What Do I Do?

I started this post over a year ago, before my facility transitioned to electronic charting. My routine has changed slightly since then, but this is still a fairly accurate description of the first half of a shift, using paper charting. I don't have time to finish the shift here, but maybe I'll write a current complete description someday...

"So, what do you actually do at your job?"

With so many images of nursing prevalent in our society, it's a valid question. I hadn't considered the general public's concept of nursing until asked this question by a young friend. I had operated with the unconscious assumption that "I'm a nurse" adequately described my professional activities. Of course, it doesn't.

The best way to answer this question for my young friend was to give a rough sketch of the day's activities. But any nurse will tell you that the tasks are not the whole truth of what a nurse does and gives for his/her patients. The emotional energy to be cheerful, the act of listening listening, acting with compassion, the fatigue and frustration take a toll also.

But all that aside, here's a brief sketch of a "good" routine day on the unit.

0650 - Badge in at the card reader. Walk to the unit, stow lunch in the fridge, wash hands. Load pockets with alcohol wipes, pens, penlight, bandage scissors, note pad, prompt card for the unit phone number and other important notes. Fill out a report sheet with an entry for each patient including age and room number, diagnosis, doctor, allergies, diet, supplements, activity level/restrictions, any tubes or catheters, IV fluids, lab work for the day, appointments for the day, and special considerations based on the Kardex entries.

0710 - Get report on each patient from the night nurse. Includes general information about the patient, significant events from the past shift and things to be aware of for this shift, as well as significant patient assessment data and doctor's orders.

0730 - Go check my patients. If they are sleeping, watch their breathing for rate, depth, regularity. If they have any monitoring equipment, record data. Print telemetry strip for any patients with heart monitors. Invariably one of my patients at least will be awake. I introduce myself and ask if I can listen to their heart and lungs. I listen to lungs, heart, abdomen. I feel pulses in arms and feet, look at any dressings, look at eyes and mouth, and generally watch to see how alert and "with it" the patient is. Ask the patient about any pain, turn and reposition him or her, and address any needs or wants of the patient at the moment. Then I move on to the next patient. If I have time, I write all these findings down on the patient's assessment flowsheet. If not, I quickly check the boxes next to the significant findings and go to the med-room to prepare for med pass.

0800 - Routine medications can be given within an hour before or after the time at which they are scheduled. 0900 is the biggest med pass of the day because almost all the "daily" medications are given at this time. With an average of 4-5 patients to a nurse on a "good" shift, administering all the medications within the 2 hour window can feel like a race. Each patient's medications are obtained by accessing the Pyxis - a locked computerized system of drawers and cubbies which only open when an authorized user with the correct password select the appropriate medications loaded in a particular patient's profile.

Once the medications are obtained and checked against patient name, date/time, specific med and dose, and prepared (by drawing up medications from vials into syringes for IV, intramuscular or subcutaneous injection), I go to see the patient in question, again checking the medications against the Medication Administration Record or MAR and the MAR against the patient's wristband and verbal answer to name and date of birth. If I've assessed this patient earlier, I follow up on any questions I have left regarding the patient's condition, current needs, and do a brief visual assessment of the patient and the environment (Is the bed wet? Is the bed alarm on? Does the patient seem confused? Is any equipment attached to the patient functioning properly? Are there environmental hazards I've overlooked, like wet floor, sharps not disposed properly?). All this can be done during actual med administration. If I haven't assessed the patient earlier, I do this now. If the patient has simple wound dressings and I have the proper materials, I may change the dressings at this point. Complicated or time consuming dressings I leave for later in the shift. During med pass, I explain to the patient (within the limits of each person's ability to understand) what each medication is for. That way, if I have time for no other education, at least I've reinforced an understanding of each person's meds, and sometimes this will earn me a little trust from the patient.

After I've made sure that the first patient's immediate needs are addressed, and that he has his call light, I move on to the next patient and repeat the process until I've passed am meds to and assessed all my patients. On my floor I've had anywhere from 3 to 6 patients at a time, depending on staffing and patient census levels. But hopefully, I organize myself so that all my patients have their meds by about 1000.

1015 - I try to take a break and tick of the assessment boxes for each patient, maybe start a little of my narrative charting. The earlier I do it, the more time I will have later and the earlier I will be able to leave after my shift ends. It's hard to write down everything that has happened - but only the important stuff. I also have to work around patient appointments, physical/occupational/speech therapy sessions and off unit treatments like Hyperbaric Therapy or Dialysis. And patient families.

Patient families are a joy and a dread. They are your best ally or your worst enemy. They can take a huge load off your shoulders or eat up hours of your time with triviality. And as a nurse, you have to deal with them. You don't really have a choice. But I digress.

Between 1015 and 1100, I do as many dressing changes/ treatments as I can and chart as much as I can. Because at 1100, another med pass begins.

1100 - Rush to check diabetic patient and feeding tube patient blood sugars. Give meds now if possible. Often the patients don't return from physical therapy until just before noon, so blood sugar checks can be a bit challenging. Lots of Zosyn IV piggybacks to hang.

1200 - trays arrive in a cart. Unlike "the big house" as the main hospital is called, we don't have hospitality people to serve individuals lunch. Nursing has to distribute trays; usually the aides do it, but I try to pitch in, especially if we have too few aides that shift. Between setting people up for lunch and giving medications, I'm usually still running after this and that. 

Provider - Patient Ratios

Staffing everywhere is tight. It's a reality of the economic downturn coinciding with a large population of aging patients on Medicare/Medicaid needing labor-intensive, expensive services and care. Nobody - patients or staff - enjoy an understaffed shift. However, frequently understaffing is an unavoidable reality. Here are a few thoughts on the reasons administration should take action to address understaffing and strategies patient care providers can use to maximize their effectiveness on an understaffed shift.

Why maintaining adequate caregiver-patient ratios is critical:

1. Patient outcomes.
The reality of human experience is that one person can only be in one place at one time and can only accomplish one task at a time. If there are five soiled total-care beds to change and one person to do the job, some of those patients will lie in excrement for the better part of an hour. There comes a point where, no matter one's efficiency, one cannot physically provide certain aspects of care to all one's patients. The question becomes not, "How best can I ensure that this person's bodily needs are met?" but rather, "What is the minimum I have to do to keep this patient from deteriorating on my shift?" Obviously, this attitude doesn't promote optimal patient outcomes. It rather begs the question, "If our patients are not able to get sufficient care to improve and return home (or wherever their destination), then why are they here?"

2. Staff Morale.
When a unit is consistently understaffed, morale among providers of direct patient care becomes very low. I think this drop in morale has a twofold basis. First, a "good" provider is put in an unsolvable quandry of "prioritizing" to the point of foregoing important aspects of care. The provider for whom quality patient care is a priority physically cannot provider quality care. He (or she) tries desperately to perform the duties of his job, but at the end of the day must admit to himself that he has failed to adequately fulfill the responsibilities for which he was hired. He is justly unsatisfied with his work and unhappy with the results. In this way, normally excellent caregivers are crippled and spiritually mutilated. Eventually, staff either burnout and leave or become cynical and insensitive toward their patients. What else can one do when one is forced to tell patients that they will have to wait to have their basic needs met?
Second, staff may lose trust in management. They feel helpless to perform their jobs appropriately and may become angry. When concerns over low staffing are voiced and no changes are made, staff begin to feel that management "doesn't care," or "they don't know what it's like," or "nothing I say will make a difference," or "they just won't do anything about the staffing problems." This attitude obviously impairs the work environment and the effectiveness of both staff and management. It propagates a defeatist attitude toward appropriate "chain of command" communication and is toxic to worker positivity.

3. Patient Satisfaction
Ultimately, the expertise of medical care doesn't much impact patient attitudes about the care facility. Many of my patients haven't a clue whether their pressure ulcer needs a wound vac or a colostomy. If you tell them that's what the doctor has ordered, most of them would agree. What they do care about is promptness in answering their call, adeptness at meeting their basic hygiene needs, a cheerful attitude, and time taken to discover who their are as an individual and deliver personalized care. A nurse or nursing assistant who is able to to deliver such care hugely increases patient satisfaction with the hospitalization experience. When call lights are not answered for twenty minutes, baths are not given when asked for, food is late or cold when it arrives, staff runs in and runs out after asking the obligatory, "Is there anything you need?" in a tone that clearly indicates they are hoping you won't need anything, and none of your caregivers have time to talk with you or hear you out, you as a patient end up feeling uncared for, insecure, and unsafe. "What if I really needed help?" they think. "I couldn't depend on anybody here to answer my call light. Why am I here if they're not going to help me?"

Strategies for Improving Effectiveness on an Understaffed Shift:
That said, here you are, one of two nursing assistants caring for 25 patients on a unit where over half of your patients are total care, many are incontinent, several are confused or have dementia and a couple are agitated enough to be in soft restraints (like mitts) and need close observation. You have twelve hours. Go!

Prioritize. In this case, that means "ration" yourself. Round as quickly as you can and make a general assessment of the condition, independence level and needs of each patient. Then focus on the incontinent patients. Get them cleaned up and dry. To be honest, that (and answering the omni-present call lights) may be your primary activity all day long. If there are patients who are constantly "on the light," it is probably in your best interest to try to take care of their needs all at once, even if they are not your highest priority patient, because answering their light all day long will take longer than taking time away from your other patients now. It may be heartbreaking, but sometimes it is necessary to tell patients that they will have to wait a while but you will get to them as soon as possible.

This is often the case with incontinent patients who are cognitively aware. You are in the middle of washing a frail, thoroughly soiled patient with several now contaminated ulcers and have to step out of the room for additional linen. (Your first change of linen was soiled again before you had even finished repositioning the patient.) As you cross the hall a patient from another room yells at you, "Hey, come change my brief! I'm dirty." What do you say? At this moment, you may only be able to say, "I'm very sorry, I will come as soon as I can, I'm in the middle of changing another person right now." Though it is painful to say and goes against personal principles of quality care, it may be your only option. The patient may not be happy, but he is more likely to be satisfied if you explain that you are helping another person with a similar problem and is confident that you will come to him when you are finished. Most cognitively aware patients understand the need to finish assisting someone else in the same position and will not hold you to blame, though they remain extremely dissatisfied with the understaffed position you and they are in.

Group your work. If you have several things that need to be done in a room, take all of your supplies in at once and do as much as you can at the same time. Pass evening water with the dinner trays.

Ask family to help. While they cannot do many things, family are often able to help reposition, feed their loved one, and carry requests to staff. If the family is especially eager, they may even wish to assist with bathing or dressing. If they are willing, take them up on their offer.

Eat something. Really. It's very difficult to leave the floor when there is so much more to be done. But it will be worse if you yourself collapse from fatigue and dehydration after having eaten and drunk nothing in twelve hours. Even if it is only for a few minutes, sit down, eat a lunch, drink a glass of water, and mentally regroup and reassess the situation. You will be more effective in giving care if you care for yourself.

Don't stress over the nonessentials. It is difficult to feel satisfied with one's work when not every patient has been bathed, and needs have been left unprovided for. But in the grand scheme of things, if your patients are alive, safe, fed, are not filthy, and have stable vital signs at the end of twelve hours, you have succeeded, even if you have not been able to accomplish for them all the things that would make for optimal hospital care. Don't beat yourself up over your failure. You are human and have done what you could with what you were given. Leave this day at the unit and go home.

Don't allow yourself to become insensitive or defeatest. Report the situation to the proper authority in the chain of command even if you think it won't do any good. If the situation compromises patient safety, implement the appropriate breach of safety reporting method. Don't stop treating your patients as persons or taking their needs seriously. Callouses protect you, but not them.

Finally, pray. Your patients are God's creatures created in His image and you are His hands to care for them. He can make the impossible possible and protect you while you and them while you are at it.