What is happening with safe nursing..

[butterball1980]

I have been an ER nurse for several years. I've always been very proud to be an ER nurse, but see some pretty sad trending in the field. I have a family member that works in the ICU, so I often hear that end of patients that have received some poor care in the ER.

I had a family report to the ER. After some issues, we reviewed medical charts to find that the nurses and the doctors filled out complete physical assessments, when there were no hands on AT ALL. The pt was literally untouched by anyone in the ER, with serious complaints. But according to the EMR, the patient had not 1, but 3, hands on physicals.

My questions were - have we become so reliant on machines that we no longer touch? Are we too hung up on real time computer charting that we can't take our eyes off of a keyboard to look at a patient during a conversation? Are we becoming dependant on smart pumps, so we don't even know how to do drug calculations anymore? Are we too worried about positive ratings and "excellent" referrels that we are falling away from the very basic care - listening to lungs or an abdomen? Is it a nursing problem? Is it a management problem? Is it just a sign of the times?

I would like to hear how other ER nurses unit's do the triage process, from the minute the patient walks through the door. Are there instances that you send a patient to a waiting room without a brief assessment and VS? Do you feel that your protocols are used reasonably or as a way to make the shift a bit easier for the doc? In relation to the last question - an example I'll give is a 34 year old presenting with chest pain, cough, heavy smoker, recent history of bronchitis, non compliant with meds. The triage nor primary nurse did an assessment prior to protocol orders and it was expected by the docs (without a verbal report or doc exam) to do a complete "chest pain" work up. IV,EKG, labs, so on. Protocol orders were ordered immediately by the triage nurse, however the PA saw the pt shortly after and had her discharged before the EKG could even be done, but after an IV and labs were drawn. Are we not using common sense, nursing judgement and critical thinking skills to do appropriate care, not which is easiest?

I'd just like to hear some other opinions and thoughts.

[JKL33]

Is it a nursing problem? Is it a management problem? Is it just a sign of the times?

Not difficult to figure out.

If it were expected that every patient would receive the kind of care I will assume you would like to see (as would I), how long do you think management would tolerate no one doing it?

If things were set up so that kind of care could be delivered, how long do you think management would tolerate everyone thumbing their nose at the idea of providing proper care as it is set up to be delivered?

Are we set up for proper care? No.

Is it expected? No - that idea has become solely lip service. It's what people come back around and talk about after someone has complained or something has gone wrong.

The business of healthcare in the ED is currently incentivized to move patients though as quickly as possible (CMS OP-18). Increased throughput itself is a worthy enough idea (decreasing ED LOS as a means of dealing with dangerous overcrowding), the problem (as best I can tell) is that the means of achieving something take many different forms and then don't appear to be thoroughly studied. Your concern about misused protocols is one such example.

Developing patient care protocols and order sets for commonly seen chief complaints will improve the efficiency of care by standardizing treatment delivery and decreasing the wait time before patients receive needed interventions. - ENA Topic Brief

Leadership hears one thing and applies it inappropriately. If protocols are being used and patients are moving through....pretty much the end of the story for them.

But then there are the "LTR" scores.

CMS appears to currently still be working on EDPEC instruments and processes

- but everyone is already doing some version of patient experience surveying. Last I knew our ED surveys only go out to non-admitted patients and there is a response rate that would single-handedly invalidate any responses received, but that hasn't stopped anyone from moving heaven and earth in the most insane ways possible in hopes of improving LTR scores.

So.

This is what we're dealing with.

There have been several posts recently about how terrible things have become which essentially focus on what nurses and physicians did wrong or did not do right. I personally don't think that is a useful attack on the issues, which are far, far beyond the reach of any individual. We are expected to move quickly and whatever it takes to make that happen is basically what is expected until something goes wrong or someone complains. Then it will be asserted that the fault clearly lies with the individual who did wrong or didn't do right. That is a fine predicament.

[JKL33]

And before anyone comes along to say that each individual is responsible for their own ethical practice of nursing/medicine so there is "no excuse" - -

Yes.

We do the best we can with prioritizing appropriately using principles of nursing and nursing ethics. Most days this comes down to doing one's absolute best for clearly sick patients and trying to hustle enough not to piss off everyone else. I would never chart something I didn't do, I'm careful with med administration and assessments, good with skills, quick, and try to be kind and professional.

I have no other solutions.

At some point this is beyond the "ethics" of entry-level workers. We are well beyond that point.

[Susie2310]

And before anyone comes along to say that each individual is responsible for their own ethical practice of nursing/medicine so there is "no excuse" - -

At some point this is beyond the "ethics" of entry-level workers. We are well beyond that point.

I disagree with the above. Each individual is responsible for their practice. The state Boards of Nursing holds nurses individually accountable for their practice. Each individual makes choices to remain employed at a facility, and to practice ethically, competently, or otherwise.

[Susie2310]

Not difficult to figure out.

If it were expected that every patient would receive the kind of care I will assume you would like to see (as would I), how long do you think management would tolerate no one doing it?

If things were set up so that kind of care could be delivered, how long do you think management would tolerate everyone thumbing their nose at the idea of providing proper care as it is set up to be delivered?

Are we set up for proper care? No.

Is it expected? No - that idea has become solely lip service. It's what people come back around and talk about after someone has complained or something has gone wrong.

The business of healthcare in the ED is currently incentivized to move patients though as quickly as possible (CMS OP-18). Increased throughput itself is a worthy enough idea (decreasing ED LOS as a means of dealing with dangerous overcrowding), the problem (as best I can tell) is that the means of achieving something take many different forms and then don't appear to be thoroughly studied. Your concern about misused protocols is one such example.

Leadership hears one thing and applies it inappropriately. If protocols are being used and patients are moving through....pretty much the end of the story for them.

But then there are the "LTR" scores.

CMS appears to currently still be working on EDPEC instruments and processes

- but everyone is already doing some version of patient experience surveying. Last I knew our ED surveys only go out to non-admitted patients and there is a response rate that would single-handedly invalidate any responses received, but that hasn't stopped anyone from moving heaven and earth in the most insane ways possible in hopes of improving LTR scores.

So.

This is what we're dealing with.

There have been several posts recently about how terrible things have become which essentially focus on what nurses and physicians did wrong or did not do right. I personally don't think that is a useful attack on the issues, which are far, far beyond the reach of any individual. We are expected to move quickly and whatever it takes to make that happen is basically what is expected until something goes wrong or someone complains. Then it will be asserted that the fault clearly lies with the individual who did wrong or didn't do right. That is a fine predicament.

When individual practitioners practice below the Standard of Care, and when patients are harmed/injured/killed/suffer a negative outcome because of this, I don't see it as unreasonable that attention should be drawn to this situation, and speaking out about this informs people as to what is happening. Knowledge is power. People reading this can choose how to respond to this information. This isn't a useless attack on these issues.

Staff are expected to move quickly; if in order to do this they practice below the Standard of Care, they have made the choice to sacrifice the Standard of Care and to provide a lesser quality of care. To the Courts, and to the State Boards of Nursing/Medicine, and to various regulatory agencies, the Standard of Care exists legally and is very real, and is what one's performance of one's professional duties is measured against. The question for each individual is: "What choice are you going to make if/when you are faced with having to perform care quickly (and unsafely) or providing safe care (more slowly) that meets the Standard of Care? If you are unable to perform safe care quickly that meets the Standard of Care, are you going to perform unsafe care quickly?" It is an individual choice. And yes, even the argument that: "I have no choice but to practice unsafely if I want to keep my job," is still a choice; safe practice is sacrificed in order to remain employed. And one can argue: "I have no choice but to practice unsafely/quickly in order to remain employed and support my family," but even then it is still an individual choice, even though it is one that some people will have sympathy with and will consider morally justifiable.

Also, you are omitting the fact that in all professions there are individuals who simply do not care about the work they are performing, and in all professions there are individuals who are negligent, lazy, careless, and incompetent; even criminally minded. Basically, people who have bad attitudes. They exist in nursing too.

It sounds as though increased state government oversight of facilities is necessary.

[JKL33]

There have always been individuals such as you describe. What has changed is that the environment has become exceedingly difficult for everyone/anyone to provide good care, including people who are neither negligent, lazy, careless nor incompetent.

When individual practitioners practice below the Standard of Care, and when patients are harmed/injured/killed/suffer a negative outcome because of this, I don't see it as unreasonable that attention should be drawn to this situation, and speaking out about this informs people as to what is happening.

No. That is wrong thinking. I will explain: When individual practitioners practice below the Standard of Care *and* when patients are harmed/injured/killed/suffer a negative outcome because of this....??? No. The situation is such that a person who strongly desires to practice nursing according the CoE and standards of care cannot easily do so. That is always a problem. Daily. Every day.

The issue is that no one cares about the state of affairs until/unless something bad happens, and then they want to blame an individual.

Staff are expected to move quickly; if in order to do this they practice below the Standard of Care, they have made the choice to sacrifice the Standard of Care and to provide a lesser quality of care. To the Courts, and to the State Boards of Nursing/Medicine, and to various regulatory agencies, the Standard of Care exists legally and is very real, and is what one's performance of one's professional duties is measured against. The question for each individual is: "What choice are you going to make if/when you are faced with having to perform care quickly (and unsafely) or providing safe care (more slowly) that meets the Standard of Care? If you are unable to perform safe care quickly that meets the Standard of Care, are you going to perform unsafe care quickly?" It is an individual choice. And yes, even the argument that: "I have no choice but to practice unsafely if I want to keep my job," is still a choice; safe practice is sacrificed in order to remain employed. And one can argue: "I have no choice but to practice unsafely/quickly in order to remain employed and support my family," but even then it is still an individual choice, even though it is one that some people will have sympathy with and will consider morally justifiable.

I'm well aware. I would guess I spend as much time thinking about these things as almost anyone. My goal in any of these discussions isn't to make excuses.

There's a lot wrapped up in all of this besides just the idea of safety, though. If this were solely about prioritizing for safety that would be easy, wouldn't it? I mean, were it just safety then the ESI 4s and 5s would be seen...never...so that we could more easily prioritize according to the SOCs to which you refer. For starters.

The last handful (or more) of ever-special "initiatives" undertaken in my department had absolutely zilch to do with safety. They had to do with one of the two quality/reporting measures I have already mentioned above...which only get to specific-incident safety in a very, very roundabout way in a galaxy far far away.

Also, you are omitting the fact that in all professions there are individuals who simply do not care about the work they are performing, and in all professions there are individuals who are negligent, lazy, careless, and incompetent; even criminally minded. Basically, people who have bad attitudes. They exist in nursing too.

I'm not omitting that at all. It's not a new phenomenon, though, and besides - people with a lot more power than entry-level employees are the ones who hire these individuals of whom you speak. I'm sure you have noticed the trend toward having little experience at the bedside, as well.

I am not responsible for any of this. I am against it.

[JKL33]

I disagree with the above. Each individual is responsible for their practice. The state Boards of Nursing holds nurses individually accountable for their practice. Each individual makes choices to remain employed at a facility, and to practice ethically, competently, or otherwise.

You can say that all day long and it is pretty much indisputable. Meanwhile, in 5 seconds I could easily put you into a situation in which you can't meet all applicable standards of care/ethics/competence - or where it can be easily made to look like you didn't. It happens every day! Every single day. Don't you find that somewhat problematic?

[Susie2310]

There have always been individuals such as you describe. What has changed is that the environment has become exceedingly difficult for everyone/anyone to provide good care, including people who are neither negligent, lazy, careless nor incompetent.

No. That is wrong thinking. I will explain: When individual practitioners practice below the Standard of Care *and* when patients are harmed/injured/killed/suffer a negative outcome because of this....??? No. The situation is such that a person who strongly desires to practice nursing according the CoE and standards of care cannot easily do so. That is always a problem. Daily. Every day.

The issue is that no one cares about the state of affairs until/unless something bad happens, and then they want to blame an individual.

I am not responsible for any of this. I am against it.

I'm not arguing that the environment isn't exceedingly difficult for anyone/everyone to provide good care.

No, it's not wrong thinking. Regardless of whether practitioners want to practice below the Standard of Care or not, if they do so, they still made a choice to do so because, knowing what the Standard of Care is, and knowing how their facility operates, they performed care that was below the Standard of Care. The fact that the environment is constantly difficult for practitioners to meet the Standard of Care is beside the point.

A lot of people do care about the state of affairs, and when something bad happens they look at the individual's actions and whether or not they met the Standard of Care. That doesn't mean they won't also look at the role the facility had in the bad event happening.

To my knowledge, no-one is saying you are responsible for any of this.

[Susie2310]

You can say that all day long and it is pretty much indisputable. Meanwhile, in 5 seconds I could easily put you into a situation in which you can't meet all applicable standards of care/ethics/competence - or where it can be easily made to look like you didn't. It happens every day! Every single day. Don't you find that somewhat problematic?

Suppose I told you that I don't allow myself to practice in a situation where I can't meet the Standards of Care/ethics/competence.

[JKL33]

I would essentially say the same for myself.

Except that, if I'm 100% honest about it, what that means is that I prioritize carefully adhering to each of those principles/standards as best I can, and that I am prepared to not have the job any longer if need be, and that's about the extent of my declarations.

Do I think what you've declared is possible in reality? I guess - hinging solely on what your job is. In a busy ED - no I don't think it's possible. I think it's something people like to believe they're doing, but in very simple ways, they aren't.

[JKL33]

I'm not arguing that the environment isn't exceedingly difficult for anyone/everyone to provide good care.

No, it's not wrong thinking. Regardless of whether practitioners want to practice below the Standard of Care or not, if they do so, they still made a choice to do so because, knowing what the Standard of Care is, and knowing how their facility operates, they performed care that was below the Standard of Care. The fact that the environment is constantly difficult for practitioners to meet the Standard of Care is beside the point.

My point (the facet of this that I said was wrong thinking) was the fact that your original statement was two-pronged: Below-standard care and a negative outcome. I say that because one of the biggest problems I can see is that everything just keeps rolling along at the usual levels of chaos until there's something that requires blame, but on any given day basics and standards are not met because we aren't set up to actually meet them. We pay attention to them after the fact, when something bad has happened, largely for the purpose of being able to say, "well he didn't do this..." or "she didn't do that...and that's why this happened." If nothing seriously bad happens, standards aren't a priority. [in case that statement requires clarification, I am referring to what I see around me, not what I personally believe]. If basics and standards of care and ethics and competence are important, then we have to act like it 100% of the time, not just when it's time for PR/damage-control.

But, with regard to the bolded portion, I will need to bow out of the discussion if that is going to be a stipulation. I could not more vehemently disagree with that general idea.

[NuGuyNurse2b]

Suppose I told you that I don't allow myself to practice in a situation where I can't meet the Standards of Care/ethics/competence.

Seriously? You think people have this kind of liberty?