For those unfamiliar with hospital nursing, let me give an unbrief overview of how my day begins.

In nursing, very little is predictable. Nursing is like riding a wooden kayak down rock filled rapids knowing that any one of those rocks, those little mischievous bumps in the road, could and most likely will, disrupt your course at best and, at worse, cause your entire day to come to screeching halt. Example: You have a patient who codes. Messes up your day every time.

Before I can take on a patient I need to:

1. Get report from the off-going nurse

2. Look at each patient's most recent labs: Yes - they wake the patients up between 4 & 6 am to poke them for blood so the labs will be available for the doctors (MDs) to view when they round between 6:30 & 8 am. However, the nurse is suppose to know what the labs are before the doctor rounds, call them with any critical findings, or make note of any significant abnormal, but uncritical labs in the doctors notes BEFORE the MDs arrive on the floor.

3. Look at any recent radiology/emergency department/CT/MRI reports

4. Make sure all MD requested labs have been carried out and see what others may be scheduled. For example, are we waiting for the patient to void so we can collect urine? I need to know this and I need to make sure my Clinical Care Partner knows, as well, so he or she will not discard what we need to collect.

Meandering Moment: Clinical Care Partners, or CCPs, (a.k.a. patient care technicians) are the people who assist the patients with basic care activities, such as walking to the bathroom, collecting vital signs, and doing accuchecks on patients with diabetes. Actually, they do a LOT more than this and nurses could not survive or do their jobs without them, but that's another blog for another day. Suffice it to say that a good CCP can make your day flow much more smoothly, and a bad CCP can make your day Hell.

5. Check each patient's chart to make sure all previous orders were noted by the off-going nurse and that they were, in fact, carried out. The nurse needs to make notes about any orders that still need to be carried out and any new orders as soon as possible after they are written.

Meandering Moment: At the hospital where I am employed, the doctors STILL write all of their orders by hand. I'm sure you've heard many a stale joke about doctors and their handwriting. Stereotypes exist for a reason people. Many are the mornings when the unit secretary, who is responsible for entering the orders into the computer, has to gather a group of nurses to see if any of them can help decipher what the doctor wrote. When the collective whole can't figure it out someone, the nurse or the secretary, has to call the doctor and ask them to explain what they wrote over the phone. Some doctors have a sense of humor about this and others get very nasty because they don't like the interruption any more than we like having to interrupt them. The solution is obvious to everyone but the doctor: LEARN TO WRITE LEGIBLY!!! Honestly, if you're smart enough to make it through medical school, you should be smart enough to look analytically at you own handwriting and have a clue about whether or not the average human being, other than yourself, your spouse or your mother, can realistically read it.

(We will eventually switch over to 100% electronic charting which will fix this problem. In the meantime, this is dangerous for everyone involved, but especially for the patients. And yet, this is how it has been done since hospitals were invented.)

OK - sorry for that very long aside. Now back to work.

6. The off-going and oncoming nurses need to round on the patients together to make sure care is bridged, give verbal updates (at my hospital we don't typically give verbal reports. We tape report and the oncoming nurse listens to that taped report, formulates questions, and we have a face-to-face when we round together), make sure the patient is aware that shift change is occurring and knows which oncoming nurse will be taking care of them moving forward.

This is ALL supposed to happen between 7 & 7:30. For 5 patients! Any we've got it good (no, great!) at my hospital. We typically only have 5 patients each. At most hospitals the nurses have between 6 & 8 patients! Most shift reports run between 2 & 6 minutes (complex patients take longer) so, on average, it takes about 20 minutes to listen to report on 5 patients. This doesn't include looking at labs, charts, radiology reports, calling doctors and rounding... JUST listening to report.

This whole process is often interrupted by a "Huddle." The Huddle is SUPPOSED to be a 2-3 minute update on the floor as a whole. Even though my patient may not be a fall risk, everyone on the floor needs to know that the patient in room 1234 is a frail dementia patient who just had a stroke and sometimes gets out of bed and tries to leave down the back stairs so we can ALL keep a collective eye on that patient. They're wily, those old folks! On my floor Huddle typically takes 8-10 minutes because my charge nurse LOVES a captive audience. We are all looking at her, looking at the clock (we don't even try to be subtle about it), then back at her, but still she drones on... and on... and on, knowing all the while that she is keeping the off-going nurses from clocking out and going home ad preventing the oncoming nurses from getting started with their work. She's not clueless, either. Just extremely passive aggressive.

At this point in my career, I am not able to get all the above done in 30 minutes. I'm just not fast enough yet. So, I have to be there by 6:30 because I don't want to be the reason the off-going nurse has to stay late. He or she is exhausted and often has to come back and do it all over again in 12 amazingly short hours! Off course, it's not the hospital's fault that I am so slow, so I am not allowed to clock in until 7. Actually, we can clock in 7 minutes before our shift begins, we have a little window, but if we clock in even 1 minute past 7 we are marked tardy. So, I really work a 13 hour day. We are supposed to get a 15 minute break mid-morning, and a 30 minute break for lunch but, on my floor, almost no one (but the charge nurse & the unit secretary) has time for the mid-morning break. So, I work a 13 hour day and get 30 minutes for lunch... except when I don't (another story for another blog day).

Even with coming in 30 minutes early, I always start my shift feeling like I am already running behind. And we are only talking about the first 30 minutes of my shift! I know this will improve with time, at least to a point. I also know that my floor is considered a very tough floor to work. Several of the nurses in our float pool refuse to be floated to our floor because it's so hard to stay afloat (no pun intended) if you aren't very experienced with our patient population.

Oh, well... just another day in paradise with much to learn. But I think we've both learned enough for today.

Until I blog again, I faithfully remain,
Lady Sybil Crawley, Transitional Nurse