So

There are days I love my job, some when I hate what being an ER nurse has become.  I would love it if I could still do nursing 1970's style.  20 uninterrupted minutes for each of my patients at a time, helping them understand all their meds, treatments, and an in-depth plan that we will work out together for the length of their stay, complete with meal times, snacks, back rubs, bed baths, etc.  It would be lovely to chat with them about their family,  jobs,  previous experience in hospitals, belief systems, hobbies, how they love to take long walks on moonlit beaches.  For the most part, though, it is a race against time, and I waste a good bit of  it apologizing for what isn't being done rapidly enough to suit them.  Priorities?  Constantly changing.  Minute to minute, actually.  A nurse's priorities are manipulated by everyone EXCEPT nurses.

Although I don't work in Massachusetts, several friends and family have asked my opinion on their proposed upcoming ballot question regarding  nurse:patient staffing  ratios.  Let me walk you through my thought process on that issue, and share this exhausted bedside nurse's perspective.

My tale begins shortly after receiving nurse to nurse report from the off-going day shift.  I was responsible for four patients in the critical care zone (strokes, heart attacks, trauma) one more than is prescribed, although there is no mandate here.  It is assumed that if one nurse is busy with something truly critical, the other will pick up the "slack".  I hit the ground running.

There are three providers, all of whom have promised patients that "the nurse will be right in".  As you can imagine, I can't be in four places at once.

(In real time, now) I am answering the call light of one of my patients who is demanding instantaneous service who has to go to the bathroom.  I can simply take off the cardiac monitor leads and disconnect the IV as he is ambulatory.

I return to my desk and computer, where I must log in and acknowledge all orders and do all of my charting.  At my work station,  I find the family members of 2 elderly patients standing at my desk.  One wants water and warm blankets for their father, the other has a mother who needs to go to the bathroom "right now".  Neither of those patients are mine.  I explain that I or their nurse will attend to them as soon as possible.  The emergent toileter relative argues that the need is immediate, so I have to take care of that patient (belonging to my zone partner who is busy with a combative suicidal overdose) before I even begin to attend to the needs of my own patients.  It is a weak, dizzy, and demented nursing home patient, and the relative is useless (as they usually are), so I hunt down another equally busy nurse to assist with transfer of the patient from the bed to the commode, which I also have to hunt down.  In addition, she is caked with stool that has to be cleaned before returning her to bed.  Naturally, the relative also wants water, warm blankets and a turkey sandwich which I ignore for now place low on the priority list of tasks.  My ambulatory patient, now back in bed,  is also now ringing for meds and to have the IV restarted.

It has been 25 minutes since three physicians have promised things to patients that I have yet to provide.

Back to my desk to print med orders for 3 of my patients.  This is a policy, also a safety issue.   I must take the printed sheets to the bedside for confirmation of identifiers and allergies.  Every med.  Every patient.  Every time.  Antibiotics and anti emetics for 2 of them.  IV fluids and pain meds for one.  Before I get the orders printed I am interrupted once again by emergent-toileter-relative-who-is-not-my-patient at my desk to demand the warm blankets and water.  I say shortly that I will send in her nurse.  I hate when people stand at my desk, it's just rude.    Unless your relative is coding, standing at the desk is like jumping the queue.  Use the fucking call light.

Here is a short list of what I must do now:
Wait behind 2 other nurses to get meds out of the Pyxis, one of which is an orientee and is being coached by her preceptor so even the commonly used meds take awhile to find.  After a couple of minutes it is my turn.  I must input my password, use my fingerprint ID, find the patient name, then pull saline, tubing, antibiotic, second tubing for the antibiotic, small admixture bag with adapter, and anti nausea meds for both patients which entails knowing what they are called in the Pyxis.  A one liter bag of saline I know is listed under "Sodium chloride", with a drop down list for how big a bag you want.  I have to hit the screen on average about 4-5 times for EVERY ITEM  I need after typing in some key letters, then wait for the door or drawer to open, then the individual lid containing only the desired medicine.  I pull out what was ordered, close the lid and drawer.  Fortunately the antibiotic and anti emetic is exactly the same for both patients and this ain't my first rodeo, so I have what I need relatively quickly.  I also get the pain med and more IV fluid for the ambulatory patient.  One of the newer nurses has a question about how to administer a medication that she has never used, so I instruct her on how it's done.  Remember that.  I am taking time out of patient care to provide information to a less seasoned nurse.  This will always be a priority for me, you cannot burn the newbs, lives literally depend on it.  I grab a couple of syringes and blunt needles to draw up the anti- emetics and drop one "set" of meds by my computer, taking my orders into the other patient's room.

35 minutes have elapsed.  Nobody has what was ordered yet.

The first patient complains about the wait, I apologize insincerely, eyeball the monitor and general condition of the patient, (note that he doesn't look that uncomfortable) while simultaneously  mixing the antibiotic.  I confirm identifiers (name, DOB) and allergies.  I hang the IV fluids.  I inject the anti emetic over 2 minutes, and during this time I assess the patient:  skin color, and temperature, vital signs, pain level, get a quick and dirty on the onset of illness.  I try to make eye contact and sound sincere but I'm pretty business-like.  There is already an IV pump in the room and I spike the antibiotic that I have already mixed, hang it, priming the tubing and feeding it through the pump.  I set the pump for one hour.  I make sure the patient has a call light and have one foot out the door to run to my next task.  The family wants to know how soon admission to comfy floor bed will happen (hours) and what time is dinner (you have abdominal pain.  Never).

47 minutes elapsed.  I repeat the procedures on the 2nd patient, but must find an available pump first which takes a few minutes. I have to retrieve a visitor from the waiting room, as all must be escorted in our ER (topic for another day).  Emergent-toileter-relative-who-is-not-my-patient glares at me from her helicoptering position at the door.  I am moving too fast to flag down.

I am back at my desk now about 57 minutes in and I haven't even laid eyes on the 4th patient.  I have done nothing but toilet a patient who isn't mine, clean up shit, give meds and fluids.  I have done nothing, really, to educate my patients or make them more comfortable, or even make them feel like I care about their problems.  Tasks, tasks, tasks.

 I discover that CT has called, along with ultrasound, for the shortness of breath and leg swelling which is patient number 4.  I explain that the doc wanted to wait on the lab test before sending for the CT.  I hunt down the physician to see if it's ok to send to to ultrasound.  First I check to see if the patient has a patent IV: yep.  Quick assessment, check the monitor and VS, then disconnect and transport the patient myself to ultrasound because there is never anyone available to transport since our last transporter, the 4th this year, quit after 2 months on the job.

I return to my desk once again.  One of the physicians wants to know if meds were given:  yes, not charted.  She thought so, was just wondering if there had been any response.  No idea.  Haven't been in the room, but haven't heard any puking and they asked about dinner, so all good from my perspective.

All of this has taken place in about 1 hour and 10 minutes into my shift.  I have charted nothing, my zone partner is nowhere to be found, and my boss wants to know if any of my patients have orders for admission to the floor and can be transported (nope) or discharged (hell no),  or can be moved out of a room for an ambulance arriving with chest pains.  That means that now any remaining  tasks care to be provided to any other patients will be put on hold while I take the next 20 minutes with this new patient.  Move family of patient in ultrasound to hallway amidst grumbles, move in new stretcher, accept ambulance report, then triage/assess/undress/EKG/place on monitor/start IV and draw labs on the chest pain patient who is from a nursing home.  This patient turns out to be an elderly 90 year old, non-verbal and demented, also combative, and therefore non-participatory in his care.  He has  2,000 meds and has never been at our facility, so they all have to be entered into the computer.  I say screw it, and merely attach the list to the chart with a sticky note to the provider that I will get to the meds when I can (our pharmacist who loves to do that shit).   It is Friday afternoon and nursing homes are well known for the tactic of sending their difficult patients to the ER at this time with vague complaints or  "chest pain".  My 20 minute intake takes about 45 minutes to an hour due to incontinence, possible fever and sepsis, while dodging swinging fists and verbal abuse.

I feel I have been a bad zone partner and not been able to help with the combative overdose, but fortunately the paramedic (bless him) has been in with her the whole time.  Her other 2 patients are fortunately awaiting admission, so need little in terms of assessment and treatment at this time (except for the soul-sucking emergent-toileter whose family member continues to glare and ask for stupid things like jello).  I carry on.  In the meantime, two of my patients are on the call bell "just" wanting updates on their admission progress (hours, you are stalled in the ER as there are no available beds on the floors), "just" some warm blankets, "just a quick question",  and at 4:15 in the afternoon to inquire if a sleeping pill will be ordered when they are admitted.  Dunno, and right now I don't care.  Not my job and not up to me, ask the hospitalist.

Less than 2 hours into my shift and I have had limited contact with my patients.  This doesn't feel good for any of us.  Its "adequate" at best.  To me it was crappy care.

Our administrative clip board commandos walked out at the end of the day knowing the department was about to implode, but leaving us with "adequate staffing".

"Adequate staffing" did not add additional personnel for the additional 12 patients in hallway beds.  There were two LNA's, one of whom was designated to sit and watch the suicidal patients in the overflow hallway beds.  The other was being ridden like a cheap pony.  There was one paramedic who was occupied.  The EKG department calls it a day at 4 PM and we have to do our own.  Just one less resource and an additional task.

If we had 4 extra nurses we would have been golden, even with non-stop ambulances and an overcrowded waiting room (5 hour wait).

With 3,  it would have meant a world of difference.

One or two even would have helped.  An extra paramedic.  A couple of LNA's.  Our secretaries were thoroughly in the weeds.

At this point I completely understood why Massachusetts nurses put this on the ballot, born of utter frustration.  More nurses, better care.

Hospital executives don't care and won't spend the money on nursing unless compelled to do so.

If I lived in Massachusetts I would vote yes.