It has been a while since my last post and THAT’S OK! It was a fairly busy/rough week. I worked two day shifts, followed by four night shifts. The day shifts were crappy due to understaffing, and the night shifts were even worse due to even harsher understaffing. I was spread so thin that I just could not give adequate patient care. I was in survival mode (meaning patient survival). It was one of those nights in which you do the bare minimum that will keep your patients alive, and prevent them from getting worse. Vital signs aren’t done as often as I like, repositions weren’t done as often as they are necessary, trachs got dirty, diapers stayed wet, and pain issues were barely resolved.

At the end of the night, my patients were alive…and weren’t sicker. However, that’s really no way to be a nurse. “Survival mode” nights really show me that the true meaning of nursing is to progress a patient further toward their optimal achievable health (rather than stagnating by giving them minimum care). In fact, everyday when I’m trying to organize my work, I try to ask myself, “what is one thing I can do today to get this patient closer to discharge?” If I can do all hands-on work, put out fires, chart, organize care, and still do something that progresses them, I know I’m nursing the way I would like.

But when you walk in for a shift, and half the staff has called in sick, or cancelled their shift, or has quit, or has forgotten that they work…it makes nursing as describe above nearly impossible.

*sigh*

Here’s how I see nursing in the future: Instead of working for hospitals, nurses will work for organizations similar to travel nursing companies, or perhaps nursing professional bodies. Nurses are commissioned by hospitals (not doctors…as that would make doctors our direct bosses…there’s enough issues there already without making it worse) to care for patients. The nurses would be paid PER patient, not per hour, with every additional patient costing the hospital more So, for example, I would be paid $100 per day for one patient, $210 for two patients, $330 for three patients, $460 for four patients. Each additional patient would be $200…so a six patient load would cost the hospital $860 per day. In this sense, I could choose to carry any sized patient load I desire. If I only want one patient, sure! If I want six, sure! I get a lot more money for extra patients due to the increased stress it causes. Plus, since each extra patient costs the hospital more and more, it would create desperation for them to keep patient loads to a minimum.

To carry this further, I think there should be a primary nurse philosophy around these patients. What I mean is that the Registered Nurse is there from Mon-Fri days and works in more of an organizational capacity; coordinating care, teaching, assessing, etc. Much of the hands-on work is performed by students, NAs, and LPNs (who’s scope of practice would be advanced further in order to accomodate the RN’s new job description).

A day would look like this:

07:00 - Review patient’s current blood work, care incidents from evening/nights, examining vital signs, assessments, charting from last 24 hours. Preparing a tentative plan of action for the day.

07:30 - Rounds! Visit each patient, spending as much time as possible with each (meaning hours if necessary!). A full head-to-toe assessment, assist with hands on tasks if necessary (usually in the capacity of teaching staff/students/patients), psychosocial analysis, discharge planning, emergent care needs, family discussion.

09:30 - Meet with doctors (or review their charting), respiratory therapy, physiotherapy, social work etc. etc. etc. regarding patients. From these meetings, care needs are further developed.

12:00 - Lunch

13:00 - Meet briefly with LPNs/NAs/students to discuss emergent care needs, and any changes to care plans as per meetings with patients and interdisciplanary team.

14:00 - Using a formal system, communicate a detailed plan of action for patients that focuses on rehabilitation and works toward progressing the patient to discharge.

15:00 - We can go home, but we each have offices (cubicles?) onsite or offsite that we can go to if we need to do research, have meetings, etc. etc. There are secretaries that keep track of our patient loads and bill the hospitals for us. We can also take this opportunity to follow up on patients who have gone home, answer voice mails/emails etc.

Learning is very much encouraged in these offices. Perhaps we have a weekly patient presentation where everyone presents their patients to the group and ideas are passed around and formed. Perhaps someone just conducted research or read an article that would benefit your patient.

During the day, we are available at all times to teach students/LPNs/NAs/patients procedures. We are available at all times to see our patients regarding psychosocial needs. We are available at all times for emergencies.

In addition, there are RNs that are specialists in being charge nurses. They work days/evenings/nights in a charge capacity. Much as they do now, they are the traffic controllers of the unit. In the evening/night, they are similarly available for ermergencies/psychosocial issues/teaching. They also act as a resource and specialist in the practical aspects of nursing and can offer advice. Some units may need two charge nurses at a time. They are paid a VERY nice salary (i.e. $200,000 per year or more). They are the cream of the crop and have experience up the wazoo! Perhaps they have taken a certification course to become a charge nurse…it would be a specialty. Nurses would strive toward being a charge nurse as it is the most revered, and highest position they can hold.

Our days are very flexible and do not necessarily have to go as mentioned above. If you are unavailable to see your patients until afternoon due to meetings or conferences, that’s OK! The charge nurse is there in case of emergencies. Our days flow as needed, and as per our necessary schedule. We are professionals, and we are given the freedom to work as though we were!

Our days are a bit longer, but they are more flexible, they are more professional, we’re better paid, we’re treated with respect, we keep regular office hours, we work TO OUR FULL SCOPE OF PRACTICE!

Anyway, this was just off the top of my head…and it is actually what I thought nursing was before I started my degree. Honest! I thought LPNs and NAs did the majority of hands on work, while RNs worked on organizing care and coordinating health care professionals. Trust me, it came to me as a shock to discover that RNs actually changed the diapers and washed patients.

Seriously…you can laugh at me! I don’t mind!

Does anyone diagree/agree/want to add onto my vision of a future RN?

I see doctors taking a fairly background role. What I mean, for example, is that the surgeon performs the surgery and then more or less transfers the care to RNs. The docs still do rounds everyday and are contacted for emergencies, but the RNs take on much more responsibility for the organization of care after surgery, only consulting doctors when necessities are out of their scope of practice. There should be an effort to respect the RNs care plan. The surgeon specializes in the specific procedure, but the RN specializes in the recovery, and the doc looks to him/her for suggestions. Make sense?

In the mean time, I feel that nurses must take a stand. Very specifically, I think nurses need to start refusing to care for increased patient loads. For example, on days shifts on my unit, four patients is considered the max. So, if I walked in and saw six or seven patients assigned to me, I would just refuse to care for all but four.

If all nurses refused to take on dangerous patient loads, hospitals would have to block beds, limiting the number of patients they could admit. Doctors would have to make tougher choices on who is/isn’t treated for their illness. Then, down the road, there would be a greater focus on health prevention so that doctors won’t have to tell people with heart disease/cancer that they can’t be treated because there’s nobody to care for them.

We’re people, not angels! We need to accept our limits and not try to dangerously stretch ourselves to exhaustion. Something in this system needs to break…and WILL break soon.

Sean