On the Issue of Hospital Staffing

I can't proclaim to note how all the other hospitals in the USA or world, for that matter, choose to handle the staffing for the floors; I can only comment on how the hospital in which I work handles staffing on my floor. That being said.....

I have just finished reading several posts in other blogs about nursing ratios in the ED. At my hospital, I do not know what the ratio is down in our ED. I do know that on the floor, we are assigned staff based upon the number of patients on the unit. Whether these people are all walkie-talkie or total care people, easily done or complex patients, we get the same number of people for whatever the census is. Included in our staffing concerns are the assistants, nurse manager, unit secretaries, LPN's and RN's. When it comes to a low census day, the first people called off are the non-essential personnel... thus the assistants and unit secretary (which if we were lucky enough to have one, would be called off. we do not have a unit secretary on our unit, do not know why. instead the charge nurse has to handle putting in all of the orders and doing all of the paperwork if the other nurses are not available to do so because the doctors give all of their orders to the charge nurse!). By non-essential, it means those not needed for essential pt care, such as giving meds, etc. Sure sometimes the nurses are called off, but if they need all of the nurses to cover all of the patients, then the nurses will not be called off.

I would love to know why the nurse manager is included in our staffing. She doesn't often work the floor. She might fill in a few minutes now and then if they are in a bind and they need her help right quick, but for the most part, she is in her office or in meetings. She also doesn't count in the staffing for the other departments that she is over either... I don't get that myself. For one thing, she surely isn't ever "called off."

I understand that they have to set limits in order to save money. "They" being the administration. But sometimes these limits are so hindering that the nurses are forced to take 6-7 patients because of circumstances and census control. Maybe you think, well 6-7 patients isn't that bad... what if 5/6 patients ... each have about 30 meds due at 0900, maybe even one has a peg tube and all their meds need to be crushed and put through said peg... one has to go to dialysis and needs weights and other specialized care... heck one is on isolation because they have c diff, and they are stooling every 30 minutes and need extra bottom care so that the stool doesn't eat right through the skin. Surely then another patient on tele monitoring is having an acute episode of afib with rvr, possibly needing transfer to the ICU to get a cardizem drip if the dig doesn't take care of it. The COPD patient is having difficulty breathing and has a hard time remembering to purse-lip breath because... well because they are hypoxic and cannot think of anything but not being able to breath. Oh and that last patient? Came in with chest pain, but tmc's are negative and tele monitoring shows nsr.. all they need is the dr to make rounds and d/c them, and ask you every hour when is the doc getting there because they would really like to go outside and smoke or just go on home.

Of course, these are just examples, but in truth, it really does happen. Prioritizing & time management do have to take place when seeing pt's like this. My question is this... wouldn't it have just been safer to allow the extra staff to come in that day so that we can perform safe pt care? After all, safety is number 1 when caring for patients. People wonder why nurses get burned out so quickly.. have a few days like the above over and over again, and it is obvious. We do the best that we can with what we have. I don't know of a simple solution to the problem unless they somehow came up with staffing quotas for pt problems, much like a drg -- but tailored to the patient and nursing care received.

Now, one thing that I really think should happen in the future is that patients are also billed for specific nursing duties, sure they already getting billed for the supplies, right? I don't know how much it costs to receive that duoderm.. but what about the time it takes for the nurse to cut it to the right size, stand there and hold it against the wound so that it will attach, and monitor it each day to see if 1) it is still intact or 2) it has been a week and needs to be changed, and etc. Doctors get to bill for procedures, why can't nurses? Why can't the patient be billed for insertion of a foley, or insertion of an NG tube? especially the ones who pull out that ng tube several times a shift? I understand that we are not doctors and do not diagnose problems or write orders. We follow the doctors orders and critical pathways for a diagnosis in order to treat the patient and hopefully send them home in the allotted amount of time. All I am saying is that there is the opportunity for nurses to also be money-makers in this profession as well. Just need some good political action on the healthcare forum? Perhaps that could allow nurses to be paid a bit more for the hard work they do and even allow for enough staff to care for patients who might need a little bit more 1:1 attention. May even attract more people into nursing.. who knows?

Finally.. after reading a comment on this topic from a non-medical person who thinks that nursing is well... non-essential. "people come to the hospital to see the doctor" GREAT! just remember that while you are the hospital, it is the nurses who carry out the doctor's orders, give you your medications (for the most part), write up the discharges so you can go home... get you your water in the middle of the night because you are really thirsty etc. It is the nurses who are the eyes and ears of the doctors, so just in case you go into vtach in the middle of the night -- when the doctor's aren't there! -- they can just possibly get in there and save your life. Next time this person goes to the hospital.. I wonder what they would do if the nurse wasn't there to take care of all of their needs.. sure won't be the doctor there giving the meds and wiping their butts if the pt isn't able to do it or watching the cardiac monitor to make sure that ST depression doesn't suddenly flip into an elevation. ok off rant :)

Just rambling....

yesterday was a hellacious day at work. good things that come from it? i finished my iv therapy class - required by my employer before i can even look at someone's veins; finished my first admission mostly by myself with a few cues from my preceptor... which i thought was a pretty good accomplishment really, considering this little elderly person TALKED my ear off LOL :) she sure didn't want to be in the hospital at all.. but she was the one who called the rescue squad? go figure on that one.

now something ironic... i just said that i finished my iv class.. now my preceptor does not start IV's, so i am wondering who will sign me off? ha. ask how a nurse on a unit doesn't start an iv.. because i do not know that answer. i guess there are just more people willing to start them for her so that she doesn't have to.

when i first accepted this position... it was because it was all that was open at the hospital at the time. i am on days for orientation right now, but will move to nights soon. it will be a bittersweet move because i enjoy the pace of day shift, but man, i really, really hate getting up early in the mornings. i set my alarm for this morning so i didn't not want to go to bed tonight... of course the puppy woke me up much earlier to let me know it was time for him to potty whether or not i was ready to crawl out of the bed. anyhow... i find myself not hating the job like i thought i would. but then again, i think it is the pace of days that has kept my interest. i am not sure what will happen when i go to nights and it is much slower. guess i will see when the time comes.

today i have to go get a thank you card for my coworkers who got me some flowers, gave me some chocolates and a little bit of spending cash for passing boards. it was so nice of them! i didn't expect anything at all from them.

sorry for all of the misc ramblings.. i think i just need more coffee!

Being Alone....

One of my patient's today told me a story of great sadness. The spouse had died just a few months earlier. A past drinking problem resurfaced with this death... and got to a point in which he passed out and laid on the floor for days before someone found him. Bleeding internally from a varices. He was lucky to have been found when he did. Although this near brush of his own death has made him realize that drinking will not alleviate the search he had been on. He understands that he damage that he has done to himself will not be undone. He also understands that he can try to do the best that he can to live the rest of his life as full as he can. I tried my best to be therapeutic... I listened very well to his story indeed. My concern was that when he returns home... will he be able to follow his own advice and discontinue the drinking? Does he have someone who can check on him every day?? I asked him about that one!

This patient isn't the only patient who I have met in my time working at the hospital who has had problems being at home alone with no one to check on them regularly. I realized that something could potentially happen to anyone who lives alone. Isn't there something we could do to help these people who are alone and not in the best of health? Just even to have someone do something as simple as check on them. I just wish I knew the answer. All I could do is ask my patient, and luckily he has someone in which he has made arrangements to have this done. It made the rest of my day go by much easier just knowing this.

Pity party of sorts

Now that school is over, nclex is finished... I wonder what I plan to do to occupy my time. Other than cleaning my house, of course. That is never ending, with a teenager and tween and all. These boys can really, really make a mess. Of course, neither of them claim the mess.. so the blame goes to my invisible child... often called, "wasn't me", or "i dunno who did it". i know every family with children also has this invisible child as well, right?

Once upon a time, I used to be really, really good at working with computer graphics. I am not sure if I want to get into that again?? I used to know how to a lot of things that would occupy my free time for hours... but I am so just not interested in that stuff anymore like I once was. I guess I just need to find a new hobby.. hell maybe even a boyfriend after all of these years of being the single mom. I dunno??? Kinda confused. I am sure this is all part of the after-school let down phase that I was told I would go through. Kinda sucks, huh, if you have been through it.

I miss the internet friends that I haven't been too attentive of over the past couple of years. I am sure that a few friendships have just dissipated because of a lack of communication. It was difficult to manage school, work, and the kids as well as maintaining friendships with barely any free time at all for myself. Now I have this time, and well, I just don't seem to have the same things in common with these people anymore. A few I will always be able to talk with, etc, but others.... may as well just delete them from my messengers.

Ok enough poor, pity me stuff.. I must get in the bed so I do not oversleep in the morning. That would be.. well.... BAD. g'nite :)

Baseball & Committment

Today is my last day of a wonderful 4 day weekend. I have a few errands that I need to do.. like go pick up my OFFICIAL new badge that has my new title on it :) Also have to go to the grocery store :( I hate going to the store with a passion. My youngest is at baseball practice at the moment, and he will have to go again tonight. That is the committment of being an All-Star.. practices every day for 2 weeks, sometimes 2 times a day. Now he wants to play AAU baseball, which if you are not familiar with it... well it costs a lot of money, requires a lot of travel, and also is a huge committment, even moreso than what we are going through right now with the youth league & all-stars. Then my oldest informs me that he would also like to try out of an AAU team. I am one person.. how can I even make that kind of committment between working nights (which will come about probably mid next month) and being a single parent? I suppose if I had to do anything, I would allow the oldest to try out first, well because he is the oldest. He really enjoys playing baseball, but he doesn't seem to have the passion that my youngest has for the game. It really puts a person in a predicament.

It's not that he doesn't love the game, but I just wonder about his committment to that type of team. AAU is serious about it, and I guess all I could do is give him the opportunity to try out. If he doesn't make the team, then all of the worrying would be for nothing. Problem is: if he didn't make the team and the youngest did, then a part of him would most likely begrudge the youngest for getting to do something that he didn't get the opportunity to do. I honestly just do not know what to do? I suppose I will just start thinking about it a little more and then make a decision later on this summer. After all, most teams will not be having tryouts until after this all-star stuff is completed and nationals, for the teams that are good enough or lucky enough to make it there. Gives me a couple of months to think. Now I am off to get cleaned up so I can run my errands!

yeah.. it's official!!

so i took the leap and took the nclex this past tuesday. never before have i ever been to the almost panic level of anxiety, but i was almost there on monday night! i couldn't even stay to watch my youngest son's final season baseball game because i was so nervous. amazing how one test will do this to you. arrived at the testing center early.... sure didn't want to be late! lol.
went through the entire ordeal of security measures to enter the testing room... took the test. it cut off at 75 questions and then came several days of nausea, nervousness, lack of concentration, etc until i finally gave in and called the bon to see my results....... i was prepared for the bad news, but they told me that i PASSED! i literally cried lol. cried from relief of all the anxiety i had been feeling the past few days. my nausea instantly disappeared. i felt 100 feet tall. how dare them make me feel like that LOL!

i just find it also amazing that 75 questions determines a person's competency to be a nurse. the questions i had were... well HARD as hell. no doubt about it. i felt like an idiot when i left that place. i had medication questions for drugs i wasn't even sure were in the drug book :) lord knows i had never heard of them.. how was i supposed to tell the nclex people what side effects or interventions to look for/do?? but it is all water under the bridge now. i no longer have to sign my name with RN-A (A = applicant) anymore! i can push forward in my preceptorship toward my goal of working the ICU. I externed in there for 9 months, and was hoping to get a job in there after school, but unfortunately, my manager, and probably wisely so, does not hire new graduates to work in the unit. so i will do my time in med-surg. learn my time management, charting, and so on, so that i can move my career forward. i owe them at least 6 months on the floor until i can change positions, but if i do have give my employer 1 year for certain.

i would entertain the possibility of working in the ER, but there are some things that just simply gross me out... like protruding eyeballs for one lol. but other than that, i know i would do much better with a faster paced environment. so we will see where the future takes me. i just know that there are several places i would entertain the thought of working and some places i have absolutely no interest in working. now that i am officially an RN, i hope many doors open for me wherever i choose to land.