"Getting Good Care in the Hospital requires Vigilance"

Nurses General Nursing


You are reading page 3 of "Getting Good Care in the Hospital requires Vigilance"

CashewLPN, LPN

348 Posts

gee... she irritated me in that article...

heres my few cents....

(its long...but I'm mad)

Ms. Linn:

I am a Licensed Practical Nurse in the boroughs of New York. I am licensed to work by the state, I studied in an accredited school of nursing, and passed the NCLEX-PN (state board exam for practical nursing). I have worked in both inpatient hospital and long term care settings. My scope of practice is that of a nurse, I work with the Registered Nurse to help give as complete care to my patients as possible.

I only list my education, so you may know where I stand.

I was directed to your January 19, 2003 article, Getting Good Care in the Hospital Requires Vigilance, on a popular website frequented by nurses-- AllNurses.com . I've read your article, and appreciate your side of the story. To be a patient is not one of the better things in life to be, I do agree. Unfortunately, you list what is going on wrong, but, you do not list causes as to why it may be happening, and imply that it is the nurses fault.

As a nurse; as a compassionate individual, I would love to personally give each patient as much care as I physically could, in a perfect environment, with no other distractions. Unfortunately, as is life, it's never that perfect.

I will use a busy Inpatient Rehabilitation Unit, 3P-11:30PM shift as the basis of most of my examples, as it is often as close to an 'average' perfect environment as you will ever find. I ask you to keep note of the TIME references here... it might prove interesting.

Please note, the unit holds 65 beds, there are five nurses (usually divided into 3 LPN's and 2 RN's, Staffing may Vary), and 4-5 non licensed assistive personnel. The patients contain every sort of patient, may it be Orthopedic (second day post op knee and hip replacements, externally set broken bones, second day post op surgical patients, often with drains still in place, Ventilator patients, Patients with Dementia, Patients with Traumatic Brain Injury, patients with respiratory disorders, patients who are dying who do not wish hospice in the hope that they will heal, Fresh Stroke patients, Cardiac Patients, as well as any other disease process where there is a hope of getting well enough to leave.)

On an average day, imagining that there are 8 empty beds, dropping the census to 55, that would be 11 patients per nurse and aide. A verbal report takes place at the start of the shift, it is usually finished by 3:30P as long as the day shift nurse has completed her duties, and nothing else is going on. As soon as report is finished, the patients are met, and assessed. 'Hello, my name is Barbara, I'll be your nurse for today. How are you doing today?' is usually met with a request for pain medications, as they have just returned from their time in the rehab gym. So, I figure, we're going to use 2 minutes each patient to meet and have a very Brief assessment (IE a once over, the patient is breathing, theres no emergency at this moment). Every time I need pain medications, I must go from the patient room to the mini floor pharmacy area (The medicine carts are being refilled by the pharmacy from 3P-4P), Check the medication administration record for the medication. Then, I must go to the nurses station, and remove the medications from a computerized narcotic box. Essentially, you need a personal code, and a password to retrieve medications. Then, the meds must go to the appropriate patient. On a good day, with no distraction, I can accomplish this in 5 minutes each time. Also, I'd like to introduce the concept of documentation. For every minute of patient care, there is approx. 1 minute of documentation that must occur, but it often gets crammed into the extra seconds we can glean from time to time.

So far, counting 5 requests for pain medication, 25 minutes. to assess my patients, 22 minutes, a total of 47 minutes.

It is now 4:17 PM, dinner trays are being set up by dietary staff. Invariably, lets say, 98% of the trays are delivered correctly... that's a 2% degree of error, or .. approx. 1 tray is not correct. Trays will be passed at 4:20-4:30

At this time, assuming each nurse has 4 diabetic patients, the nurse must check their blood sugars. The Machine itself takes 30 seconds, the explanation of what the nurse is doing as well as performing the procedure takes approx 1 min, 30 seconds, then explanation of the reading figure, another minute each giving us a total of 3 minutes each, again, barring distraction. 12 minutes gone. Oh wait... I forgot one thing.... there are only 2 machines to assess blood sugar readings on the ENTIRE UNIT. Being on the side of hopefulness, lets say, we are the second nurse to get the machine, and that each machine has batteries. 12 minutes waiting and charting time (no time is wasted idly standing, there are not enough chairs, we can not sit.), then the 12 minutes for our checks. Now, due to our lack of equipment, and time constraints, our diabetic patients have their trays, and their blood sugars have not been tested yet.

Ok, now, it is 4:41P. Diabetic medications such as insulin and oral medication is passed (you should not give a sugar lowering agent without checking the patients blood sugar, doing so can be dangerous) assuming that you have to give all 4 patients medications, at 1 minute each, that puts us at 4:45P (again, barring all distraction)

The List for the admissions is being assembled on the floors white board. It will not be final until 5PM. In hoping for a 'perfect assignment' lets say each nurse gets 2 admissions, and, begins starting the paperwork. This takes approx 5 minutes each for basically verifying which patient is going where, assembling all the paperwork (a rehab admission is approx 25 pages long, 10 of them are devoted specifically to nursing).

4:50, calls for report on these patients begins, at approx 5 minutes a piece in report itself, and 2 minutes of waiting (and charting) on hold, 14 minutes gone. It is now, 5:04P

Allowing the "hour rule' (medications must be passed between 1 hr before time, and 1 hr post time its due.. eg, 6PM med meds are typically given between 5 and 7) you now begin your First Medpass. 11 patients, at 5 minutes each, (setting up meds, explaining meds, and administering meds). 55 minutes. Guaranteed, at this time, you will get requests for bedpans, the bathroom, tissues, water, et al. It is often passed to the aide, who, at this time is assisting patients into pyjamas, passive motion machines (for new knee replacement patients), brushing dentures, and helping with bathroom runs. Assuming that there are 5 more requests for medicine related items, at an extra 5 minutes each, 25 more minutes. It is now 6:20.

The admissions now typically arrive. They typically are unfed, medical orders are typically received with the patients. It takes approximately,20 minutes for the late food trays to arrive, Settling the patients, transferring them to the rehab beds, and taking care of any immediate concerns (pain management, comfort, bowel and bladder needs, cataloging clothing and personal items brought in ) takes approx 30 minutes EACH. It takes approx 20 minutes for them to eat. This leaves us at approx. 6:50 for the first patient to be done, and ready to be formally admitted. The 10 pages of the nursing assessment, with about 2 minutes of explanation and getting the required signatures per page, it is 20 minutes, barring the patient or family has questions, or issues such as inability to read English, Spanish, Russian, or Cantonese, inability to see, inability to sign (many new stroke patients cannot sign due to weakness) or dementia type confusion. With a Very Rapid skin check and physical assessment (we need to know if there is any skin breakdown, and when it occurred) we can assume it will be approximately 7:10P at the time the bedside portion of the first admission is completed, and returned to the unit clerk to be entered into the computer. Assuming that the other patient is sitting ready, their assessment and admission can begin at this time, and can be finished by approximately 7:30P (remember, this is just the admission paperwork, not the standard floor paperwork).

Remembering the 1hr rule again, 8PM and hour of sleep medications are now passed from 7:30-9:00 ( remember, now we have 13 patients, at 5 minutes each or 65 minutes, plus an extra few minutes each for medication requests.)

9P, now, the admissions are formally completed, all values and medications are entered into the form, as well as patient status. Assuming 15 minutes each it is now 9:30PM.

Dressing Changes are done now, assuming that in your 13 patient there are 7 dressing changes, at 7 minutes each (explaining, setting up, and doing) would be 49 minutes. It is now 10:19.

We now have 1 hour and 40 minutes of the shift left. We did not take dinner, or go to the bathroom, and, yet, it was a perfect night-- I mean, nobody asked for anything.... nothing like tissues, or their garbage bags to be changed...

10PM Blood sugars, and medications... assuming that we have 5 diabetic patients, and 5 Ten PM medications, 5 minutes each.... 50 more minutes gone, 50 minutes left until the next shift comes in...(and we pray that they come in with no call outs... )

10:10PM... Now, we document, including Flowsheets on each patient (1 minute each, we;re moving fast) Notes (one each, it takes 2 minutes for a unique and pertinent note) and odd requests (the occasional sleeping pill and pain med, lets assume 2, at 5 minutes each) lets add that up.... 49 minutes.

10:59P-- Bathroom period, over at 11:00

11:00-11:30P report to night shift.

Wow, Ms, Linn-- a perfect night, I mean, we allotted a minute for a bathroom break.

now, imagine we toss in an emergency situation-- add an hour anywhere during the shift, and allot an extra hour to catch up on the documentation afterwards...

now, imagine that you have no relief, odds are that you are mandated, as in FORCED to tack an extra 8 hours to the end of your shift.

So, drawing from this example.... how do we get more, and better care to our family members, or worse... to ourselves?

Here are some ideas...

1) Have a family member or friend around who can help the patient with things such as tissues, ice and water.

2) Please remember to say 'Please' and 'thank you' to the nurses, after all, we are people too.

3) If something is wrong-- eg a full garbage can, or a mess somewhere, please direct the complaint to the nurse or aide... we will let maintence or housekeeping know... but, as nurses, we often don't have the time to take out the garbage, or change the beds.

4) Please make use of your surveys.... hopefully, management will get the picture and hire more nurses to get things done....

5) Lobby to government. Insist that we need more nurses and more aides.

Tell me, Ms. Linn, if you had a job, nay, a Career, where you are educated and tested, specialized in your field, Would you tolerate no break periods, no meals, and a chance that you will not be able to go home at the end of your shift? Would you tolerate Short Staffing?

We nurses do..... why? I hear you ask.... its because we CARE to do the best job we possibly can in the conditions we are faced with.

May the Goddess help us if all the nurses were to stop working one day.... It'd be a very bad day indeed...

Thank you for your time,

Ms. B. Casuso, LPN

--- Barbara Casuso

--- [email protected]

--- EarthLink: The #1 provider of the Real Internet.

Hellllllo Nurse, BSN, RN

3 Articles; 3,563 Posts

Ms. Barbara Casuso-

Brava Brava Brava!



20 Posts

In regards to your article - Getting good care in the hospital requires vigilance-, you have not told the whole story. You have only worsened the already poor view the public has of nurses. If I were super woman I could answer every call light, every question, complete all of my paperwork, have time for lunch,etc etc. It is simply impossible! Instead we have to prioritize, we make sure our patients get thier meds safely, treatments safely, emergencies are tended to in a fast efficient manner. Perhaps you should use your press pass to spend some time with nurses and get the real story as oppossed to adding fuel to the fire of the already ignorant public's perception of nurses. There is simply a lot more to it than meets the eye. Please tell the real story to the public and help the country's nursing shortage. More and more nurses will be retiring soon, this shortage will peak in 2006. We do NOT need to be treated like criminals by having our patients families ask us our name and write down everything we do every time we enter our patients room. Why do you think something as negative as that would help? I ask you again to redeem yourself by making it known to the public about the nursing shortage, and what it's really like to be a nurse.


K O'Malley

136 Posts

In my experience the nursing staff avoids like the plague patients and/or families who write down everything . We figure that they are trying to find something to sue over and very often they are. I have no objections to patients who ask what meds they are receiving. Often it stops a mistake in its tracks. Its unfortunate, but rushing around in a frenzy because of short staffing and being interrupted 100 times while trying to pour meds is a perfect set up for many errors. When I first went into nursing it was an absolute rule that a nurse preparing meds was not to be interrupted. Of course that was in the days when we had a med nurse.


34 Posts



772 Posts

l just go a reply from Ms. Linn....here it is in all its glory:

Hello --

Thank you for your comment. Who placed the blame on nurses?. It was

obvious the column talked about system problems that can only be addressed

by administrators and reforms that need to go well beyond hospitals.

Virginia Linn

Post-Gazette Health Editor

34 Blvd. of the Allies

Pittsburgh, PA 15222


1,244 Posts



34 Posts

HUMMMMMMMMMMMMM..... do I expect any different .... tune in folks for as the hosptial turns and churns.....


1,244 Posts

Gee, however did we get that idea??? :rolleyes:

Getting good care in the hospital requires vigilance


Tuesday, January 14, 2003

By Virginia Linn, Post-Gazette Staff Writer

In recent weeks, I've received more complaints than I can remember from exasperated family members trying to ensure good medical care for their loved ones. Not while they were at home, but in the hospital.

Virginia Linn

For many, it required 24/7 vigilance and repeated visits to the nursing stations to seek basic assistance such as janitorial services, water cups or a change of dirty linens that had been soiled for hours.

Here were some of the complaints:

A 90-year-old Squirrel Hill woman with a swallowing problem was given a "Nothing by mouth" order from her doctor, meaning she was to receive no liquids or food by mouth. But several times, cafeteria aides left food trays at her bedside. The practice continued despite complaints from her daughter.

One morning at 3, the daughter got a call at home from a hospital nurse with news her mother wasn't doing well. The nurse had been feeding her ice cream.

An 84-year-old woman on a fluctuating dose of the blood thinner Coumadin was admitted to the hospital with other medical problems. Her son said the nurses failed to follow her strict drug regimen and after she was released, she experienced related complications that landed her back in the hospital. While there, she went hours without water, despite repeated requests to the nurses, and often was left without for a bedpan.

The daughter of a 96-year-old Munhall patient was horrified at the condition of her mother's hospital room during a lengthy stay: On one day she found dirty latex gloves, toilet tissue and bloody bandage wrap on the floor and an overflowing garbage can. There were no paper towels in the room for more than two days and the bathroom often lacked hand soap (How was the medical staff washing their hands?). Staff administering drugs often failed to read medical charts, and had to be corrected by the daughter about the proper drugs and doses.

When her mother was in a critical care step-down unit, her care was entrusted to unsupervised nursing students for extended periods.

The daughter ultimately took her complaints to the Pennsylvania Department of Health, which conducted an unannounced investigation. In a letter to her, the health department said the investigators found no violations.

These are just a handful of complaints I've recently heard involving respected hospitals throughout the city. These complaints would take weeks of investigation and interviews to confirm, but the pattern of these concerns shows that something is not right. Are families just becoming more proactive or critical in their assessments of hospital care? Or is care deteriorating before our eyes?

Most hospitals have patient representatives who handle complaints, but families often find them ineffective.

Charles Inlander, president of the People's Medical Society, a consumer advocate group based in Allentown, Lehigh County, is not surprised about these complaints.

"When we started the organization in 1983, the No. 1 issue was hospital-related problems," he said. That hasn't changed. "The hospital is the most unsafe place you can be when you're sick. If you have to be there, you have to be assertive -- not obnoxious -- but assertive."

There are many things families can do to ensure the best care, he said. First, enter with the right attitude.

"You're not in custody, you are the patient. You are the customer. You have the right to have your questions answered, you have the right to prompt service, the right to information not easily made available, the right to complain and the right to ask for a different nurse or a different staff member. The law supports this in every case."

There's more:

If possible, have someone with your loved one 24 hours a day. Patients often are too sick or intimidated to push for what they need.

As soon as you get to the hospital, make it clear that you'll be keeping a close watch on your loved one. Write down everything that happens -- the name of every person who comes in the room, what he or she does, the condition of the room, etc.

If a nurse doesn't answer a page promptly, call the hospital switchboard and ask to be connected to that floor's nurses station. They'll be sure to pick up that phone.

If your problems are not being addressed, call the hospital administrator. If a secretary tries to refer you to the patient representative, say "no", and insist on talking to the administrator.

"That gets you very quick action," Inlander said. "The hospital does everything it can do so you won't complain. It doesn't want problems."

But there's a flip side. The complaining relative becomes a pariah among hospital staff, said one daughter. "You're public enemy No. 1."

After her experience tending to her mother in the hospital, she said "you feel like you've been through a war."

You can find other strategies in the People's Medical Society book, "Take this Book to the Hospital With You: A Consumer Guide to Surviving Your Hospital Stay" by Inlander and Ed Weiner. It's available at local bookstores or Amazon.com for $5.99.

As some Amazon reviewers learned, simply displaying the book on their hospital bedside table prompted staff to be more attentive.

Upon a patient's discharge, many hospitals distribute surveys so the patient can evaluate the stay. Take full advantage of this.

Bill Lieber, a travel agent who lives in Squirrel Hill, was admitted to a local hospital in late November for pneumonia.

After a five-hour wait in the emergency room, he was taken to his hospital room where there were two uncovered wastebaskets filled with Kleenex and dirty paper towels. They were never emptied during his three-day stay.

He needs a special breathing machine to sleep because of apnea, but staff didn't install it until after midnight -- hours after he normally would have been asleep.

And two requested urine samples went uncollected, each sitting by his bedside until the next day, and became too old to be tested.

"I sent it to everybody," he said about the hospital survey. "This was the worst experience I've ever had."


1,244 Posts

I got the same email, so i just copied and sent the above post.


772 Posts

Obvious you are not blaming nurses? Either you are lying or you are such a poor journalist that you cannot make your points clear. I happen to know that you have gotten responses from several disgruntled nurses who interpreted your intentions the same as I do. Perhaps we should have sent them to the editor instead since you are "obviously" not a classy enough journalist to retract when you are wrong....here are some direct quotes from your article, in case you forgot:

Her son said the nurses failed to follow her strict drug regimen and after she was released, she experienced related complications that landed her back in the hospital. While there, she went hours without water, despite repeated requests to the nurses, and often was left without for a bedpan.

One morning at 3, the daughter got a call at home from a hospital nurse with news her mother wasn't doing well. The nurse had been feeding her ice cream.

If a nurse doesn't answer a page promptly, call the hospital switchboard and ask to be connected to that floor's nurses station. They'll be sure to pick up that phone.

sound familiar?............LR RN

this was my reply to ms moron.


1,173 Posts

Wow...how do you guys rate?? She didn't even respond to my e-mail!

+ Add a Comment

By using the site, you agree with our Policies. X