Moans, Groans and Parking Tickets.

I have been on a course in The Big City this week. Now - top tip and handy hint, if you sidle up to whoever is in charge of your learning budget, approximately two weeks before the end of the financial year, and ask for a silly amount of money for a course run by an outside agency, chances are, if the money's there, you'll get it. Seems that if the money isn't used then it gets sucked back up into the ether never to be seen again - it doesn't get carried over to next year or anything sensible like that, it actually gets taken away from you the following year as you obviously didn't need that much in the first place. So Learning Budget person will be delighted to give you as much cash as they've got.


The course sounded good on paper, Advanced Assessment - chest x-rays, blood results, that sort of thing. And the course content should have been good - apart from our Tutor, who sadly appeared to be teaching entirely for his own benefit, and didn't appear bothered if we were keeping up or not, or actually, whether we were even alive. In one particularly gruelling 3 hour session post lunch, where he had been examining blood results on a micro-cellular level, my mind had wandered away from macrophages and eosinophils, and instead I was imagining him bursting into song, and how that would have been more entertaining. My boss, who was sitting next to me, obviously had the same idea at the same time, and scribbled " Blood Results The Musical" on a bit of scrap paper. It has been a very very long time since I have been told off in a classroom, and a very long time since I have flushed quite that red.....


I did learn however, after 20 years of nursing, that I have been putting my stethoscope in the wrong way round. Ear pieces point forward, not back as I have been doing for years. So the week was worth it.


Also in the last month or so our Trust has been clamping down on car parking. Now we have a particular problem with parking, and spaces (and permits) are fiercely fought over. They are now issuing tickets with a £50 fine, and are involving the DVLA if they are not paid, so almost everyone has been caught out recently, and there is a lot of bad feeling about.
Occasionally I have to travel to another site, some 25 miles away. The times that I have to be there mean I cannot catch the free bus, and I have to drive. I do not get petrol money for this. They recently built a new "staff car park" at this site. There is no mention of permits, and access is via a swipe card system, with your staff ID. I had been gaily swiping in and out with no problems, until one day, after a 12 hour shift, I found a ticket on my windscreen! It seems that you DO have to have a permit after all (which costs around £230 a year). I am absolutely NOT paying this ticket. What I do not understand is why anyone would spend a morning ticketing the staff car park - everyone in there has had to swipe to get in - we are all staff. So why target staff? And sadly our parking people are actually our own staff, paid extra for this "service", so not even an outside company to blame. Who is paying who to go to work?


And lastly, the word "gotten". It 's driving me mad. A friend tells me that originally it was a UK English word, but the US pinched it, and we dropped it. Now it appears to be making a comeback - I read it in three separate places yesterday. STOP IT!! While I accept that language has to evolve, surely it doesn't have to DEvolve. "Become" is far more elegant. And yes, I am turning into my Father.

Nurse Ratchet has been quiet for a little while now. Now for those that know me, that's a flippin' miracle, but for a range of reasons I haven't written anything recently. Mainly that the last few months have been the same old slog, same old tired phrases being bandied about, same old mud being slung, same old buns flying overhead. I have been spurred into reappearing by the lovely Nurse Anne, and her recent post on cost cutting at the hell-hole she works at (and good luck Anne in your job search - you deserve a break).

We too are heading towards the end of the financial year with song in our hearts, for we have so many beds unoccupied that we are planning to close almost 10% of them in the next couple of weeks. This will enable us to "work differently" and "smarter" and generally make us a more efficient, streamlined establishment heading for the beacon of all beacons, - Foundation Status. With CAPITALS 'cos it's important. We'll save money, have no need to employ those pesky agency nurses who cost us so much money, and all our patients will be cared for in an environment that is "fit for purpose" - oh, and has windows.

Brilliant. So, tell me then, why I have just spent the last 4 nights putting patients into hastily found beds that were languishing in bed stores/under staircases/in corridors/and housing them in areas used for day time procedures which are then stopped because they are full of in-patients. Tell me why I have had to employ extra staff every night to sit with these poor patients in their definitely NOT "fit for purpose" areas. Tell me why I haven't had a break in 4 nights because there were an unseemly amount of people in the A&E department every night, most of whom were actually reasonably sick, and I didn't have anywhere to put them except into those hastily made beds that the porters had spent all night looking for.

I have a curious sense of deja vu. Last time we did this, we shut lots of beds - "re-organised", lost a lot of staff in the process, opened the beds up pretty much as soon as we'd met the financial target, had no staff because they had all left, employed expensive agency staff to staff the newly opened wards, care suffered, finances suffered again....and so it goes on.

I also lost my voice last night - a blessing some would say, in fact the Sister in A&E said that at least I wouldn't be shouting at her about breaches...and discovered just how very difficult it is to try to keep a hospital afloat and sound authoritative when you sound like a small mouse stuck in a cardboard box down a hole.

“Smarter Working”

That, apparently, is how we are going to manage this year’s Winter Crisis. We are NOT going to have another winter like last year – Oh no. Heaven forbid. We are not going to manage our patients being sicker, more elderly, and staying in hospital longer by simply opening extra wards – the financial burden will be too great...all those expensive agency nurses...

No, we have a new plan. It is so fundamentally different from any plan we’ve had before that it will almost be revolutionary in its instigation. We are, ladies and gentlemen, going to Work Smarter.

Now that irritates me on so many levels I barely know where to begin. For a start, the grammar is simply awful – my Father would immediately correct me if I spoke those two words together – I can see him shaking his finger at me and sighing “If you must say that at least say “work more smartly””

Ok, suppose all our winter pressures could be solved by this “smarter working”. Lovely. What new , innovative ways of working are we going to bring in? I have no clue actually. Unless I’ve missed something, all I seem to hear every day is the same old , tired old, sentences I have heard every day since I have been doing this job (and that’s a while now). “The doctors need to go out there and discharge more patients” – you don’t say. “The community needs to give us more beds”. Really? “We need to be more accurate when we predict our discharges”. Hang on, I may need to sit down, all this smart new information is wearing me out.

We are also trying to tell the Doctors how to do their jobs a lot more aggressively than we ever used to. Now, being a nurse, I am fully aware that doctors need a gentle nudge in the right direction at times...and that sometimes there really is a simple solution to getting a patient discharged that doesn’t require another 10 inpatient tests, but usually that simply involves speaking to someone senior with a bit of sense. Recently, at our daily bun fights , there seem to be a lot of scoffing at medical decisions, lots of head shakings at the absurdity of admitting this patient, or that one. Actually, when you go and read the notes, or talk to the patient, there is usually a pretty good reason for whatever is being scoffed at, we just don’t have all the facts. But we are continuing to convince ourselves that the “fault” lies elsewhere, and not in our room.

All this “new” working would be great, if ever we got the chance to close our extra capacity wards long enough to even try being “smarter”. Every day for months we have been facing an uphill battle , to get the patients out of the cupboards we have put them in overnight into proper beds, so they can have the treatment they require in order to make them well enough to go home. Then, by the afternoon we can start to look at today’s patients, and squeezing them into the few remaining beds, then at night we open the cupboards again and start all over again. It’s exhausting, no less for the poor patient who is getting moved like a chess piece across the organisation.

But it’s ok folks, if the doctors just discharged more patients, and the community gave us more beds, we would be able to work smarter ,and the winter would fly by in a haze of fuzzy loveliness.

Hysteria Ward.

Staffing. It annoys me. For heavens sake - is it not a given that we will be short staffed every Friday afternoon and every Monday morning??? Why are there so many navy blue types able to work Bank on a Saturday and Sunday but by some miracle no staff on a Monday morning?Monday's are rubbish. No discharges over the weekend - after all, we do not appear to offer a 7 day service - sorry Granny, you can't go home to your own home on a Saturday as your carers all of a sudden will have too much work on (but never fear - they are bound to fit you in NEXT weekend), oh, and your family will be away, and your Doctor's will have not written up the TTO's (even though you have not changed your medicines from when you came in), and you have to do stairs with the physio (even though you were perfectly able to walk to the hospital shop yesterday) and you may need a kitchen assessment with the OT (oh please, dear god, don't make me put the kettle on.....) oops - I appear to have strayed from staffing.

I hear the same old crap every ward round. Medically fit for discharge. But no-one wants to take responsibility. Dear Lord - those poor Elderly Mentally Ill folk. They are with us for months. I get pressure on me to move these poor people to "a less acute ward". That sometimes means that they are moving 2, 3, 4 times an admission. That is so not going to help.

I tell you what would be nice - a 7 day a week service,everyone, just working a 7 day week.

Wake up Nurse Ratchet

Ok, so I've had a wake up call. Last night I worked on the "Assessment/admissions/somewhere you go so you don't break the 4 hour target" ward. It's the first time in years that I haven't done my overtime either in A&E or my own team. And strangely enough I really enjoyed it - and realised how far removed I've become from real life. Jeez - it took me 'till 0300 hrs to catch up - they'd had such a busy day that pretty much every one of my patients (and I only had 5) had fluids running behind, IV AB's not given,hourly urines not done - not to mention the very demanding patient who was in tears as her fan had broken. I have to say that I neglected her, and her "lesser" needs to sort out the chap with neutropaenic sepsis, and the woman I had going to Theatre for a laparotomy, and the ALD with the pump that kept turning off, meaning her drug regime was about 6 hours behind. Bloody hell it's hard. I left the demanding patient for an unacceptable amount of time while I dealt with my poorly patients, but managed to catch up, as I said, by the morning.
It's really really hard to work in these places, not helped, I am sure, by my lot telling you that you have to churn the patients out, and get them in. I saw some really good examples of good nursing last night, my hat is firmly off.

I am eternally glad that I have done my time in these places, and that I actually don't need to spend every day going home handing over everything I haven't done anymore, because there hasn't been time.

It's a scary old place, and it's only September.

Ratchet Turns a Corner.

I find it a bit difficult to rant when I'm on annual leave - I'm having far too much of a nice time not thinking about all the things that get on my nerves at work.

So I'm off to sunny climes tomorrow, along with 20 or so of my closest friends and some of their children, to celebrate my "significant" birthday. Most of us have something to do with the NHS, so no doubt there will be some, probably heated knowing us, discussions about our jobs, and how much we think we could change the NHS if only they left it up to us.

Not too many I hope, I'd rather get stuck into the wine and cheese personally.

I'm sure that when I return to work there will be a thing or two that annoys me enough to post - until then...

I was doing a bit of summer cleaning today, and I came across something that a fellow member of staff had written a good few years ago, which I had completely forgotten about. It was at a time when our Trust was struggling financially - well, who wasn't -and I was not alone in finding it very very funny.

Unfortunately the "Management" had obviously popped their collective sense of humour in a deep cupboard somewhere, and took rather a dim view. Which made it even more funny really. Financial targets at the time were "de rigeur", pretty much to the detriment of everything else. There were severe restrictions on booking agency staff, wards were closing,every last penny was being scrutinised. Study leave had been cancelled, and it was proposed that all mandatory training was done in the staff members own time. As you can imagine, there was a reasonable amount of very bad feeling about.

These are just a few exerpts from the missive, which, rather foolishly in retrospect, was posted liberally around the hospital.

" As all staff are aware, this Trust's financial position is, to be blunt, up shit creek and unable to afford a paddle. As a result, stringent measures have been introduced to help recover the deficit. These measures have been thought up by a highly paid team of experts after a jolly nice lunch."


"As staff will now be working increased hours there will no longer be a need for study leave or training. The Trust believes experience is everything."

"There will be no compassionate leave. The Trust has run out of compassion. It is unlikely that that it will have any in the near future."

"All sickness MUST be verified by a death certificate."


"General anaesthetics are expensive. Patients will be now given the option to bite on a stick during surgery. This is expected to lead to a reduced demand for the service."

"To cut down cleaning costs staff will be expected to put a broom up their rear end and sweep the floor as they go."

"The Trust hopes that these measures will go some way to recovering the financial deficit. In order to implement this a total of 508 managers will be introduced .These managers will have no prior knowledge of the health service and therefore will not have the frankly blinkered view that some clinicians seem to have - we are sick of hearing about patient care. It is no longer deemed to be of importance."



I wish I'd written it - but I didn't. I didn't get hauled into an office and given a warning.

Still quite relevant though, and only to become more so I fear.