So disappointed in hospital RNs and MDs

[carachel2]

I'm an RN, now FNP x 5 years with over 15 years of ER/CCU and ICU experience. Is it old fashioned to expect RNs to do a full assessment at the beginning of their shift?

I have a colleague/NP friend who has been in the hospital now x 1 week. I will spare the details, but she was admitted, discharged, admitted urgently to another hospital and then transferred back to the original hospital. In her whole WEEK of admission, she says just ONE RN and one MD even put a stethoscope to her back. A pleural effusion was MISSED because no one did this basic assessment. Is this the norm now? Do med/surg RNs chart their "make believe" assessment every day?? How do they do this and just flat out lie every day without being caught ? She spoke up at first, but soon tired of feeling like some crazed out NP who was being so picky about her care. She thought it would be interesting to see who would and who would not do an assessment. She says the new RN will come on shift, say hello, walk up to the in room computer and start charting a bunch of notes, pass meds and then continue with the same pattern all day. No bowel sounds auscultated, no lung sounds auscultated. Magical patient care without touching the patient !! This is at a pretty major size hospital too in a major metro area. I have to say I experienced something similar a few years ago but not nearly as bad.

Thoughts?

[calivianya, BSN, RN]

When I have proof that not living up to my facility's ridiculous standards actually hurts someone, maybe I will feel more guilty. Even previous posters pointed out that q4h is the standard for mouth care, not q2h. My facility also requires q15min water temp and two sources of patient temp when cooling and rewarming. I would like to hear how you all would handle this. These are not 1:1 patients; you would still have another patient. Only one patient temp pulls from the monitor. The one attached to the cooling blanket does not sync to the computer so you can only get q15min second source temps and water temps if you are in the room at that exact minute. If you take a 30 minute lunch, you by default are going to miss two sets of temps. If your other patient poops and it takes you more than 15 minutes to clean up, you are going to miss some temps. So, do you get written up for missing your temps, or do you skip lunch and neglect your second patient to make sure you are in the room every 15 minutes on the dot? I would like to hear how you perfectly honest charters would handle this situation. There are usually at least 5 of these patients on our unit at any given time, so this is a patient type you would have a couple times a month at least. It is not like this is an every now and then occurrence.

I do think that false documentation is horrible and I hate that I do it, but my facility's standards are ridiculous and impossible to complete, and I am not going to be fired for being honest. I am glad so many of you are willing to lose your jobs left and right for your integrity, but I am not. My patients are important and I do the best I can, but I am just as human and just as valuable as my patients are.

[NightOwl0624]

I do think that false documentation is horrible and I hate that I do it, but my facility's standards are ridiculous and impossible to complete, and I am not going to be fired for being honest. I am glad so many of you are willing to lose your jobs left and right for your integrity, but I am not. My patients are important and I do the best I can, but I am just as human and just as valuable as my patients are.

I appreciate your honesty, and do agree with you. The standards where I work are impossible to live up to. We are audited constantly, and anything that does not follow policy to the letter will be duly noted (and remembered). Things must be documented to the minute (restraints, pain assessments, etc.). How anyone can run from room to room on the exact moment that each is due is beyond my time management skill level. I seriously doubt that checking restraints 5-10 minutes late will cause any harm to the patient, but it will trigger corrective action to the nurse. Unfortunately, I also feel that if I am 100% honest, I won't be employed for very long.

[Graduatenurse14]

I'm brand new RN still on orientation so I'm in an odd place of wanting to do what my preceptor does and follow her directives and move more quickly since the orientation is so very short (156 hours of time doing patient care and 36 hours of classroom time) and we are so busy trying to get everything checked off the list (there's a real list of skills that I have to see and/or do) so I will be ready to be on my own the date that I'm due to be. Also, we have to do a certain number of overnights where there are far less opportunities to see/do them.

Do we do full head to toes on everyone like taught to in school? Not on every patient, every time. I think the thing that gets missed the most is a good anterior and posterior auscultation of the lungs (unless you're post op, then you do get one) We always do a focused neuro assessment Q4 hours since it's a neuro floor. Is it right? No. Do I want to do things differently when I'm on my own? Yes. I won't be tied to the stupid list that seems to be more important than real life patient care.

[Graduatenurse14]

In reading calivianya and NightOwl0624, it made me think of this real-life example of how RN's time is filled up where I work:

When a patient is getting IV pain meds they must be re-assessed in 30 min and then again in 60 min. and documented both times because an ED MD didn't reassess and something bad happened to the patient X number of years ago so now this is the policy even though the standard of care in the US for IV meds is reassessment in 30 min. and 60 min. for PO meds.

I get it, I really do but then there's stuff that I'm simply shocked at the way other things are done that are causing a high amount of med errors and are not wise for RN's to do in protection of their jobs and/or license.

[mandy13086]

I've been a nurse now for 6 months so I'm still new to it all, but i definitely make sure I do assessments because u just never know. I'll even go back and add things to my charted assessment if I notice something later that i hadn't in the morning. I don't understand how people don't do a decent assessment. I think (I hope) most of my floor does them..I've seen many & in report I've been told Patient X has crackles in their lungs, for example. I've also been told that, though, & I listened & they were clear...

But i noticed in nursing school how many nurses didn't do them and I was shocked. I understand the push for time..but I would be too nervous to miss something. I work on a very busy med surg floor, 6 to 1 ratio..but I make time for it. My facility is making us do bedside report..and as much as I kinda still hate it, it's helpful too. If the offgoing nurse says Patient X has a CDI abdominal dressing, then while I'm still listening, I politely ask the patient to have a look. If it is, great, if it isn't..i know to add that to my to do list. Drains..same thing. I had 1 time where they had 2 urethral stent bags, offgoing nurse told me about them, but i had never seen them. So i asked to look & assess together. Those bags were extremely full & could have become a problem had i not known they were needing to be emptied so early. For that & some other things, bedside reporting is helpful for us as nurses too. Sometimes report takes too long & I'm behind on assessments so i may, then, pull my meds & do my assessments at that time, but they get done. Idk..I understand the "too busy" response, but i agree..it isn't safe. Time management plays a large role..& no, not everything will get done, but an assessment needs to be.

Fortunately & unfortunately, it isn't possible in the system we use to copy & paste data nor is it quick for me to see what the nurse before me charted. It's easier to just do my own assessment. The only thing that auto populates is the wound section..everything else does not. I think that may keep some people more honest.

[dudette10, MSN, RN]

I appreciate your honesty, and do agree with you. The standards where I work are impossible to live up to. We are audited constantly, and anything that does not follow policy to the letter will be duly noted (and remembered). Things must be documented to the minute (restraints, pain assessments, etc.). How anyone can run from room to room on the exact moment that each is due is beyond my time management skill level. I seriously doubt that checking restraints 5-10 minutes late will cause any harm to the patient, but it will trigger corrective action to the nurse. Unfortunately, I also feel that if I am 100% honest, I won't be employed for very long.

Charting in real time, which is never on-the-dot, will get you corrective action?

See, this is why I roll my eyes so hard at charting requirements with regard to timing. Anyone with half a brain knows it's completely unrealistic to chart exactly every two hours, but it's expected during an audit. "They"--whoever "they" are--know it's a lie and don't care. I would argue that it actually promotes lying because there's no way in hell it can all be done in a single shift exactly on time.

Nursing is is a world of micromanagement and it drives me nuts.

[NightOwl0624]

Charting in real time, which is never on-the-dot, will get you corrective action?

See, this is why I roll my eyes so hard at charting requirements with regard to timing. Anyone with half a brain knows it's completely unrealistic to chart exactly every two hours, but it's expected during an audit. "They"--whoever "they" are--know it's a lie and don't care. I would argue that it actually promotes lying because there's no way in hell it can all be done in a single shift exactly on time.

Nursing is is a world of micromanagement and it drives me nuts.

i know, right?

if I were ever hauled into court I don't know what I would do. Obviously no nurse could be so perfect as the documentation.

i can't wait to leave bedside nursing

[jadelpn, LPN, EMT-B]

Since her diagnosis was sepsis, anemia (secondary to ulcerative colitis) with oxygen saturations of 88-93% and tachycardia...I think she would have been happy to have someone put a stethoscope to her back at least and listen. Seriously.It's astounding that it's not being done. I think one could forego the neuro,skin, etc. assessment but listen to the lungs and bowels please !

Goodness! I can't not believe that this patient was not monitored closely. Sounds to me like she may have needed a higher level of care until stable. Sepsis can kill people, people!

Your friend needs to speak to whomever is in charge of patient complaints. This was a serious condition that should have been monitored closer. Education and procedure changes at the very least.

Unfortunetely, churning out a bunch of nurses and throwing them on floors with little orientation leads to not even knowing what one is to be listening for. Most new grads are computer literate, can be told "be nice to the patients, the goal is 99.9% patient satisfaction" and they get that. What is not being taught is "here's how you do a head to toe. Learn it, know it, and do it at the start of every single shift, period."

Part of that assessment is knowing when the patient is off of "normal" or baseline. And the ultimate goal is NOT a smile, a "can I get you anything, I have the TIME!!" and other scripted foolishness when the patient is septic, perhaps have a major change in mental status, perhaps a fever due to this (which for adults, even a 101 fever actually hurts) is left tachy, and has an O2 sat in the toilet.

Even if the patient were not an NP, I would be asking some tough questions, and expecting some changes in practice.

[nonnocere1988]

That's terrible. I'll give meds late if I have to. Every pt gets a head to tie assessment. I need to know their baseline and if anything has changed since report. If a pt has a time sensitive med, I'll pass it and continue on with assessments. As far as I know, my colleagues do the same.

[Susie2310]

Goodness! I can't not believe that this patient was not monitored closely. Sounds to me like she may have needed a higher level of care until stable. Sepsis can kill people, people!

Your friend needs to speak to whomever is in charge of patient complaints. This was a serious condition that should have been monitored closer. Education and procedure changes at the very least.

Unfortunetely, churning out a bunch of nurses and throwing them on floors with little orientation leads to not even knowing what one is to be listening for. Most new grads are computer literate, can be told "be nice to the patients, the goal is 99.9% patient satisfaction" and they get that. What is not being taught is "here's how you do a head to toe. Learn it, know it, and do it at the start of every single shift, period."

Part of that assessment is knowing when the patient is off of "normal" or baseline. And the ultimate goal is NOT a smile, a "can I get you anything, I have the TIME!!" and other scripted foolishness when the patient is septic, perhaps have a major change in mental status, perhaps a fever due to this (which for adults, even a 101 fever actually hurts) is left tachy, and has an O2 sat in the toilet.

Even if the patient were not an NP, I would be asking some tough questions, and expecting some changes in practice.

A similar situation happened to my family member, and you are correct.

[Red Kryptonite]

Just found out last night my MIL had a poor reaction to anesthesia for an outpatient procedure Monday and landed in ICU. She's 2 hours away and I'm fighting the urge to drive up the hill and start meddling. I know too much about hospitals to leave anyone I care about alone in one! Apparently she's already had one fall when staff tried to get her up. FIL is with her but he's an emotional mess....today will tell. If she gets out of ICU today as hoped, maybe I won't. If she stays in I may drive up or encourage my husband to go.

[Susie2310]

Your friend needs to speak to whomever is in charge of patient complaints. This was a serious condition that should have been monitored closer. Education and procedure changes at the very least.

This is a great idea, but I have found it to be easier said than done. At the medical facility my family and I receive our care from, if one wishes to complain about medical care received one is required to write to an address on another campus with details of one's complaint. There is no patient advocate/patient complaints office that a patient/family member can just walk into, that I am aware of.

A while ago I had the trying experience of making a complaint about the quality of medical care a family member had received from another specialty, to my family member's physician. I believed it was appropriate to discuss the matter with my family member's PCP, as the situation was important for the PCP to know about. It was not easy to do this, even though I believe I was polite, as the physician was very defensive, and actually began shouting at me. The physician tried to dismiss my concerns, saying my family member didn't suffer a serious adverse outcome. Well, a serious adverse outcome was narrowly avoided, but it was too close for comfort. My family member, who was present, found the physician shouting at me to be very stressful. The physician did reluctantly issue new instructions for monitoring my family member in these types of situations in future.

In my experience, in practice, complaints are not welcome, and are not received well.