Posts Tagged Health Care Silliness

Nurses Practice Beyond Their Scope — And It’s Not a Bad Thing

A very good, if obvious, idea on the use of RNs: nurses should be used to the full extent of their abilities. From the Toronto Star (and kudos to the paper for their Nursing Week insert in Saturday’s edition):

“The bottom line is that we’re wasting valuable resources with our RNs,” says Doris Grinspun, the Registered Nurses’ Association of Ontario’s chief executive officer. “European countries like the U.K. have been using RNs to their full capacity for years. It will be a missed opportunity for the public, taxpayers and patients if we don’t move to full utilization of our nurses.”
[SNIP]
[Grinspun] wants the province to recognize the education and expertise of registered nurses, and to agree that they could be doing more within the scope of their practice, like diagnosing patients, ordering diagnostic and lab tests, conducting pelvic exams and prescribing medications.
Though the mandate of Ontario’s action plan for health care is to find ways to maximize the system, full utilization of care providers isn’t possible until the government revamps policies about who can bill for certain medical procedures. “We should be using nurses and all health-care providers to open access, increase the timeliness and quality of care and to contain cost,” she says. “But if a nurse does a pap smear, the doctor doesn’t get paid. If a nurse diagnoses a child’s ear infection and prescribes antibiotics, the physician doesn’t get paid. I go berserk when I see doctors taking blood pressure,” she says. “Nurses have the training to free up a doctor’s time in primary-care settings so she can focus on more complex situations.” Plus, the move to grant registered nurses more autonomy on the job would lower the waiting times for patients to be seen, meaning there will be fewer patients showing up at walk-in clinics and emergency rooms.

Not exceeding their scope of practice

The (somewhat) amusing thing about this idea is that nurses (or least those working in in high acuity areas like ICUs or Emergency Departments) already do all much of this in an highly unsanctioned, unregulated and unofficial way. Let me provide a simple example. Suppose I am triaging an exceedingly anxious patient with chest pain, and decide the patient requires an ECG — which incidentally I can order under medical directives. I explain the test to the patient. I tell her ECGs measure the pattern of electrical activity in the heart and therefore can show dysfunction. I place the electrodes across her chest and limbs, and carry out the test. The printout shows a patient in a regular sinus rhythm with no acute abnormalities.

Do I tell my agitated patient, whose anxiety is growing by the second, that (A) the ECG shows her heart is performing in a normal way and that we need to do some blood tests to confirm everything is okay, or (B) that the physician will discuss with her the results of the ECG when he sees her — which might be in a couple of hours?

When I was a new nurse, some years ago and being a good, diligent practitioner, I would have told this patient (B). This was not to dog my responsibilities or pass off work to the physician. (B), in fact, is the correct answer. Interpreting a test for a patient is considered a form of diagnosis, and in Ontario and most jurisdictions, making and communicating a diagnosis is considered the exclusive preserve of nurse practitioners and physicians.

But this is the deal. I have been educated how to interpret ECGs. I know how to tell atrial fibrillation from SVT from sinus tachycardia. I know what ischemia looks like, and I can spot ST elevations in a steam bath. More importantly I have the judgement to recognize the borderline cases and defer to the physician. Additionally, it seems to me, cruelty, indifference and bad nursing can be defined by a nurse telling a patient — especially one that is anxious —  that she needs to wait to speak to the physician about her ECG because of “the rules.”*

I am not for stupidity in the form of thoughtless adherence to regulation. I am not for cruelty either. So I decided a long time ago, that on balance, it was altogether better for the patient to have this information, rather than sit in the waiting room in a state of high anxiety. Even if my professional regulatory body has officially determined I can’t because technically it is beyond my scope of practice.

And so it goes. Nurses quietly and unofficially violate the scope of practice all the time. We push the envelope. We add blood work we think the physicians have missed. We slip in chest films because we know they need to be done. We order ECGs on patients we don’t like the look of.  We review lab results with patients. We cajole specialists into “having a peek” at a patient if we are worried about them. We tell patients — sometimes in very circular language, to avoid the damning “communicating a diagnosis” — what really is going on.

Why do we do it? Sometimes we know physicians will support us. Sometimes it’s to avoid difficult conversations with physicians, or because physicians won’t listen to the opinion of a mere nurse. (One physician I know of absolutely refuses to order serum lactates on obviously septic patients, because a positive result means she needs to follow a complicated sepsis protocol — even though the literature is pretty clear that early and aggressive intervention in sepsis saves lives.) Bottom line: we do it in the interests of the patient.

Should nurses be permitted to utilize their full knowledge and skills? Absolutely. It’s better for patient care and better for nursing work life. And also we need to formally regulate what nurses do already, to protect nurses themselves.

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*The College of Nurses of Ontario, my professional regulatory body, would probably, and unrealistically suggest the alternative of getting the physician to speak to the patient immediately after doing the ECG as the “proper” course of action. But think about it this way: my ED probably does 30 ECGs (if not more) in the course of a 12-hour shift; if it takes a physician 5 minutes to discuss the results with a patient, then 30 x 5 minutes = 150 minutes = 2.5 hours.  That’s a pretty big chunk of time, and in a busy department, is not going to happen.  And that’s if you could get the physician to come out to triage to see the patients to begin with. It is simply not good use of his time and is completely unnecessary. Which rather demonstrates the point of the article quoted above.

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Insert Snark Here

English: Linear Skull Fracture with arrow poin...

What this patient did not have

Mr. CD, 88, took a little tumble at the nursing home when he slipped on a loose rug (or something, the details are a little vague here), obtained for his trouble a scalp laceration the length of Q-tip on his temple, bled like a stuck pig, transported by EMS, triaged, assessed by both MD and RN, x-rayed, CT’d, declared medically cleared and fit to go home, deblooded, stapled, tetanus’d, acquired a head dressing worthy of a maharajah, and finally sent back to the nursing via a private ambulance and their ill-paid yet (hopefully) competent attendants.

Whereupon the RPN (i.e. LPN for you out of province types) or whoever was minding the door of the nursing home refused to take the patient back.

“Oh my God, he needs to go back the emerg,” she said, eyeing, perhaps, the overwrought head bandage. “He has a skull fracture! I can tell!” And promptly sent him back, alert, oriented x 3 — and bemused.

I have only two possible explanations for her extraordinary statement: she either is wasting her time at the nursing home and depriving humanity of a set of assessment skill so exquisite she can, using her psychic x-ray powers, detect a skull fracture under approximately twenty layers of clean, white 4 x 4 sponges and tape gauze, or else she thinks despite all the assessments and investigations, we are complete boobs. ( Admittedly, I have a sneaking sympathy at times for the second possibility.)

There is actually a third possibility, but I am far too polite to mention it.

That’s all I got. Feel free to insert your own snark.

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TV Series Hot

Gob-smacklingly stupid or hip advertising? I’m leaning towards the former. Via CBC:

A Stockholm hospital that published an online ad looking to fill a summer position with a nurse who is “TV-series hot” says it was “written to catch people’s attention.” 

“We want people to be curious and have a little imagination,” said Elisabeth Gauffin, head nurse at Stockholm South General Hospital (Södersjukhuset) to the Metro newspaper.

My Emergency department colleagues

The ad read, in Swedish: 

“You will be motivated, professional, and have a sense of humour. And of course, you will be TV-series hot or a Söder hipster. Throw in a nurse’s education and you are welcome to seek a summer job at Södersjukhuset’s emergency department.”

(“Söder” literally means “south,” but here refers to Södermalm, a fashionable district in Stockholm. Think “Soho.”)

The hospital’s nursing manager said the phrasing wasn’t meant to exclude anyone based on looks. 

I (sort of) get what the hospital was trying to do. Readers may have noticed I’m not without a sense of humour. But I’m not sure the “And of course” phrasing of the ad effectively signals the intended irony. It’s a little pathetic the hospital needs to rely on a tired old cliché to recruit nurses. Ultimately, I think, the ad trivializes what nurses actually do in Emergency departments, and reinforces public perceptions and stereotypes. As a well-seasoned RN, I would be somewhat disinclined to work there. But maybe it’s all lost in translation, and the ad is deliciously funny in the original Swedish.

Incidentally, for the record, I am not “TV series hot.” On the other hand, I know to work the buttons on a defibrillator.

[Thanks to my friend Leigh for sending this along to me. Her comment: “Laugh or cry?? Mostly exasperation I think. Add more horror that the survey results show that people think this is appropriate!”]

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Doctors Are From Mars, Nurses Are From — Oh, To Hell With It

News flash! From Fierce Medical News, here’s the shocking headline:

Docs, nurses miscommunicate on respect, job role

When you guys pick yourselves off the floor from laughing, here’s the money quote:

In particular, the survey found differing views of how doctors treat nurses. According to 42 percent of nurse leaders, physician abuse or disrespect of nurses was common, whereas only 13 percent of physician leaders said it was common. Fifty-eight percent of nurse leaders considered disrespect for nurses uncommon, while 88 percent of physician leaders said it was uncommon at their healthcare organizations.

“I do believe nurses and physicians are on two different pages when it comes to communication,” Pam Kadlick, vice president of patient care and chief nursing officer for Ohio’s Mercy St. Anne Hospital, said in a HealthLeaders Media article. “Nurses have a tendency to give a very detailed report, more than what a physician may want to hear; hence, the physician may interrupt, seem to be abrupt, even rude at times.”

But most physicians don’t consider such behavior to be disrespectful, she noted.

You’re telling me abuse of nurses is all about physicians being insensitive, maybe, and nurses having too many hurt fee-fees? Really? And nurses are supposed to be surprised that physicians “don’t consider such behavior to be disrespectful?”

Why does this sound like a ’80s sitcom?

Why does this sound like this report is trying to validate abusive physician behaviour?

You can only shake your head. And you just know, somewhere, in a darkened office maybe, in an obscure corner of a mega health care corporation, a manager is reading this report and exclaiming, “I knew nurses were to blame!”

I will very happily concede abusive behaviour of all kinds has declined markedly in my own time as a nurse, though I will say I work in an institution that enforces a zero tolerance policy against abusive behaviour. Moreover, the physicians I work with, shoulder to shoulder, are lovely and professional, and there is a true sense of collaboration. This makes for excellent patient care.

However, by no means is this true everywhere. So let’s not pretend the brow-beating, the mocking, the chart-throwing, the patronizing  — to be blunt, treating nurses like you wouldn’t treat your mother, daughter, wife, bank clerk, Wal-Mart greeter, housekeeper, or dog — still doesn’t go on. Denial will never fix the problem, either from physicians — or nurses.

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Karma Sweet Karma

The latest instalment of Nurses Behaving Badly featured the night charge and the day charge (i.e. me) getting a status asthmaticus organized in Resus 1 a few minutes after shift change. It’s probably reasonable to wonder why the two Resus Room nurses weren’t attending (and attentive to) the situation, especially after we paged the physician and the RT in quick succession for a possible intubation, and especially since both of them were less than twenty feet from where we were working.

We thought at first they were getting report on the only other patient in Resus, but after 10 minutes or so we began to wonder how long it actually takes to give report on a stable, routine, admitted, pain-free NonSTEMI.

Meanwhile we got the patient on high-flow oxygen, assessed, drew blood, did an ECG, set up stacked Ventolin treatments, placed two large bore IVs, hooked the patient up to the cardiac monitor and generally got organized to tube the patient.

Turns out they were looking at a jewellery catalogue, drinking coffee, texting, socializing, what have you.

Grrrr. And when the night charge asked our two colleagues to cease and desist from shopping and tweeting and trading bon mots and actually do some, you know, nursing, we got the “whatever” look: face squinched up, hands up in the air, eyes rolled. The look that manages to convey a dishful of entitlement and irritation, with a light sauce of fuck you to complete.

Double grr.

By the time I gave my report, it was nearly an hour after shift change. But what goes around comes around. There is cosmic retribution and it is just.  That night Nurse Tweedledee and Nurse Tweedledum received, in addition to the now intubated status asthmaticus:

A cursing psychotic patient in four point restraints

A cursing drunken 20-year-old who managed to pee and puke all over herself all at once

A VSA*

Another VSA

A non-compliant insulin dependant diabetic in DKA 

And just before shift change, a fulminating CHFer, which required them to stay long after their shift was over.

In short, they had a craptacular night. The complaints, the bitterness, I am told, from the pair was tremendous. They needed to leave. They had child care issues. Husbands needed vehicles — and one of them was written up for being late. They were tired as no nurse in the history of the universe was tired. Why are we so afflicted? they moaned. What did we do to deserve this?

Karma, baby, karma.

The cosmic lesson being simple, work starts promptly on the hour. Not after fifteen or twenty minutes of “social” time. Be considerate of your colleagues. They’ve been working for twelve hours and want to go home. Many, many, bonus points if you come in ten minutes before to get report so the nurse you’re relieving can get out on time.

To say I had any sympathy for either of them would be a bald lie. Can you say schadenfreude?

 

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*VSA = Vital signs absent.

 

 

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Don’t Tell Your Patient This. Or That.

Jo over at Head Nurse had an interesting question about a month ago. She was prepping for an interview for a Reader’s Digest article called “50 Things Your Nurse Won’t Tell”. It’s a common format for RD, I soon learned after checking their website, and features such articles as “50 Things Your Flight attendant Won’t Tell” and “50 Things Your Waiter Won’t Tell You”. In turn, the articles prompt answers along the lines of “Yes, the waiter will really spit into your soup, and how!” See the comments section in Jo’s post for the nursing version.

But the more I thought about it, the more I thought the question as posed by Reader’s Digest was curiously framed. Nurses are supposed to provide information to patients; withholding information seems like, well, unnecessary power-tripping. In fact, I will tell patients things I am not supposed to mention, like about the cosmic suckiness of hospital food (because it does) and how an ECG looks — but if I bring you in right away after doing it, you pretty well know it’s not good.

So there is very little, in the end, I won’t share. There are some things, however, that are beyond the pale. Here’s my short list of ten things I will never, ever tell you, my patient:

  • Anything that would violate confidentiality of anyone in the known universe. Not only because it’s unethical, unlawfully and probably fattening, but also because it’s none of your fracking business.
  • That your dire medical emergency is not, in fact, likely to be all that dire, though I do understand you may have been misled by the name “Emergency Department” into thinking that since you are here, it must be an emergency.
  • Anything that would tend undermine my physician or nurse colleagues. It’s nasty, and more importantly, I have to work with them.
  • You’re about to die. A situation where a patient is fully awake and aware and whose death is imminent is fortunately relatively rare. Even so, I’m not going go to pipe up and say cheerfully, “I think you’re about to cack, so get ready for the ride of your life.” That, as they say, is way above my pay grade.
  • What I really think of the peculiar family dynamics circling your bedside. Opening up that particular can of worms never ends well
  • About your dirty underwear. Yes, we do notice. No, I will never speak of it.
  • Similarly, your body odour will go unremarked. I will not tell you that you’re perfumed like the thing that rudely crawled under the front porch and expired. Even if you stink, you still have dignity and worth as a human being. But if I come in right after assessing you with a basin of hot water and rather a lot of soap and towels and wearing a bright yellow gown and mask, don’t be surprised and/or offended.
  • That I strongly question a pain scale of 10/10 if you’re drinking an extra large Tim’s double-double while telling me this at triage.
  • Along the same lines, claims of severe migraine will provoke some internal doubt, but nary even a raised eyebrow, if you’re also allergic to every analgesic and NSAID in the known universe except Demerol.
  • Your claims of alcohol consumption will be automatically tripled for accuracy.

I’m sure every nurse has his own list. At the same time, I wonder what patients really want to hear from us.

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Observations and Assessments

Notions too small for a blog post, all in one place.

Stormy weather. Some of you probably noticed a slight lack of presence here the last couple of days. The wind storm which swept over Ontario last Thursday left us without electricity, telephone and internet service, as well as blowing out an upstairs window and knocking over a fence. The power (or hydro as we say in Ontario) came back the same day; the telephone and internet returned only last night — there was some damage to the local wireless tower as well. The really bad news is that not only are Canadians voting in a federal election today, but that it’s also tax deadline day here in Canada. Because of the lack of internet access, filing was impossible* — and I have, as of writing thirteen hours and ten minutes to find my T4 slip and load up TurboTax.

The Good News. You were all spared — and I am pretty sure my American readers are especially grateful — a blog post about the various parties’ positions on health care. Believe it or not, I did wade through all the platforms, and they essentially ranged from generally sucky with bright spots  to really awful and/or nonexistent. (Hello, Conservatives?) Given the demographic wave which is about to wash over and possibly overwhelm the health care system, and the high priority Canadians place health care as an issue, some sort of debate around this issue might have been useful. Yet we heard nothing at all.

Oh, no, not again. Just so you know, for reasons previously stated, I am ignoring Nurses Week.

New meat. Some shout outs to some new (to me, anyway) nurse bloggers: RNnnnrGrl and Frazzled_razzleRN, The Adventures of a Nursing Student, and in particular Dreaming of Call Bells, who blogs from Moose Factory, Ontario.

Death over the airwaves. A new British television show will show will show footage a terminally ill man dying:

The death of a terminally ill 84-year-old man will be broadcast on British television in May, as part of a series documenting the life cycle of the human body.

A man suffering from cancer and identified only as Gerald will be shown taking his final breath — at home, surrounded by his family — on the second episode of the BBC One series Inside the Human Body.

Speaking to BBC listings magazine Radio Times, host Michael Mosley defended the footage, saying producers did not want to “shy away from talking about death, and when it’s warranted, showing it.”

He acknowledged that the decision to include the footage would inevitably draw criticism.

“I know that there are those who feel that showing a human death on television is wrong, whatever the circumstances. Although I respect this point of view, I think there is a case to be made for filming a peaceful, natural death — a view shared by many who work closely with the dying,” Mosley said.

Similarly, a new documentary shows a terminally ill cancer patient in Oregon taking a lethal (and legal) dose of euthanasia:

I’m not squeamish about death, and theoretically, anyway, I would support physician-assisted suicide. But when confronted with an actual person planning her death, I start having a hard time with it. It seems, well, too cold-blooded. Am I wrong?

Hospital food is awful and bad for you. This seems to be as true in Australia as it is in Canada. Inadequate nutrition is a serious issue in the deconditioning of elderly patients (see here, for example).

Doctors have called for a hospital food review, because patients are being discharged malnourished.

Australian Medical Association state president Andrew Lavender said the below-par quality of hospital food, set serving times for three meals a day, and a one-size-fits-all approach could lead to patients checking out malnourished.

“A lot of patients do become malnourished in hospitals,” he said. “They are trying to improve nutrition, but when you’re cooking for 700 or 800 people the quality is often not up to scratch.”

“Generally, the elderly and those who are sick don’t have an appetite and there isn’t much of a follow-up in terms of what someone doesn’t eat. People having major operations are in a state where their body requires extra nutrients to recover and they often they don’t get that. People do depart hospital down in weight.”

And yet, when looking for increased efficiencies in hospital budgets, the kitchen is often the first place to get the axe.

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*I mean, who does paper returns anymore?

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Observations and Assessments

Notions too small for a blog post all in one place.

April Foolishness. I guess I got  — or more likely annoyed — a few of you with my little April Fool’s prank. In case you missed it, I faked a news report from Trout Creek, Montana (pop. 261) stating the local hospital was going to fire all it nurses and replace them with housekeepers. I even put up a picture of some hospital in India, complete with palm trees (in Montana!). Some of you waxed quite indignant before realizing it was the First of April. What’s interesting is how readily people believed it — which speaks volumes about nurses’ perceptions about how they are valued by their employers. Which is to say, not much.

Nurse goes all postal on Craigslist. This epic rant has been making the rounds — those with delicate sensibilities may want to avert their eyes:

Well, after a year of getting rejected I have finally decided to give nursing the bird. FUCK YOU NURSING FIELD! Too bad the schools and media are still insisting that people go to RN school. Believe me THERE IS NO FUCKING SHORTAGE! New grads are considered garbage. On top of that, the degree serves no purpose in any other setting. BSN is a complete waste of time and money.

I know, “some people got jobs”. That does not justify the majority (1000’s) who did not and are now working retail for minimum wage. There is something fundamentally wrong with this country. My school counselors, nursing instructors, media and nurses I know urged me to go into nursing. As soon as I got my degree and the check to the school cleared I heard the unmistakable sound of the door to nursing closing—slamming actually. And it is not just the economy. Hospitals turning huge profits stopped new grad programs and hire foreigners.

It is over. I am a stale grad and I am out of options. The new graduates fresh out of their precepts will be flooding the market to add to the already rancid oversaturated pool of disgruntled STALE GRADS. So, I guess giving up a nice job for school, dedicating 6 years (yes, I was foolish enough to get the BSN), dropping 20 grand and putting up with nursing school stress was all for nothing.

And no, higher education is out for 2 reasons. One, you need RN experience to qualify for any NP program. Second, why would I throw more money at a system that just failed me and ruined my life? It is clear that the educational system is bunk. I am completely embarrassed at the education I experienced at the California State University–It is appauling.

I hate nursing. I hate it so fucking much now. The true colors of the profession are now clear. So, now society can have a derelict because that is what I intend to become. I now plan to make a living mooching off the system.

It would probably take a year of posting to unpack all of this. Suffice to say, I do have the tiniest bit of sympathy for her, as I graduated at the nadir of nursing joblessness in the ’90s and was forced to work part-time for the first three years of my career. That being said, I wonder at her commitment to the profession, despite the six years of expensive education; one senses she wants her dream job handed to her on a platter. It doesn’t work like that. So I’m with everyone else: don’t let the door hit you on the way out. Or else come to Toronto — I know some 5 North nurses who would love to have you as a colleague — and they’re hiring.

Uterus, uterus, uterus. In another take to the uterus-as-filthy-word story, now you can incorporate your womb. (Thanks Terri!)

Take me to your leader. In case my American friends and readers haven’t noticed, we’re finishing up the second week of a federal election campaign, where the forces of light and the agents of doom and darkness will collide in a colossal battle for the heart and soul of the nation, etc. Being the flaming left-wing commie-pinko-socialist I am, I will prevaricate until the very last minute till inevitably holding my nose and voting Liberal. All which is to say, if I seem more, um, political in the next few weeks, I can’t help it, it’s the environment.

Hope they were praying for epinephrine. Speaking of Members of Parliament, there’s a report in the Le Devoir this morning that three Conservative MPs witnessing a severe allergic reaction on a flight to Taiwan responded by laying on the hands and praying. I guess I slept through that part in my critical care courses where Prayer comes before Airway, Breathing, Circulation. [ Via. ]

Non-nursing blog shout-out:  Worcester College Gardeners — actual professional gardeners charged with the maintenance of 26 acres of grounds surrounding Worcester College , Oxford, U.K. Reading through the blog puts lie to the notion of effortless gardening: it becomes quickly very apparent all those charming, perfect English garden scenes Canadians wax green over are the result of some pretty intensive labour. What I could do with a flock of minions and unlimited cash!

A pair of quacks. I was happy to learn that both Mehmet Oz and Andrew Wakefield, the fraud-mongering anti-vaccination advocate, were recipients of the annual Pigasus Awards. Oz — and any self-respecting  nurse is always glad to see him taken down a notch or two — was given the award for promoting such quackery as energy fields and faith healing and advocating the bereaved call a psychic for consolation. (Why is this jackass still on television?) Wakefield got the award for continuing to peddle his nonsense despite being called out by the Lancet and the British Medical Association.

Mini-rant. To anyone who has cut and paste from this blog: it has come to my attention bits of my writing — which I remind you are not free, in the sense you can use them at will — are being circulated unattributed and altered contrary to the copyright notice on the bottom of this page. Please note that even if you did not see the copyright notice, you are still subject to its provisions. In other words it is your responsibility to ascertain your obligations.

I really don’t mind people lifting my writing so long as it’s unchanged and attributed to me. I actually like it, because it’s free publicity. But when I find my original work altered to the point where my authorship is in doubt, it starts to piss me off. When you don’t link back to me, you become a thief.

P.S. When I write “shit” I mean “shit”, not some milquetoast euphemism you have determined won’t offend your readers — which  incidentally doesn’t nullify the copyright either.

P.P.S. Why do I think it’s a losing battle?

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Hospital Replaces Nurses with “Super Housekeepers”

Hospital officials in Trout Creek, Montana fired all their front line nurses yesterday. Yep, all of ’em.  According to Avrile Fisher, the chief nursing officer (who in a fine bit of irony, was not fired):

“We were looking to cut costs and improve patient care,” said Fisher. “Providing all nurses with alternate employment opportunities was an innovative solution which will allow us to stabilize our budget and remain regional health care leaders.”

[SNIP]

Under the plan, nurses will be replaced by specially trained “Super Housekeepers”, who will assume many of the duties traditionally assigned to nurses. In addition to providing bed baths and feeding patients, the workers will dispense medications, monitor heart rhythms and start intravenous lines.

Reaction to the plan was positive. Edith Roussilon, a patient at the hospital’s Frequent Visitor Clinic, believes the changes will result in faster, safer care. “Those nurses are paid too much,” she said. “I trust the hospital to make the best decision in making sure I get my meds on time.”

Opposition from the state’s nursing association is fierce, but Fisher remains undeterred. “The fact remains,” she added, “that nurses are a drain on the system in terms of resources, and there is no good evidence that patients benefit from nursing care.”

Sign of things to come? Remember when a certain politician said nurses were like hula-hoops, in that they go in and out of fashion?

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Yep, It Was a Disaster

Nurse K had an interesting take on my blog post the other day about dealing with an over-crowded ED: it was a disaster, pure and simple:

In short [she writes] if, really truly, your hospital is using 25/27 beds for admits and there is no way to transfer them out or transferring would be significantly delayed and six critically-ill people are coming in via ambulance…I don’t care what’s going on or what country you’re in, that’s a disaster. Seriously.  If this is your hospital, and people are being shitmonkeys and refusing to assist you, start busting out the triage tags.  Page every administrator out there.  Say you have a disaster and are starting your Disaster Code.  Maybe someone will cancel a meeting if the media starts calling.

I’m not sure if she’s fisking me, engaging in some not-so-gentle mockery, or using my post to buttress her conceptions about the nature of Canadian health care: referring to the Canadian public system as commie-pinko-socialist is probably a clue. In any case the point is taken: it was a disaster. It’s an ongoing disaster. It’s funny how sometimes it takes someone outside the situation to point out the obvious.

I will say, however, that Nurse K’s suggestion to implement the disaster plan — in Ontario, known as a “Code Orange”” — isn’t feasible. In my hospital, at least, it’s a decision that needs to be made jointly amongst the charge, the manager and the ED physician, and  in any case tends to be reserved for external mass-casualty disasters, like busloads of HIV-positive haemophiliacs crashing on the 401, not for severe hospital-induced multi-system dysfunction. So what’s a harrassed, stressed-out charge nurse to do?

Nothing. Get all rowdy with equally harassed and stressed out bed flow managers. That’s about it.

The point is that at my hospital and at many others there is no plan.

Why? Because 1) we cope, and 2) hospital administrators see emergency department over-crowding as “normal”, intractable, and somehow not a serious hospital problem. Both are wrong. We do cope, but we carry on in way an over-heating engine run for a while before it finally seizes up and stops functioning. Sick time and turnover are increasing: not a sign of a well-functioning department. And the problem is fixable. I know the Ministry of Health is working, albeit slowly, on long-term solutions. But somehow, it isn’t better knowing various health officials, flaks and functionaries are busily at work introducing systemic reforms when the problems are much more immediate. If I can think of four or five ways to improve flow of admitted patients out of the ED without even opening new beds or breaking into a sweat, then surely it’s not beyond the grasp of hospital management. All it takes is will and prioritization — which sadly seems to be lacking.

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