Feeling Abandoned

Sometimes at work, I feel abandoned and unsupported. I feel like no one is around to help me and I have to provide total care for all of my patients. I can't rely on the doctors, the aides, the technicians, the secretaries, the other nurses on my unit or on my unit coordinator (charge nurse). I really don't like days like that.

What happens from time to time is that because of the room assignments of the patients in the unit, I end up all by myself. I am not physically near any coworkers. Naturally, people congregate where they're working, and when I'm on my own, then there's no one to talk to. I get lonely. So it was with yesterday - it laid the groundwork for a bad day.

Yesterday an unusual thing happened - orders for a patient written 12 hours earlier had not been entered in the system. That means medications didn't get sent up for that patient, and orders for a chest xray didn't get entered (so they didn't come get the patient for the xray), lab orders weren't entered (so the labs weren't drawn). Human error and unfortunate timing contributed to the oversight. Here is what I think happened:

• The patient came back to our unit at shift change. He came to the unit at about 3:00pm, promptly went to procedure and wasn't seen again until 7:00pm. Things are vulnerable at shift change.
  
• I was involved with a sheath removal in another room right at the time the patient returned; I wasn't available to receive the patient. I had another nurse take report. She did, and scribbled it down on a sheet of paper in her own short hand. She left the sheet of paper on the desk for me and went off to deal with issues for her own patients.
  
• The night nurse came on at shift change. I gave report from my limited experience with the patient and the scribbled report.
  
• The night nurse was a float nurse. She doesn't normally work on our unit. She doesn't know intimately how we do things on this unit. She probably assumed the orders were taken care of.
  
• The unit secretary on that night was sick and not very "with it" that night.
  
• Since the float nurse didn't know how the unit works, she didn't realize certain things were missing for this patient. For example, she didn't get concerned when they didn't come get the guy for the xray. She didn't think it was unusual that there were no lab tests scheduled. She probably didn't wonder why the second antibiotic dose didn't show up from pharmacy. And, in her defense, why would she? These things are supposed to be taken care of.
  
• Another contributing factor was that when the patient came back from procedure, doctors, nurses and family were buzzing around in a tizzy. His procedure was complicated (not dangerous, though). It is likely that the chart got picked up and put down many times and somehow never made it to the secretary's desk to be entered.
  

The end result is that the secretary in the morning caught the fact that the orders had never been entered. Ah, that explains why it is 10:00am and the patient still hasn't gone down for his xray! (It is usually done between 6:30 and 7:00 am.) I felt bad about it, and it rather ruined my day. No one yelled at me, at least.

But how can you not feel criticized when doctors or nurse practitioners ask you "where is the INR?" (lab test)?

Guess who gets to pay for the mistake? Me. The nurse is ultimately responsible for the entering of orders (accurately), and the carrying out of doctors orders. I oversee the entire path of care the patient experiences during my shift portion of the hospital stay. Yes, I have help, but I am the responsible party. That is why I have legal registration and why I supposedly get paid the "big bucks."

I am also responsible for checking the doctors orders, in that sometimes they forget things (yes, in fact I do want an EKG after procedure! I'm so glad you noticed!) or check a box to give the patient morphine (Oh, silly me. The patient is allergic to morphine!! I didn't really want to order that). One phone call is not a huge deal. After the 50th or 60th call, you get tired of checking up on them. Just do it right for God's sake.

The docs get complacent that we will catch their errors. When we don't catch their omissions/errors we end up paying. And we get the consequences - drop everything and draw this lab test now! Stop what you're doing and call down to xray so this patient's xray gets done! I don't care what you're doing now, drop everything and do what I need, says the doctor, because I cannot be slowed down.

Eh, it is what it is. Mostly the system works well. Sometimes things fall through the cracks.

On Autonomy

My workplace is certified as a Magnet Hospital. This means that we are supposedly a great place to work for nurses - and other things, follow the previous link for more info. In general, it really is! One of the principles of being a Magnet Hospital is supporting autonomous practice for nurses.

I don't know what I think about that. In reality, autonomous practice is a balance between doing what the nurse think the patient needs and the legal scope of practice. Legally, registered nurses can't do some things (like prescribe medication). Where I work, I have very little autonomy. Personally, it's OK with me, but the lack of control over how my day goes gets frustrating.

None of us has control over when patients are scheduled, when they arrive, when the doctor takes them to the lab, when they come back from the lab, and when they go home. My manager feels that we shouldn't have input in these things - it is our job to accommodate and serve. She is the conduit through which we communicate with the organizations that make these very decisions. Our input can stop with her if she doesn't advocate for us. This happens.

For the most part, the requirement for these events is "right now." Well, hell, I can't be in two rooms at one time. I can't be giving an insulin shot to patient X while I'm gathering a medical history from patient Y. Everyone wants it now. And everyone's priority is the most important.

There's only so much I can do. The so-called solution to this problem is "prioritizing" and "delegating." Many times, establishing priorities works, but it is not 100% fail proof.


Thanks for listening. I needed to write this down to feel better. Keep in mind that I still like my job and like my career. It is like anything in this imperfect world. You know.