False Economy. A phrase that I've seen used a lot recently, one I've used myself. It means something that initially is cheaper but works out to be more expensive in the long term. It's something I feel can really be applied to nursing, I was going to say particularly the ward I work on that the moment but I have seen in on many wards.
Staffing. We are under staffed. We regularly have shifts where on 4 of 6 slots are filled. Sometimes as little as 3, and on a good day 5. The last couple of shifts I worked were fully staffed, a rarity, and it was wonderful. We don't have enough staff, but they won't employ more full time nurses. This however is a false economy, because with all the shifts being filled by bank and agency it would have been cheaper and far less stressful to employ another full time staff member or two.
I can't believe how many days have passed since I last posted. Time is flying by and Christmas is nearly upon us. Unfortunatly I have to work Christmas day this year, which I have to admit I'm very disapointed about, however you gotta do what you gotta do and we'll just have to try and make the day special for all the patients.
I wanted to draw your attention to a charity my hospital is involved with. Facing the World.
F A C I N G T H E W O R L D is a children's charity. It has been set up some of the UK’s leading craniofacial surgeons so that children in desperate need, living without hope in the world’s poorest countries, can have access to the very best surgery that can transform their faces and radically change their quality of life.
If you only look at two things on that website please look at the short film linked on the main page, it's in the bottom blue box with the dial up or broadband link. I would also reccomend that you go to the Case Studies page. I think what this charity does is amazing, and it is one of the few charities that has really moved me.
Tuesday, December 18, 2007
Wednesday, December 05, 2007
'Tis the season
The Bronch season.
Bronchiolitis is a common respiratory infection that affects young babies and children. Their bronchioles (smallest airways) become infected by a virus,becoming inflamed and causing a build up of mucus. Some babies become very unwell with this condition and this can mean admission to hospital.
Initially it presents as a common cold which then worsens and affects their breathing. They develop rapid breathing, a rasping cough and a raised heart rate.
In some children these symptoms worse and they have increased difficulty in breathing. They have a rapid respiration rate, will be using their accessory muscles to aid their breathing, this can be very tiring and lead to exhaustion, in this case they will need support in hospital. They may also struggle to feed as they find they become too breathless.
Treatment. We give oxygen. We sometimes give inhalers, though these don't always work well. CPAP - a form of non-invasive ventiliation to assist breathing. IV fluids to correct/prevent dehydration. Nasogastric tube feeding until we can reesatblish breast or bottle feeding.
I hate Bronch season with a passion. Bronch's are incredibly hard work.
a) They may be on oxygen. Hopefully you get a set of nasal prongs in and hopefully get them stuck down and then hopefully they won't keep trying to pull them out. If they're on oxygen they require hourly observations and being on a sats monitor.
b) Sats monitors are a great tool for nurses. They allow us to continously monitor the childs heart rate adn oxygen level. When there's a good trace. Which there usually isn't because the child is kicking it's foot around and doesn't like have the plaster attached. You will also notice that monitors increase parental anxiety. They become number watches, obsessed with the heart rate and oxygen levels, but they lack the experience to intepret the machine and it's readings, to knwo when it's accurate and when to be concerned. They require more reassurance and will frequently buzz for you worried that their child's oxygen level has dropped. Of course there is the opposite extreme. The parent who has seen you silence the machine before and think it's okay for them to do the same, not realising that you're also making an assessment when you do that. You then pop along an hou later to discover the child's oxygen levels are too low. Sometimes they even turn it off without telling you, because the alarm was annoying them.
c) NG feeding. This may be a continous feed or a bolus feed. Blous feeds take a considerable amount of time on an already busy shift. If they're very unwell we have to reduce their feed because the expanding stomach restricts the lungs ability to inflate, and if they're really very unwell we may stop feeds altogether and rely on IV fluids for hydration and the occasional comfort feed. This leads to d)
d) Irritable. Bronch babies, when they are unwell, are some of the most irritable and unsettled children I have come across. They feel rubbish, they're tired phsycally from the effort of breathing, will probably not be sleeping well and they're hungry. They are some of the hardest babies to settle, a nightmare for the parents and in turn for the nruses when the parents are at their wits end and asking you for a solution (or jsut ignoring thier child)
Where I'm working we put Bronch's into double bays. They're infectious, but with the number of Bronchs we have we double them up as they both have the same illness. Unfortuantly we so often seem to have one sick one and one slightly better one. Sick baby and mum keeps slightly better baby and mum up all night, causing frustration for everybody. Then slightly better baby goes home, and sick baby becomes slightly better baby and we get a new sick baby in and it begins again.
Hospital is the worst place to get a good night's restful sleep!
Bronchiolitis is a common respiratory infection that affects young babies and children. Their bronchioles (smallest airways) become infected by a virus,becoming inflamed and causing a build up of mucus. Some babies become very unwell with this condition and this can mean admission to hospital.
Initially it presents as a common cold which then worsens and affects their breathing. They develop rapid breathing, a rasping cough and a raised heart rate.
In some children these symptoms worse and they have increased difficulty in breathing. They have a rapid respiration rate, will be using their accessory muscles to aid their breathing, this can be very tiring and lead to exhaustion, in this case they will need support in hospital. They may also struggle to feed as they find they become too breathless.
Treatment. We give oxygen. We sometimes give inhalers, though these don't always work well. CPAP - a form of non-invasive ventiliation to assist breathing. IV fluids to correct/prevent dehydration. Nasogastric tube feeding until we can reesatblish breast or bottle feeding.
I hate Bronch season with a passion. Bronch's are incredibly hard work.
a) They may be on oxygen. Hopefully you get a set of nasal prongs in and hopefully get them stuck down and then hopefully they won't keep trying to pull them out. If they're on oxygen they require hourly observations and being on a sats monitor.
b) Sats monitors are a great tool for nurses. They allow us to continously monitor the childs heart rate adn oxygen level. When there's a good trace. Which there usually isn't because the child is kicking it's foot around and doesn't like have the plaster attached. You will also notice that monitors increase parental anxiety. They become number watches, obsessed with the heart rate and oxygen levels, but they lack the experience to intepret the machine and it's readings, to knwo when it's accurate and when to be concerned. They require more reassurance and will frequently buzz for you worried that their child's oxygen level has dropped. Of course there is the opposite extreme. The parent who has seen you silence the machine before and think it's okay for them to do the same, not realising that you're also making an assessment when you do that. You then pop along an hou later to discover the child's oxygen levels are too low. Sometimes they even turn it off without telling you, because the alarm was annoying them.
c) NG feeding. This may be a continous feed or a bolus feed. Blous feeds take a considerable amount of time on an already busy shift. If they're very unwell we have to reduce their feed because the expanding stomach restricts the lungs ability to inflate, and if they're really very unwell we may stop feeds altogether and rely on IV fluids for hydration and the occasional comfort feed. This leads to d)
d) Irritable. Bronch babies, when they are unwell, are some of the most irritable and unsettled children I have come across. They feel rubbish, they're tired phsycally from the effort of breathing, will probably not be sleeping well and they're hungry. They are some of the hardest babies to settle, a nightmare for the parents and in turn for the nruses when the parents are at their wits end and asking you for a solution (or jsut ignoring thier child)
Where I'm working we put Bronch's into double bays. They're infectious, but with the number of Bronchs we have we double them up as they both have the same illness. Unfortuantly we so often seem to have one sick one and one slightly better one. Sick baby and mum keeps slightly better baby and mum up all night, causing frustration for everybody. Then slightly better baby goes home, and sick baby becomes slightly better baby and we get a new sick baby in and it begins again.
Hospital is the worst place to get a good night's restful sleep!
Tuesday, December 04, 2007
Structure
Well after MMW's suggestion I'm writing a post on the structure of nursing. This is based on the heirachy where I work now, though I think it will be fairly similar all over - it certainly was similar where I trained.
So, there are three types of nurse you'll come across on the ward.
Staff Nurse, someone employed permanently by the hospital - that's me.
Bank Nurse, someone who has signed up to the hospitals internal nursing agency - that can also be me - usually someone who already works in the hospital and wants extra shifts.
Agency Nurse, someone who works for an external nursing agency. Sometimes they're good, often not too bad but slightly more a hinderance than a help, and occasionally absolutely awful.
Why would someone want to work for an agency? Agency nurses get paid higher rates than Staff or Bank nurses, (Bank nurses earn slightly more than Staff Nurses) - the ward waits as late as possible before "putting the shift out to agency" in the hope someone cheaper will agree to do it.
Less responsibility.
Agency nursing is flexible; you can work which shifts you choose.
However the downsides to Agency nursing:
Shifts may not always be available when you want them
Depending on where you work you will be unappreciated and looked down upon, you also run the risk of being given the difficult patients or those no one else wants to look after - I don't believe this is true of where I work now, I think we treat our agency nures fairly well, that's why we have some regulars who keep coming back to us.
On the ward I work on we have 20 beds, this closes to 15 over the weekend. On week days we (hopefully) have 6 staff, on week nights 4 staff, and on weekend days 4 staff and weekend nights 3 staff. At night you can expect to care for 5 patients, if fully staffed. On days 3-4, if fully staffed.
Some of the patients we have require a lot of nursing intervention, 1:3 may not sound like a lot but depending on the patient the workload can be very heavy, and day shifts are always busier than nights. That being said, nursing 5 patients overnight can also keep you very busy. We have a lot of jobs that are supposed to happen on the hour, an example of the hourly jobs you may have to do for 5 patients overnight could be: 3 pump readings, 3 sets of observations, 1 set of inhalers (on some hours rising to 2), giving a feed hourly or two hourly, plus on various hours on top of that IV antibiotics (which I'm not yet trained to do), observations for other patients, medications. I often find that I'll have just finished my hourly jobs just in time to start the next hour.
However, I have trailed off the topic for this post. Sorry for that rather boring interlude! Back to structure.
Band 5 - This is a Staff Nurse, generally speaking, in their first 5 years of nursing, after this point to progress through the pay scale you would have to move up a Band. You have lower and upper Band 5's, which represent the old D and E grades, basically those with more or less experience. These lettered grades were removed with Agenda For Change, but we still refer to them.
Band 6 - This is a Senior Staff Nurse, in some places they may be called a Junior Sister or Charge Nurse. They have more responsibility than us lowly Band 5's, which is one reason why some nurses choose not to move onto Band 6 despite reaching a cap in their pay. Where I work we currently have 5 Band 6's, two of which are very part time (2-4 shifts a month).
Band 7 - This would be the ward Sister, or where I work Ward Manager. The Ward Manager is similar in role to Sister but as far as I can work out is less clinical and more office based. We have one Ward Manager.
We have recently had a Modern Matron come into post, in the last few weeks, this is a very new position for us and I'm guessing it is a Band 8 position. He previous was a Ward Manager, and now manages the whole of children's unit with Ward Manager's in each ward.
Now, that is our basic structure for ward Staff Nurses and Managers, but there are a couple more "important" roles. During the day we have a Paeditric Bed Manager, and you've guessed is he manages the Paeditric Beds. He keeps tabs on all the beds and cubicles available across the unit and the demand for them in A&E. Any child admitted during the day needs to go through him, and he makes the decision about where to allocate them. At night this role is filled by the Site Manager, who has the unenviable job of being Site Manager/Bed Manager for the whole of the hospital. They need to keep track of the admissions, discharged, allocations and transfers as well as any staffing issues that may arise. Our last key person is the Senior Nurse (not to be confused with Senior Staff Nurse). This person carries The Bleep, and their responsibility is staffing; if someone calls in sick they have to speak to the Senior Nurse, they have to be aware of staffing across the unit and make decisions about where to send nurses to cover if we're short staffed. This is usually a Band 6 or above nurse, though some of our more experienced Band 5's will also do it. This is also on top of thier normal patient workload as staff nurse that day or night. Oh, and we have a shift co-ordinator in charge of every shift, this can be almost anybody who's been there at least a few months!
So that's how it all works. Kind of! I know this was probably a bit of a long winded and boring post, but I think understanding what goes on "behind the scenes" will make my blog make more sense!
So, there are three types of nurse you'll come across on the ward.
Staff Nurse, someone employed permanently by the hospital - that's me.
Bank Nurse, someone who has signed up to the hospitals internal nursing agency - that can also be me - usually someone who already works in the hospital and wants extra shifts.
Agency Nurse, someone who works for an external nursing agency. Sometimes they're good, often not too bad but slightly more a hinderance than a help, and occasionally absolutely awful.
Why would someone want to work for an agency? Agency nurses get paid higher rates than Staff or Bank nurses, (Bank nurses earn slightly more than Staff Nurses) - the ward waits as late as possible before "putting the shift out to agency" in the hope someone cheaper will agree to do it.
Less responsibility.
Agency nursing is flexible; you can work which shifts you choose.
However the downsides to Agency nursing:
Shifts may not always be available when you want them
Depending on where you work you will be unappreciated and looked down upon, you also run the risk of being given the difficult patients or those no one else wants to look after - I don't believe this is true of where I work now, I think we treat our agency nures fairly well, that's why we have some regulars who keep coming back to us.
On the ward I work on we have 20 beds, this closes to 15 over the weekend. On week days we (hopefully) have 6 staff, on week nights 4 staff, and on weekend days 4 staff and weekend nights 3 staff. At night you can expect to care for 5 patients, if fully staffed. On days 3-4, if fully staffed.
Some of the patients we have require a lot of nursing intervention, 1:3 may not sound like a lot but depending on the patient the workload can be very heavy, and day shifts are always busier than nights. That being said, nursing 5 patients overnight can also keep you very busy. We have a lot of jobs that are supposed to happen on the hour, an example of the hourly jobs you may have to do for 5 patients overnight could be: 3 pump readings, 3 sets of observations, 1 set of inhalers (on some hours rising to 2), giving a feed hourly or two hourly, plus on various hours on top of that IV antibiotics (which I'm not yet trained to do), observations for other patients, medications. I often find that I'll have just finished my hourly jobs just in time to start the next hour.
However, I have trailed off the topic for this post. Sorry for that rather boring interlude! Back to structure.
Band 5 - This is a Staff Nurse, generally speaking, in their first 5 years of nursing, after this point to progress through the pay scale you would have to move up a Band. You have lower and upper Band 5's, which represent the old D and E grades, basically those with more or less experience. These lettered grades were removed with Agenda For Change, but we still refer to them.
Band 6 - This is a Senior Staff Nurse, in some places they may be called a Junior Sister or Charge Nurse. They have more responsibility than us lowly Band 5's, which is one reason why some nurses choose not to move onto Band 6 despite reaching a cap in their pay. Where I work we currently have 5 Band 6's, two of which are very part time (2-4 shifts a month).
Band 7 - This would be the ward Sister, or where I work Ward Manager. The Ward Manager is similar in role to Sister but as far as I can work out is less clinical and more office based. We have one Ward Manager.
We have recently had a Modern Matron come into post, in the last few weeks, this is a very new position for us and I'm guessing it is a Band 8 position. He previous was a Ward Manager, and now manages the whole of children's unit with Ward Manager's in each ward.
Now, that is our basic structure for ward Staff Nurses and Managers, but there are a couple more "important" roles. During the day we have a Paeditric Bed Manager, and you've guessed is he manages the Paeditric Beds. He keeps tabs on all the beds and cubicles available across the unit and the demand for them in A&E. Any child admitted during the day needs to go through him, and he makes the decision about where to allocate them. At night this role is filled by the Site Manager, who has the unenviable job of being Site Manager/Bed Manager for the whole of the hospital. They need to keep track of the admissions, discharged, allocations and transfers as well as any staffing issues that may arise. Our last key person is the Senior Nurse (not to be confused with Senior Staff Nurse). This person carries The Bleep, and their responsibility is staffing; if someone calls in sick they have to speak to the Senior Nurse, they have to be aware of staffing across the unit and make decisions about where to send nurses to cover if we're short staffed. This is usually a Band 6 or above nurse, though some of our more experienced Band 5's will also do it. This is also on top of thier normal patient workload as staff nurse that day or night. Oh, and we have a shift co-ordinator in charge of every shift, this can be almost anybody who's been there at least a few months!
So that's how it all works. Kind of! I know this was probably a bit of a long winded and boring post, but I think understanding what goes on "behind the scenes" will make my blog make more sense!
Monday, December 03, 2007
Return
I've been meaning to write ni this for a while now. Thank you MMW for your comment, it was a kick up the arse, I'm sorry it's taken so long to write since then.
Since I last wrote I have completed my nurse training, started working a staff nurse in a busy SW London hospital, ended a 4.5 year relationship and began a new one.
I've wanted to write so often recently, but this has usually been following a bad day at work where the madness of the NHS boils my blood! I still LOVE my job and it's partly for this reason that I've not written. I don't want this to become a negative "The NHS is Bad" blog.
However, I suspect many of my posts will remark upon the state of the NHS and nursing today. I will endeavour to include something positive, because the job is not all bad and there is still a lot of reward in it.
I was recently asked a question about the current NHS, red tape and political correctness. I've decided for my first post I shall copy my reply in here.
Sometimes I feel that the paperwork that has sprung up from politically correct government think tanks and public inquiries impedes nursing care. It detracts from what is important; caring for the patient, not just doing tasks, but caring for them, being with them and supporting them. I wonder why a paitent's ethnic origin is important to document, as far as I'm concerned everyone should receive the same high level of care and be treated individually. 4 hourly waiting time in A&E, if a patient isn't transferred/discharged within 4 hours they "breech" and this is a terrible thing. I think they explode or something like that. I frequently run (literally) down to the A&E department to collect patients before they breech and at the cost of my own patients on the ward: their pain relief has to wait, their dressing change has to wait, their feed has to be late. I'm sure as far as the governemnt is concerned this is good nursing: the patient in A&E isn't waiting more than 4 hours, but would an extra 15 minutes really make a difference?
But then I think about Victoria Climbie (if you've not read the Laming Report I sincerely reccomend you do, it's not pleasant reading but I believe awareness is the start of prevention). That child suffered terribly and was failed by so many people and services. A lot of systems and paperwork have been put in place since then with the aim of protecting children and preventing the reccurence of such a tragedy. Surely this a good thing. Yes, it's a pain in the arse when you have 5 different referrals and telephone calls to make, but if it can prevent a child's death or maltreatment then it's worth it in my eyes. Whether it would have actually made a difference in Victoria's case I don't know, personal accountability has to come into it at some point, beyond whether you ticked boxes and filled in a referral form. But we're trying.
So, after that long-winded and off track response I agree with Doc: Too much red tape is a bad thing, not enough is worse. The difficutly is trying to find the balance. In the NHS most red tape is aimed at improving patient care. Or am I being naive? Perhaps it's aimed at improving the hospitals bank balance. Whether in reality patient care is improved, I think you'd need to look at that on a case by case basis.
I'm going to leave it there for now, though this is something I will come back to.
MMW: Please give me time to catch up with you blogs! I'm incredibly out of the loop, I can only apologise.
Since I last wrote I have completed my nurse training, started working a staff nurse in a busy SW London hospital, ended a 4.5 year relationship and began a new one.
I've wanted to write so often recently, but this has usually been following a bad day at work where the madness of the NHS boils my blood! I still LOVE my job and it's partly for this reason that I've not written. I don't want this to become a negative "The NHS is Bad" blog.
However, I suspect many of my posts will remark upon the state of the NHS and nursing today. I will endeavour to include something positive, because the job is not all bad and there is still a lot of reward in it.
I was recently asked a question about the current NHS, red tape and political correctness. I've decided for my first post I shall copy my reply in here.
Sometimes I feel that the paperwork that has sprung up from politically correct government think tanks and public inquiries impedes nursing care. It detracts from what is important; caring for the patient, not just doing tasks, but caring for them, being with them and supporting them. I wonder why a paitent's ethnic origin is important to document, as far as I'm concerned everyone should receive the same high level of care and be treated individually. 4 hourly waiting time in A&E, if a patient isn't transferred/discharged within 4 hours they "breech" and this is a terrible thing. I think they explode or something like that. I frequently run (literally) down to the A&E department to collect patients before they breech and at the cost of my own patients on the ward: their pain relief has to wait, their dressing change has to wait, their feed has to be late. I'm sure as far as the governemnt is concerned this is good nursing: the patient in A&E isn't waiting more than 4 hours, but would an extra 15 minutes really make a difference?
But then I think about Victoria Climbie (if you've not read the Laming Report I sincerely reccomend you do, it's not pleasant reading but I believe awareness is the start of prevention). That child suffered terribly and was failed by so many people and services. A lot of systems and paperwork have been put in place since then with the aim of protecting children and preventing the reccurence of such a tragedy. Surely this a good thing. Yes, it's a pain in the arse when you have 5 different referrals and telephone calls to make, but if it can prevent a child's death or maltreatment then it's worth it in my eyes. Whether it would have actually made a difference in Victoria's case I don't know, personal accountability has to come into it at some point, beyond whether you ticked boxes and filled in a referral form. But we're trying.
So, after that long-winded and off track response I agree with Doc: Too much red tape is a bad thing, not enough is worse. The difficutly is trying to find the balance. In the NHS most red tape is aimed at improving patient care. Or am I being naive? Perhaps it's aimed at improving the hospitals bank balance. Whether in reality patient care is improved, I think you'd need to look at that on a case by case basis.
I'm going to leave it there for now, though this is something I will come back to.
MMW: Please give me time to catch up with you blogs! I'm incredibly out of the loop, I can only apologise.
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