime, is not diabetic ...and is still getting poked QID for 2 weeks and no one asks WHY! -weighing a demented MRSA positive pt daily because we are worried he is not eating enough...takes 2 staff, a disposable sling for the lift-scale (don't have scales built into the beds so have to hoist the person up on a lift q moring to weigh him)...not dialysis, not CHF...just to see if he is eating...heard of a calorie count, labs, weigh once a WEEK? -pt on IV fluids for "hydration" and is already tolerating tube feeds...heard of water? We can put that in the tube too. -intake and output on everybody whether it makes any sense or not. Why do we complain about workload but don't question if the tasks we are doing are making any difference? We need not blindly accept MD orders or policy...I say question everything and ask WHY

Had to reply when I saw the term "little man". We have the most amazingly annoying doc who is all of 5'2" who has been dubbed by one of our ward clerks as "the little man" for code. His tantrums are viewed as just that and not taken too seriously but he is out of control sometimes. Outside of the tantrums, his most annoying habit is being too chatty when you have other matters to tend to. I was busy at the desk one day, he called and as soon as I heard his voice the phone disconnected, rang again, he started talking and it hung up again. I was just thrilled and told the ward clerk that I was so glad they had installed a Dr. Soandso filter on the phone!

HI, We have the same issues here in Canada. We have 12 vacancies for nurses on our general internal medicine teaching unit that only has a total of 32 positions (full and part-time combined). Our ratios look good on paper (4-6 pts per nurse on days, 30-32 pt total on unit and 2 health care aids for day and evening shifts) but I am not able to deliver optimal care every single shift. You usually feel like "well I did the best I could"... not how I want to feel at the end of the day. All the stress adds up and you leave for easier or more supportive enviornments. There are just so many options for nurses now why would someone put themselves through it day after day? We wrote a letter to all of the higher ups and they did respond by hiring a private HR guy to do 1:1 interviews with all the staff. He is supposed to generate a report. It is too late for me. I am going back to my teaching job as a clinical instructor and the whole while I am teaching the "right way" I will know that in certain areas they will be lucky just to keep their pts breathing through the shift. I am on a much lighter unit (cardiology) this time with the students per my request as the former ward just feels unsafe on so many levels. The disparity between workloads on this cardiology unit versus the general medicine one seems almost criminal at times but I am taking advantage of it this time. I refuse to play the martyr anymore and will try to effect some measure of change from the inside by trying to educate students to fight for improvements in the future. I still hope something positive comes from our most recent attempt at making managment accountable.

Hi, Our unit does CAPD and we had a nurse injure her back the other day as she had 3 pts on Cylcer and the large bags are so heavy. I was wondering if anyone out there has a system for dumping these bags to prevent injury. We end up dragging them to the pt BR (can't be too good for your back). Some nurse hike it up onto a commode at the bedside and wheel it to the BR but then again, it can be hard to find a commode when your pt needs it never mind for this purpose so not sure this is the best answer. Any ideas? TIA

HI, We have something called Core orientation and it lasts 2 days. Has classroom presentations for things that are hospital-wide policy, such as documentation, discharge and admission guidelines, etc. There are also skills reviews for central line care, wound care, tube feeding, etc. The presenters are educators from various units of the hospital. The manager that hired the employee negotiates with the new hire as to how long they feel their orientation to the specific unit needs to be. They are buddied with a senior nurse for a set period of time, which can be extended if the new hire or the person doing the orientation feels the person may need more time before flying solo.

HI, I am from Canada so can't speak to the rules in the US, but I would be surprised if there wasn't a strict policy at your facility as to how to do this. You mention a chart and this is what I would go with as long as it is from your procedure/policy manual. I have learned (especially while being in nursing education recently) that it is NEVER a good idea to trust word of mouth when it comes to your own practice. Using more heparin, for example, than is indicated in your policy for a certain line could end up with you in court if that pt were to bleed out and found to have a high PTT. Stick with the hospital policy. If you are unsure as to what type of line you are accessing don't access it until you are sure. That is my best advice.

The reasonable approach is my plan. I have surveys drafted to gather actual data to show just how the change is affecting the nurses (I also have surveys for the MDs and other staff) The surveys allow for positive or neutral responses to the change as well. I will argue for whatever the majority of nurses feel will help them. I have gathered data that states charting needs to be done contemporaneously, etc. to also help support our position. I don't intend to even mention that I know why the change was made unless this hand is forced. One of the questions on the survey does ask the respondent what they felt was the reason for the change was, as I want to illustrate that there was poor communication with the staff as to the rationale in this change of practice. I, for one, insist on knowing why I am doing something the way I am doing it. I know that quality of documentation is a focus for her so I plan to approach it as an initiative I am starting to improve documentation on this unit. The survey is to ensure the nurses feel switching back will help so it is not just my or a few other's "opinion" but based on good data. She did this in such a knee-jerk fashion that she gathered no baseline data so now all we have is the opinion of the nurses as to whether this has made the quality of their charting suffer. Only if she rejects the data and refuses to listen will I go to "guns-a-blazing".

We are guilty of not claiming the overtime we have on this unit. With so many junior staff there are many times when people are there up to an hour after the end of their shift- saw 3 of them still there 45 minutes after day shift ended today. No one claimed overtime. I will be encouraging nurses to claim for it whe I start my regular charge position May 9th. I am guilty too. I was there 45 minutes over due to a staff meeting (regarding the new computer system) and didn't claim it but think I will ask the manager to approve it on Monday as I am back that day. You are right that consistently forking over more money would get their attention faster than most things. I am just amazed that a person in this position would use their authority to try and enforce an unapproved change in charting policy. I have to wonder if this is some sort of breach of some ethic/policy somewhere.

Regarding privacy, there is no info about diagnosis, etc kept near the room (the bedside charts are just binders with a cover stating the info is confidential and the only stuff in there are vital signs and glucose results and things like the pt has edema, etc...no progress notes, no test results, etc.) This binder is not inside the room but out in the hall by the pts room- anyone attempting to access it would be seen by staff. I stated this in a previous post "I do believe in protecting a pts' privacy but only using measures that make sense. We still have the fluid balance sheets on the door and this has the pt's name and medical numbers on it (it is addressographed) so the other sheets like a vital signs record, I don't feel, has any more info that would compromise the pt's privacy. I mean what could someone do with a blood pressure reading that would invade another person's privacy, really? Our privacy act (PHIA) is alive and well in this hospital and we all sign a pledge, etc. I just think we have to be careful not to go overboard and be protecting pt's privacy in ways that are not balanced with the risk. We have a cover on the bedside data that states the info is confidential-I think this is sufficient for the degree of risk. Again, all other areas do this so in the health authority's opinion, it is acceptable practice from a PHIA (our version of HIPPA) perspective. Brenda

Sometimes when I read this kind of stuff here...the cold of Canada doesn't feel so bad. We seem to have far more rights when it comes to stuff like this. It would be considered wrongful termination...and our Union would hear none of that I can tell you. Not only that, but if you didn't have extra health insurance coverage, you would get disability benefits from the government to partially cover the lost wages for time you were off. Ahhh, socialism.

I originally discussed this matter at the following link-https://allnurses.com/forums/f8/charting-systems-question-fighting-management-215122.html#post2130185 Since posting this information, I have finally found out why the changes to our charting system were made. As I said, we are WAY behind the times and our hospital was still using Nurse's Notes rather than integrated progress notes. The majority of staff was very much in favour of having integrated notes even though it meant having to fight for the main pt chart to enter them at times. One older nurse (allergic to change) made a comment about this change within ear shot of the director that went something like, "Well if I can't get the chart then I just won't be making any notes." Obviously a tad extreme and silly a position. In response to this lone comment the director decided she would force all nurses to HAVE to go to the chart by putting all chart components in there- VS record, glucose monitoring record, etc. Things that should be kept by the bedside- and still are in all other teaching hospitals in our region. None of the changes had anything to do with privacy at all. They were to punish a nurse for a comment and now we have all sorts of complications (see previous post for details) What are your opinions on this? Is this abuse of power? I have decided that because it is not hospital policy, a nurse could decide to not conform if they so chose. We are part of a professional body (and Union) and we are to govern our own practice. I have surveys drafted to review the nurses' positions, mucho literature supporting point-of-care charting, etc. If I present this to her and she doesn't budge do you think we could just revolt...and put the door charts back? Again, this is not hospital policy but the actions of one knee-jerk dictator who wouldn't be able to fire us anyway. We live in Canada so this is public health care. Let me know what you would do....I tend to be a bit like a dog with a bone so I think I know what I will be doing but find feedback here very valuable. Brenda, all fired up in Canada

Hi, You are sounding a little like me now. I am forever convincing the staff about the benefits of change and trying to calm the naysayers when we have a change in procedure or a new system implemented. I have been a "super-user" (their term- not mine) for every new pump, medication system, etc. as it has come down the pipe. I am one of those people who thrive on change. I flip my jobs every 4-5 yrs for this very reason. I am a trainer for the hospital with the new computers as well and have spent many of my classes convincing people of the benefits of this change while they grumble away. I take issue with those people who are afraid of change and refuse to see the benefits because they are caught up in all the negativity. I annoy those types with my gung-ho attitude. I also analyze each change for aspects that could be improved upon before I jump on board, however. I just don't believe that this charting change makes sense. I do believe in protecting a pts privacy but only using measures that make sense. We still have the fluid balance sheets on the door and this has the pt's name and medical numbers on it (it is addressographed) so the other sheets like a vital signs record, I don't feel, has any more info that would compromise the pt's privacy. I mean what could someone do with a blood pressure reading that would invade another person's privacy, really? Our privacy act (PHIA) is alive and well in this hospital and we all sign a pledge, etc. I just think we have to be careful not to go overboard and be protecting pt's privacy in ways that are not balanced with the risk. We have a cover on the bedside data that states the info is confidential-I think this is sufficient for the degree of risk. I do think you have me pegged as far as the privacy thing sometimes rubbing me wrong. One of the big reasons I had issues with the privacy act was that nurses were then denying family any info over the phone. So when the 80 year-old wife of a pt on the ward would call to see what type of night her husband had, people would just say they cannot release any info. I had a problem with this. The pt wanted his wife to know, his wishes were not being followed and we now made his wife worry for no good reason. Some nurses would release info, others some type of info and the more staunch ones would say absolutely nothing beyond what pt inquiry would say like "stable". Pt satisfaction surveys indicated that poor communication with the family regarding the plan, etc. was one of the primary problems they had with their hospital stay. So, to address this I (forever the change agent) developed a release of info form for the pt's to sign when they were admitted to our unit. On it the pt could give their permission to release info over the phone to family, or only to give info in the pt's presence, no info released, etc. It also allowed them to name a spokesperson for the information thereby saving the nurses' time if the family had many members calling in succession and we would direct other members to the pt's chosen spokesperson. It worked quite well as it respected the pt's wishes, left families less stressed and pts feeling like there was better communication. Often, I just take a phone to the pt's bedside and let them speak to the family member directly. Our pts must pay to rent a phone in their room so many do not have this (I think it is horrible that we do not provide in-room phones for our pts) Of course, others cannot communicate and we must speak to families for them. If you have point-of-care charting devices with a computer system I don't get why people would write things on a paper first and transfer it later. This seems inefficient. If they are too busy then it should be apparent that recording the data twice takes more time. It sounds like a vestige from the old way of doing things and that people have not fully embraced the evidence-based method of real-time charting. Research supports charting data as you gather it rather than waiting and doing it in "bursts". We have to try and make this work with the new computer system and I am glad you have pointed out this as an issue as I will be trying to get staff to take full advantage of the time saving properties of real-time charting. It takes a big change in approach for some that are used to writing things down. Charting right at the bedside rather than outside the room should also reduce the risk of other people seeing the info you are entering on the screen- thereby protecting pt privacy. I am really going to advocate for the bedside thing as it is making more and more sense as I ramble on about it right now. Thanks for getting my juices flowing about this. This is the discussion I need to help me in my quest. (I have also surveyed my fellow nursing instructors to find out what other hospitals are doing. They have told me that all the acute wards have beside charts. So it does look like we are an island in the storm- a big strength for my argument).

Thanks for your reply, I figured the only real argument for this method would be that of privacy. Unfortunately, the staff were never told if this was, in deed, the reason for this. I should let you know more about the situation. This is an acute internal medicine ward with 34 patients, many with renal failure and we do peritoneal dialysis on this unit as well as having a variety of other pt conditions. I am not fighting this change because it will make my life easier as I am a Clinical Resource Nurse (charge nurse), so my job is centered at the desk and having all the pt info at the main desk is actually better for me. It is not, however, better for our over-worked, under experienced staff who we have right now. This is a ward in crisis with very junior staff and daily safety concerns due to an inequality between acuity and experience and chronic short-staffing. They need every spare second they can muster. Thing is, there has never been a case where a patient, family or other individual has brought an issue of an invasion of their privacy to light when using this system. No one has ever had a complaint nor has there been a negative consequence from a privacy standpoint. This is where I feel evidence must support the practice. Is there a greater risk that someone could access this info that shouldn't be..(which, by the way does not contain diagnosis, prognosis, address info, etc.)? Yes. Has this actually happened in all the years it has been done? No. The charts are not right inside the room but rather by the door so accessing these charts is obvious to any staff member in the hallway at the time. On the other hand, there have there been real delays in treatment with real physical consequences and a noted and marked decline in nursing charting quality since the change. I feel this is a matter of pt safety which outweighs privacy in my opinion. Also, as I mentioned, this is not a permanent change in policy as we will have computer documentation beginning in less than a year. My issue is that they choose now, when this ward is in crisis, to place yet another hardship on these nurses. Other wards are not doing this. Easier wards. If this were true hospital policy, I agree that I might have to find a way to live with it, but clearly this is not hospital policy if only 2 wards out of about 32 are doing it. So my argument will be to leave things as they were and had been for the past umpteen years until the computerized system is implemented...this fall. I feel this will be viewed as an act of good faith by the nurses on behalf of the management and show support for this staff who have been having a mass exodus of late (they have lost over 12 nurses in the last year totaling over 200 years worth of seniority to lighter wards and all were replaced with nurses with less than 1 year experience...well not all were replaced- hence the chronic short staffing.) The very issue you raise of poor documentation is the thing I am trying to address with opposing this action. These nurses are not charting VS done at 0800 until 1500... this is not timely. They are trying their best, but sometimes they do not begin any charting on their pts until after 1400 on the day shift...this cannot be good from a legal standpoint. I believe in integrated progress notes and have no issue with this. Perhaps if management will not budge then the idea of at least having the nurse's clipboards separately at the desk as you describe may work as a compromise. I feel this still removes the accuracy and timeliness of point of care charting that is supported by the evidence but I could live with it if it helped the nurses do their charting more promptly and completely. I am leaving a teaching position and summers off to return to this place and try and help out where I can. I will hold off my actions until I have results of the surveys I drafted as I need to be sure the majority feel the way that those nurses who approached me with the problem do. I support decisions that make sense but I am having real trouble with this one. Thanks again for your thoughts, Brenda

Just wanted to let you know that there are still diploma (RN) programs in Canada. I teach at a Community College in Manitoba that offers an "Accelerated Diploma" as well as a degree (BN) jointly with the University of Manitoba. So there are still new grads without a four year degree in Canada. Brenda

Thanks, Yes I am looking for this type of info. I bet most feel the way you do. I am hoping the vast majority of wards have a bedside charting system for the components that make sense like VS, etc. I plan to bring this to the attention of the director when I present our case. I have developed surveys for the staff (health care aides, nurses, ward clerks, doctors) to assess everyone's feelings about this change but these are with the manager right now and I hope they are not going to tell me I cannot circulate them as I will be forced to go to above their heads on this issue. I believe it is a case of an employer directly impeding on the nurses' ability to practice safely. I think things are quite different here in Canada but I would appreciate any ideas on how to fight a bad policy (not that this is hospital policy as it is only being done on 2 wards). Brenda