Nurse Ratchet

Moans, Groans and Parking Tickets.

2010-05-23T11:59:00.006+01:00

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.

2010-03-29T19:25:00.005+01:00

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”

2009-11-10T11:45:00.003Z

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.

2009-10-20T01:30:00.004+01:00

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

2009-09-24T23:19:00.006+01:00

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.

2009-07-08T19:17:00.005+01:00

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...

2009-06-25T19:41:00.003+01:00

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.

A Beautiful Turn of Phrase .

2009-06-22T20:55:00.005+01:00

Just a quick note that I had to share...

We had an escapee today, who, sadly for him is a young man with short term memory loss. He was found by the police thankfully, and returned to us, after trying to have a little nap on the pavement. That in itself is not funny at all, but the police report made great reading. Now I have no idea if the police have secretaries to type up their reports, or if, as I rather wistfully imagine, have to create their own reports, typing with deep concentration, two fingered at an ancient word processor, but the wording was fabulous.

A "MOP" (member of the public I think) witnessed the patient "lying desecrated on the pavement". When asked if he was OK, the patient "got up, shook himself, and walked famously away"

There's nothing you can say to that really.

2009-06-18T00:21:00.006+01:00

Well it’s Summer. The grass is green, the sun is showing itself more often than it’s not…and I’m working the bare minimum again - isn’t it great. Bank work, as everyone knows ,is utterly weather dependent, a bit like my finances, which always take a significant downturn at this time of year. So I’ve been busy spending all my money on going away, and complaining bitterly about having to work around my holidays. Which means I haven’t had much time to rant frankly, having too much of a lovely time not at work.

The good weather also brings out the worst in Joe Public, on a sunny weekend anyway.
A few weekends ago, I was stalking through A&E, (clipboard in hand, naturally), and I witnessed a ridiculous amount of drunken, rude, abusive, behaviour, from my city’s finest; the sunburnt, unwashed (there should really be a law against taking your trainers off whilst drunk on a trolley) off their heads general nuisance that were clogging up a department full of otherwise perfectly sick patients. I will not qualify the idiots with the classification” patient”.

There was a particular young fool, who we had removed from the department several times by the police, for threatening to hit us all, staggering about flailing at passers by, and peeing on the floor - all because he wanted to be left to sleep for “a few more hours”. As we all know, the 4 hour target does not actually permit “a few more hours”. I had my clipboard in hand remember. Oh that and he tried to punch the Sister.

What really sticks in my mind about this, is the other patients he affected.
There was an elderly gentleman, with a Zimmer frame, whose wife had just suffered a cardiac arrest, and had died. This poor chap had no family, no “significant other”, no-one at all in the world. As we took him in to say his goodbyes, and desperately tried to think of who we could get to care for this man now, not just tonight, but next week, next month, this drunk, abusive fool was taking up 3 nurses’ time, 2 policemen, and both our security guards. Right outside where the elderly chap was quietly sobbing. He may have been a bit deaf, but he certainly heard that.

On the same theme, another drunk man that had fallen and sustained a head laceration, and therefore been sutured, and kept in overnight for observation, refused to leave this morning as I would not fund a taxi to take him home. I really am becoming a bit intolerant.An ambulance brought him in to the A&E department, at great cost, we’d cared for him even though he’d been abusive when drunk, and then we were expected to ferry him home in a taxi!! This is getting ridiculous now. After several hours of plain stubbornness on my behalf, he eventually conceded, and caught the bus home.

I love the summer, but it has it’s ups and downs.

Clipboard Anger.

2009-05-20T22:57:00.005+01:00

There are those who think that those nurses, like me, who no longer do ward work, have in some way, sold out. I disagree. Quite strongly.

There are nurses who, for the duration of their employment, will work on wards, some being happy to stay at the level of staff nurse, some advancing to Ward Sister (or “Manager” as it’s rather depressingly now called). We need them. We need experienced, battle hardened nurses to teach the new generation of nurses, to care for the patients in a way that is only learnt through blood, sweat and tears. There are also, however, experienced battle hardened nurses who don’t follow the traditional promotional route, and end up as something else altogether. In my team we all have an acute background, mostly A&E, Medical Assessment Units or ITU. Most of us wanted more money (is that a bad thing?), better hours, and more responsibility than we were getting in our old jobs. Our ambitions are not better, or worse than those who wish to continue ward nursing, but different. However, while we continue to be only band 7’s, we are at the mercy of the higher echelons of management, and are frustrated a lot of the time by mind numbingly ridiculous “targets” and frankly sometimes insane “changes to working practice”.

It’s our job (well I think so anyway) to inject some sanity back into the process, and thank god I work with a team of people who have been blessed with a great deal of common sense. The day to day grind of fighting with everyone (funnily enough, rarely the ward nurses, it’s usually those way above them), in order to try to meet those self same targets, and “changes”, without letting it all get horribly out of hand, is, as I’ve said before, challenging to say the least.

I know it’s difficult for ward staff to understand why we move staff about (for example)– it’s because we have to, to try and balance the load. We’re very lucky in that we are not restricted to which (expensive) agency we use. We move people because a) a nurse hasn’t turned up b) 2 staff have gone off sick half an hour before their shift starts c) there’s been a double booking and however hard we try no-one can be in two places at once-and d) another bloody nurse hasn’t turned up – not because we haven’t tried ALL the agencies and have come up with nothing. Really.

Yes the four hour target is painful – but the patients appreciate being seen a damn sight more quickly. There is an urgency now which just wasn’t there 5 years ago. Is this a good thing? I’m not sure, but maybe for the doctor who I found in the canteen reading the Sunday papers, while his patient had been waiting 3 hours to be seen,( and who told me he was in Theatre) at least I have a reason to ask him to finish the crossword and crack on. Bugger it – I hadn’t even had a coffee that day!

The “breaches” are painful. We all know that there are far more deserving cases of a four hour breach than we allow ourselves. And the finger pointing and blame allocation for each and every one is just not healthy – (I’m talking about healthy for me now, and the A&E staff, and the Doctors...). But there is a little bit of me that sees that even if the target is flawed, the idea may have been sound in its inspiration. I’m just not quite sure what happened in the translation.

I know that wards are really busy, and “hotbedding” someone is awful. I also know that the Assessment Unit is akin to Beirut most days, and the old stick with a fractured NOF and a UTI who has been climbing the walls in A&E won’t get the care she needs in the Assessment Unit. That is not an exception -that is daily life.

There are those, like Dr Crippen, who would have us believe that nurses should forever stay at the bedside. I disagree. I suggest that there is a need for nurses like us, with experience, common sense, and a hearty sense of humour, to try and at least equalise the madness. As much as there is a very real need for nurses who remain at the bedside, with all of the above qualities.

I’m trying to think of an end paragraph that won’t sound trite, but I can’t ,so I’ll leave it there

2009-05-06T21:09:00.005+01:00

Oh I despair. I really do. You have good days, you have bad days, you have really really busy days. For all those that think we CSM's wander about having coffee, nursing our clipboards, well, it's nonesense.
I have had possibly one good day in the last 6 months. I think. Mostly I charge up and down corridors, pissing people off by just trying to get my job done. Had a particulary busy day today, 2 cups of coffee at handover and half a leftover curry at the lunchtime witch hunt (sorry, bed meeting), not much in a 13 hour shift.
I know I'm not a ward nurse any more, but believe me I still remember the crappy shifts, the going home worrying more about what you hadn't done than what you had, the late handovers, the constant pressure from everyone to get everything done RIGHT NOW. At least now I get to hand over to people my own grade and level of experience , and know that I don't have to stay to make sure everyone can get the job done - because I know they can. Do I miss it? No. I did my time (15 years of it) and frankly had enough. I still like my patients, and thankfully my job still allows me some decent patient contact, or I wouldn't do it. I AM STILL A NURSE! But someone has to keep the bloody place running. Someone has to have the sense to stop the pancreatitis going to a care of the elderly ward - just because there's bed's free.

Someone has to sort out the staffing on the extra capacity wards. Someone has to take the junior doctor aside who's just been to her first arrest and is devestated. I did all of those things today. And managed half the beds in the hospital. And sat there in the witch hunt being told it was my/our fault that A&E had been so busy - we were obviously not managing effectively.We are constant scapegoats, probably because we have our fingers in so many pies. We're easy game.

My high point today however, came when a Surgical Consultant, well known for his lack of social skills, challenged me as to why a patient of his was still "on hold" and was not yet on his ward. I really try to be polite, I really do. There are 16 patients in the assesment unit who all need his ward. Another 10 in A&E being seen, who will need his ward. A couple of patients at another hospital, who need his ward.And I'm faced with 3 discharges. However hard I try, I do not create the capacity, I just manage it. Obviously you prioritise, but there is only so much I can do. When I politely asked him if he would care to prioritise which patients got the three precious beds, he became annoyed, and told me that it was my job to do that.A reasonably heated discussion ensued. I am told that the patient will die if I don't get him in - and it will be my fault. What about the 16 emergencies on the assesment unit? will they get better if they stay in that madhouse? This will be my fault, and mine alone.After reaching an impasse, I stalked off down the corridor, thinking that Marks and Spencer looks more attractive every day. Guess what. He found another couple of patients to discharge (that weren't even on my list), the patient got in, and once again I was saved from being solely responsible for someone's death. I would like to point out that he had already done his ward round, and those patients were ones he had gone back to see, in order for his patient to get in.I didn't ask him to discharge at risk, that is beyond my remit. Will they be back in tonight, because they weren't quite ready to go home today? Maybe. We'll see.

Phew. As I said, I despair.

Look into my eyes....

2009-04-29T18:34:00.009+01:00

Oh I really am trying to keep up – I really am. What with early morning tradesmen of varying punctuality (and skill…and, in the case of one,.creepyness), 13 hour shifts, and trying to fit in a wee bit of a social life I’m all of a dither! Still, halfway through another jolly old 50 hour week with my sense of humour nearly intact.

However.

Why why why oh why do people think that I carry a bleedin’ crystal ball about in my pockets, along with my expanding nurse pack, my spare SHO pack, 15 pens ,a pair of scissors, a pair of artery forceps (for undoing things), a tourniquet, a roll of micropore (I know, naughty me..infection control),keys to the office, hand gel, lip salve, sweet wrappers and my bleep. Where do they think I have space for the wretched crystal ball?

You know, that crystal ball that tells you when a patient has gone home that you weren't expecting on ward B. Or that there is a spare nurse on ward C .The one that would have been really useful to have so as to have avoided going out to the expensive agency for ward C, and to have sent the wrong speciality of patient to ward D because you thought that ward B was full. So that poor patient on ward D gets moved twice because the Consultant wants all their patients on ward B. Or the crystal ball that tells you that some bright spark has thought it’s a good idea to move all the patients round and fill all the side rooms because someone is noisy at night.Without telling anyone. So when a suspected Noro virus comes into A&E and you think – hooray – straight to the side room on ward B please….(and the patient is at 3hrs 40….). Poor old ward B. It’s not all their fault. It’s just that I really really wish people would TELL me things so I can actually try to do my job efficiently, and not waste people’s time. I know people are busy, but more work is created by NOT telling me what’s going on. I have a bleep. Bleep me.

Gillian McKeith Eat Your Heart Out.

2009-04-19T03:36:00.010+01:00

A patient has just asked me if there is any way he can use the internet – to do his “weekly weigh in” for Tesco…?? On closer questioning, he told me about this fabulous new service that Tesco, in their bid for world domination, are offering..

For the princely sum of some £80 for six months, they will give you diet and exercise advice, offer you an “on-line mentor”, a weekly “weigh in” (where you get an on-line pat on the back from your on-line mentor”) and a diet plan complete with recipes. But here’s the really clever bit. At the touch of one button only, the weekly food needed for the recipes can be ordered on-line and delivered to your door! Simply brilliant.

Not only do you not actually have to speak to anyone, but food you probably never would have bought in a million years can be popped in a van and straight to your fridge! Think about it, you’re actually saving money. Honest.

Very very clever. And just a little bit scary

Work in Progress

2009-04-17T11:32:00.002+01:00

I have spent the last three weeks trying to have a new bathroom installed. A fairly simple task you would think in this current economic climate. Er - no.

After getting a simply ridiculous quote from a bathroom company I decided to go it alone. I have friends in trade, a few phone calls and I was sure I could swing an electrician, plasterer, tiler and plumber for a whole lot cheaper. After all, I manage to organise a hospital for heaven’s sake. (well most of the time anyway).
So, managed to pin them all down for quotes, great. Silly me thought that when I had a quote, and accepted it, that the work would actually get done – mistake number one. It appears that despite the daily tales of doom and gloom spread by the media, trade is actually quite brisk. I really should have asked everyone what their time lines were before I got stuck in – mistake number two.

Tiler duly arrived and ripped my bathroom apart – good. Then the plumber rang to say he was going to be a bit busy for a few weeks – a few weeks! And would it be ok if he took the bathroom out sometime in the future. Meaning the plasterer and electrician would have to be put off. I lost two plasterers that week. Eventually bathroom was removed and is currently sitting on my patio (apparently plumber will take it away, honest, but the van’s a bit full....)

So I have a loo that needs flushing with a bucket and absolutely nothing else. Would have been ok if the plasterer hadn’t gone to a funeral the day before he was due at mine and partook a bit too enthusiastically at the wake. Needless to say one hung over plasterer didn’t come.*sigh*

Anyway, he’s in at last and hopefully there will be no more delays (apart from the tiles that were supposed to arrive last week but have been held up at the suppliers..)

Apparently (according to my guys) the reason they’re all so busy at the moment is that they’re mainly working for Health workers..we seem to be cushioned from the “Credit Crunch”, and are all taking advantage of it to have our properties upgraded. Hospital workers are keeping the tradesmen and women of Britain in work. Which is why it’s taking so long to get anything done.

Hoist by our own petard.

The Management.

2009-04-12T16:07:00.006+01:00

Nurse Ratchet has been eaten by crocodiles. Trodden on by an elephant. Fallen down a really deep well shaft with only a little drop of water at the bottom……(thankfully)
Actually I’ve just been really really busy, at work and at home and didn’t realise how quickly time speeds past when you’re trying to fit in a bit of shut-eye around a lot of shift work.

Swapping shifts about can get ever so confusing for your poor kidneys. Mine have no idea whether to kick in all guns blasting or just pack up for good – various favours and last minute covering for sickness means that I seem to have worked day and night shifts almost at the same time – or it feels like it anyway. Sometimes though, when you’re so tired that everything seems a bit surreal, sometimes you notice things that normally would pass you by.

Like the way all “The Management” seem to point fingers at each other and allocate blame when everything is not going to plan. How people appear to turn into small children and sulk when some of this finger pointing turns up a few facts that may well have contributed to everything not going to plan
“He made me do it!”
“It wasn’t me, it was him!”
And Bart Simpson’s favourite – “It was like that when I got there!”
This last one can be effectively applied throughout the nursing profession in order to blame the previous shift for whatever it was that has gone wrong. You’ve all heard it before –

“The night staff didn’t do the obs/drugs/phone the relative/tell me the patient was dead”
For “night” replace with “early” “late” etc.

No one seems able to take responsibility for their own actions, especially if those actions have resulted in a cock up. Grown women and men are reduced to schoolyard bun fighting right from ward level up to management level. It is not productive. We do not “learn from our mistakes” as we’re too busy blaming our mistakes on someone else, or denying we ever made a mistake in the first place. So the mistakes get to happen again . And again. .

And even crazier than that - on occasion, like last week here at my gaff, there was a hulaballoo because there were breaches in A&E. There were people "officed", there were points being scored left right and centre, people were ducking as the buns flew overhead.
It was really busy. There were lots of people to be seen and not a lot of doctors. Everyone got seen, most people got sent home, no one died.
But it was someones fault. Had to be. Stands to reason. It couldn't possibly be just the fact that 20 odd ambulances arrived in an hour could it? From the top down the baton of blame got passed ....

Perhaps those that allocate blame should spend a little more time on examining the doctor's rotas to see why Mondays are always hell and we have so few doctors on, and a little less time saying "well, it wasn't me"

NHS Manager ? I don’t think so.

2009-04-03T20:10:00.006+01:00

Two words that are guaranteed to strike fear and loathing into the heart of any self-respecting front line worker. NHS Manager. NOT to be confused with Clinical Site Manager. Oh no no no, the clue is in the “Clinical”. Honest. Bear with me.

For anyone that doesn’t know what a CSM does, I’ll give you a little glimpse into my world. Well, what the CSM’s get up to round my way anyway.
We’re band 7’s for a start. Not on “NHS Managers” pay – Band 7. Same as ward sisters, shift leaders in A&E, that sort of thing. Not a fortune considering that most of us have worked in the NHS for 20 years or so. We wear a clinical uniform, because we offer clinical support as a big part of our job. Most of us wouldn’t do it otherwise. We’re nurses after all.

Before Matrons came into being again, that’s pretty much what we were regarded as, now they’re back, at Band 8, we’re kind of in limbo as to how people perceive us. When the Matrons jobs were advertised I admit I quite fancied one. I had some vision of doing the job I was already doing, but with lots more time to spend on the clinical side, supporting staff, wiping my finger along a dirty surface and tutting, ensuring all my nurses had neat tidy uniforms, my wards were staffed., everyone knew what they were doing...good god I must have accidentally taken something trippy. Who was I kidding. After getting hold of a job description I realised that the Matron’s jobs were nothing like that. There was far too much emphasis on meetings, (and meetings to decide on the time of the next meeting), audit tools, “benchmarking” (and the English is??), target ticky boxes...not AT ALL what I had envisaged.

So, back in CSM land. It can be a shitty job honestly. Christmas was rubbish. For the first time since I qualified I really considered chucking in Nursing altogether. Busy as hell, about a third more patients than last year, and when the all important targets were not met, being told that we were “not working hard enough” and we’d “lost our grip”. Not bloody funny when you’d run around for 13 hours without a drink of water trying to get the poor old sticks on trolleys into a bed, wherever there was a spare corner to put a bed. And my, were there some spare corners.
It can also be a great job. What other job can you go to 3 arrest calls, catch a pigeon that’s flapping about the Care of the Elderly ward, answer a patient complaint and sort it out, help out in A&E at the trauma that’s just come in, go to a ward and help a new nurse put an NG tube down, and have an argument with the Renal team all before tea. It’s fast, it’s different every day, and it’s a challenge. One hell of a challenge sometimes.

Least favourite job is of course moving staff. Site managers are uniquely placed in that they are probably the only people that have a complete overview of the whole hospital, and have no bias towards one area or another. We know if the Care of the Elderly ward goes one nurse down it’s a disaster, but if it’s another ward with the same template, they can ‘manage’. When people are cocooned in their own area they sometimes find it hard to appreciate what a bloody awful time someone else may be having. We know.

People wouldn’t think that managing beds can be a clinical exercise but it really is. “The Management” would have us fill every bed regardless of the patient, if it means we meet whatever target is important at the time. I like to think we bring a little commonsense into the equation. No – we will not take the 18yr old appendix and put him into a bed above the 99 year old fractured hip from a nursing home. This can sometimes take some inventive bed management, 4 way moves blah blah, but if it means we’re doing the right thing.....

And no, we’re not all flaming perfect. Some days we’re short tempered and downright annoyed at all the brick walls we hit just to get something simple done . You’d think ringing a ward and asking how many empty beds they’ve got is simple? Wrong..
“Well we’ve got 3..”
“3?? But I’ve given you 2 patients”
“but they’re not here yet “
“so when they get there you’ll have 1 left?”
“no, 3”
“3 after the 2 patients arrive?”
“but they’re not here yet....”
Aaaarrrrgggghhhh! See what I mean? So sorry if we’re a little curt at times.

The worst thing you can call a Site manager is a “NHS Manager”. Believe me.

Out of the frying Pan.....

2009-04-02T02:12:00.006+01:00

Ok, so I’m coming out of the closet. There are just too many things that I need to get off my chest that I can’t do unless I fess up and admit it – I’m a Site Manager.

Yes – one of those ghastly people who take your staff and move them around the hospital just for fun. Who is solely responsible for there not being enough beds to put people in. Who puts patients into cupboards in the middle of the night when all the beds have run out just to see who will write to the paper first. You may have seen me pelting up and down the A&E corridor, a patient under each arm and a pile of notes balanced precariously on my head, muttering wildly about something that sounds like “beaches” but can’t quite be heard over the gnashing of teeth .

I admit it. I carry a clipboard. Well, not a clipboard, but a folder full of stuff. Stuff I need. Go on – try me. Ask me what the number is for X agency for when the nurse hasn’t turned up – in my folder. The number for pest control when someone’s seen a rat lurking outside the back door? In my folder. Pathway for Neutropaenic sepsis? In my folder. Admission criteria for paediatrics? Action card in case of a major incident? Three pages of handwritten lists of things to do with little boxes to tick when I’ve done them? (god I hate myself for still doing that) – in my folder. Don’t mock the folder. I get a lot of “folder anger”. One Doctor called me a “Clipboard Nazi” – I was a little hurt, but you grow a tougher skin when you carry a folder.…..

There is a definite feeling that people who carry any sort of "clipboard" are unfeeling, tunnel visioned administrators sent to combat your target fatigue with yet more far flung frankly unimportant but look good on paper objectives.True. But I carry a folder.

Who would know the number to call when you've had a Jewish death and it's Good Friday? Who know's where to find that elusive piece of equipment? Who's got random lists of Doctors who might just want to work tonight since the SHO went off sick? Who knows what time the pizza takeaway closes on a Monday night?

The lady with the folder, that’s who.

Can Anyone Tell Me The Time?

2009-04-01T03:26:00.005+01:00

I’ve been on a bit of a rollercoaster this last week or so with shifts – nights, days, nights again – and strangely enough, I am quite perky. It must be hysteria. The nights I am back on are, to be fair, my choice. I’ve given up smoking- eek, no…”stopped” smoking, so I’m keeping myself busy. I’m relying on good old will power and poor old Alan Carr- it worked for 2 years last time; let’s hope I’m not stupid enough to give in again. I’ve also decided to have an alcohol free period – which sort of ties in with the smoking – I won’t be tempted if I don’t go to the pub etc. My house is therefore like a new pin, my dog has been walked to within an inch of his life, my car is free of …well, all sorts of stuff, and if anyone comes round to see me they are in danger of being bustled into a corner and lightly dusted. And I’m very very chirpy….weird.

We have just found out that there is to be yet another reshuffle in our team/division. The job that had been done by two people will now be being done by three, completely different people. Because three people are better than two it would seem. As has been completely disproved by the amount of people at my gaff who didn’t exist 5 years ago, in charge of discharge planning and execution.
There seems to be a team for every eventuality – delayed discharges, difficult discharges, delayed transfers, intermediate discharge, integrated discharge……….sorry, I dropped off for a moment there. And have the number of discharges increased proportionately? Have they hell. There are just a lot more people wandering about in funny uniforms, not sending people home, and doubtless filling in the endless paperwork needed to justify their existence.

I’m not knocking the people that do the job, no doubt they believe they have the patients best interests at heart, but all these different groups, working at cross purposes to each other, seem to slow down the whole process rather than speed it up.

It drives the poor ward staff insane. In the middle of trying to run a shift with 2 nurses down and Mrs Smith asking for her pain killers for the 5th time they have a succession of people all asking the same questions with a very slightly different twist. “Have you filled in a S2, V5, P45??” “has she been seen by the IDT, ICT, PRB, LWT?”

I’m sure we’re ticking all the right boxes in some file or other, but I’m certain that we’re no more efficient at getting people home than we were 5 years ago; however we were probably about 50 salaries better off.

2009-03-28T18:00:00.002Z

Education Through Fear

There’s a lot to be said for it. I remember the day I came for my interview at my current hospital, some years ago. I had arrived in a new town, and had no idea where I was going. A kindly elderly gentleman courteously held open a door for me, and seeing me looking a little bewildered, offered to show me where my interview was being held. Some years later I found myself sitting in a classroom with said kindly gentleman, absolutely terrified. Little had I known at the time, but he was an eminent Consultant, now retired, but still teaching (yes – and teaching nurses too!).
This man was renowned worldwide for his work in his field, and hospital wide for his terrifying teaching style. Every single one of the students would be asked questions as he went along, and woe betide you if you had not done your homework. You would be singled out for ridicule, held up in front of the class and made to blush furiously while your fellow students tittered nervously, just glad it wasn’t them. We learnt though. We went home and did our homework.

Unlike the current frankly wishy-washy way we are now encouraged to learn- in nursing anyway. I am currently struggling through a degree in nursing, not because I’m finding it hard, but because I find it incredibly dull. I don’t think it will make me a better nurse; I’m doing it because at my level of seniority I’m expected to have a degree. I trained before P2000, so in academic terms, am at the bottom of the pile. However – I can nurse – it’s what I was trained to do. I doubt whether writing an essay on the “Sociology of Nursing” will make me more able to deal with an emergency situation, or comfort a relative, or juggle the 3000 things I need to juggle to get through the day. Am I ever going to write a research paper? No. Will learning about management styles make me change mine? No, it seems to work quite well as it is. I’m not saying I don’t want to learn, I just don’t want to be patronised.

A great deal of my lectures have been of the “power point presentation, with a handout of the presentation given at the same time, while the lecturer reads the handout out to you” type. It makes you want to gouge your own eyes out with boredom.

And if you don’t get your essay finished on time – you get an extension. If you don’t turn up for class – that’s OK, you’re allowed to miss 20% of lectures. If you don’t know the answer to something that you were supposed to look up the night before – never mind – try and look it up when you get the time in your busy life.

Bring back education through fear – I might just actually finish this damn degree then.

2009-03-27T14:39:00.001Z

Pervader of General Dreadfulness.

I spent several hours of my night shift last night attempting to convince a patient who was in the acute phase of alcohol detox, that we were not, in fact, in the pub, (although it would have been preferable). I have spent countless hours of my life ducking blows and administering sedation to patients like these, but this one actually made my night. He was intelligent and articulate, and seemed to have astute insight into the workings of the NHS. At one point he told us that we were “raving lunatics trying to achieve an unattainable goal”. Good grief– uncanny.

These type of patients are notoriously difficult to care for. For a range of medical reasons they require admission to hospital, but once deprived of alcohol, often become violent and a danger to staff and other patients alike. All too often whatever detox regime is considered trendy (or cheapest) at the time is inadequate, and junior staff (both nurses and doctors) are too nervous to increase doses in case, well, in case the patient stops breathing. Which leaves us with a problem. What do you do with a violent patient who is threatening other patients? When enough sedation to fell an ox has not been effective and the patient is STILL throwing the ward computer out of the window– what now? The answer probably is to get the detox regime right from admission, but sadly that’s not going to happen in 100% of cases. Which leaves us with a ward full of frightened patients, assaulted nurses, not to forget the patient, who is usually going through hell.

It would be nice to have a safe area where the patient could sit out their hallucinations – say a nice comfy room with soft walls...well, they could be observed, and they wouldn’t be able to hurt themselves or anyone else.....it’s usually only for a day or two at most.. Somehow I think that somewhere along the line we’d be violating someones human rights. Well, it was only an idea.

One last thing – my chap from last night, as we were once again explaining that it really would be better to keep his clothes on, looked me straight in the eye and said “ You madam, are a pervader of general dreadfulness “

Ok ,the grammar’s not perfect but he’s not well. I quite like it. Nurse Ratchet – pervader of general dreadfulness. Got a ring to it hasn’t it?

Welcome back. I think.

2009-03-26T01:37:00.002Z

Nurse Ratchet is back. After a prolonged leave of absence, I am returning to the fray, ready or not. Swiss sanatoriums aren’t cheap you know. I have licked my wounds (mostly inflicted by those eloquent and well mannered folk on Doctors.net), and, fully medicated, intend to crack on.

For those of you that may have missed it, I caused quite a stir some years ago with a short lived blog that was initially written in response to Dr Crippens unwavering dismissive and often very patronising, attitude towards Nurse “Quacktitioners” , and their wont to misdiagnose , or rather diagnose, above what he perceives to be their level of medical expertise. I was surprised at the lack of support that nurses showed each other (and still am frankly), and in a burst of solidarity for my fellow professionals, decided to attempt to redress the balance.
In hindsight, and what a wonderful thing that is, I concede that I could have done my fellow professionals a bigger favour by paying a little more attention to detail with the example I used, instead of being caught up in the heat of the moment, and the point I was trying to make. Well, it was my first post, and I was young and naive in the world of the Blog.

Lord. What a commotion ensued when a link to my blog was posted on Doctors.net. The vitriol! The abuse! The bad grammar! The most memorable insults (and insults there were many) included being called a “stupid bint”, and one polite and well mannered medic accusing me of being a “fat nurse in a badly fitting dress who spends her time at the desk eating chocolate” . All of a sudden things took an entirely different turn. Where I had been trying to garner some support from nurses for each other, I suddenly realised that the issue had changed altogether. This was now about how we, doctors and nurses, as fellow professionals, as colleagues, were not at all united in a common cause. Far from it. Further from it than I had realised.

I retreated rather rapidly, tail between my legs, shocked at how the anonymity of the web allows people the “freedom” to ridicule and lambast one another. As I said, I was naïve in the world of the Blog.

Well, here I am again, let’s see how it goes.