Thursday, 3 April 2008

What's Goin On!

Posted by : Ain't No Angel

Sitting here on a week off from work following a week of night duty I can get pretty bored. There's me, the cat, Dr Phil and the xbox. Good friends to a man (or cat), but they don't compare to how unbored I generally am at work. Things are usually quite frantic there, eventhough we have a well run shop. Its gotten me thinkin though about what I be doing from one end of the day to the next, and what kind of things it is that seem to keep me so occupied.

So today, I'm thinking that I'm going to share with you all the things that keep me busy in work, along with a little of my thoughts on each.

(This may take a while, its going to be one of those stream of consiousness type posts.....)

1) Patients

Well Duh , I hear you say, and you'd be right. Its primarily the reason I go to work everyday, and most of the time its the patients that make my job so cool, rewarding and interesting. Sure, it'd be great if it was like ICU and they all were asleep all the time, but then I'd miss the banter, the craic and all the good stuff. I'd also miss the tears, the anger and frustration and all the little things.

2) Dealing with Dr's

We're normally not to bad at this. Because we're pretty specialised we have our own teams and everyone gets to know each other pretty well. There is generally someone from the team on the ward all the time, so getting things done is rarely a problem. Things start to go wrong when you are dealing with Dr's from teams that have patients all over the hospital. Even something simple like getting laxatives charted can be a nightmare and take hours. Why? Well sometimes, its because said Dr is a fool/lazy/badly organised, but 99% of the time its simply because they are so so so busy running around the place trying to be all things to all men that they simply can't get to you.

I've posted about how I hate how our NCHD's are treated in this country, particularly interns so I'm not going down that road/rant again, but in this day and age, you'd think someone would come up with a solution that meant Dr's wouldn't have to work for 2 days straight with about 4 hours sleep in-between, if they're lucky.....

3) Bureaucracy

Now I know everyone, no matter what job has this issue, and in Ireland the HSE has rightly gotten stick for the increasing bulk of admin workers it employs, so lets not beat that horse again. I'm talking about the nonsense I have to deal with directly, not the people in the ivory towers of HSE/DOH-land.

For a start, despite the amount of worthless admin we have, there simply aren't enough ward/doctor/general secretaries around. Our own ward clerk is a legend. Highly organised and intelligent, she can sort out a multitude of things for you but she's a minority. I've worked with loads, who are useless. When she's not around, getting a patients old medical notes from storage can become a Hurculean task, up there with peace in the Middle East.


Because there's no-one in the records dept free to get it and bring it up.

Never mind that though, what about the litany of paperwork that have to sign, tick or otherwise file on a daily basis on every patient I meet. Add to this mix, meetings, radioographers and their nonsense from time to time, plus the additional hassle of dealing with HR from time to time, porters and finally cleaners (who won't clean or who aren't allowed to clean certain things or areas).

It can all get pretty painful sometimes!


  1. Hi Ain't No Angel,
    Great blog!

    I'm an Irish doc who left due to the crap conditions and working hours in Ireland. I'm currently working in New Zealand, which treats docs pretty well, and our hours are extremely humane. I've noticed the health system here is run very very well, and in particular, one thing I've noticed that makes it run really well and benefits the patients, is the way the nurses work here.

    Don't get me wrong, there are some really awesome Irish nurses, I've worked with some great ones, but unfortunately more and more these days, we hear the phrase "That's not my job".

    Nurses here, if a patient complains of chest pain, do an ECG, give GTN, do a set of obs, and call you unless the patient is clearly crashing. If they suspect a patient is in retention, they do a post mict bladder scan. Many take bloods and site IVs, and only call you when they don't get them in. They take verbal orders for meds. They give first dose IVs-that's a BIG one that's always annoyed me intensely. In Ireland, many times nurses would go so far as to make us give the first dose of say, IV Augmentin, even if the patient had already had it on this admission, and we were just restarting him on it.

    In one ward where I worked for six dreadful, awful, horrible, soul destroying months, they took it to new heights. The SHO before me had warned me that they made her cut an elderly man's toenails before as they had said he would be a falls risk and it was not their job, and that it would be her fault if he fell and they'd do up an incident form. They used to bleep me when I was on the consultant ward round multiple times to come and send faxes for them to nursing homes. Once, when I mentioned that the ward clerk could do it, they said "Oh, it has to be the doctor that does it!"
    Once they tried to make me make up an insulin infusion, which I refused.
    Granted that was one ward with a HUGE problem with female NCHDs and the rest of my experiences have not been that bad, but half of our working hours at home are spent doing things that here nurses or other staff who are based on the one ward do because it's much more sensible to have the person who is there all the time do the jobs they can do that need to be done.

    It doesn't make sense that nurses call doctors off of the ward rounds, out of the clinics, out of A&E, to do jobs they can do themselves but won't. It doesn't mean we're not happy to do them, but we can't always come up and do an ECG, take bloods, do a bladder scan, give an IV med etc etc.
    These practices need to be reexamined in Ireland, as they are contributing greatly to unacceptable delays for patients and increasing our working hours for no good reason. First dose IVs in particular, I don't understand. If we chart it, we're responsible.

    I don't mean to sound disrespectful or anything, I really respect nurses and their work, but I just wonder why this "it's not my job" thing happens if they can do the job. It would benefit the Irish health service so much more if this attitude was removed.

  2. Btw, I certainly don't mean to direct this at you! You sound like a really nice nurse, and the fact that you even KNOW about our working hours, let alone care, says so much. Most nurses at home were not aware that we were forced to be on for 36 hours straight and didn't believe us or care if we mentioned it. In fact, the reason I mention this on your blog at all,is that you seem to be aware of the deficiencies in our health service, and want improvement. If perhaps these jobs were undertaken by nurses, some of the work you do now that could be done by, for example, care assistants etc, could be done by them, and so on and so on. Nurses are a highly trained resource, and I see them making beds etc, at home, which frankly, is a waste of a nursing degree. And I know your time constraints are as bad as ours sometimes, but the thing is, if nurses were not constantly having to wait for docs to get time to come and do our bits-ward rounds, discharges, admissions, drug charts, etc, then their own work would speed up too. Nurses have power in Ireland, and if they fought to have their nursing experience recognised in appropriate work, and for auxiliaries to do the rest, then it would happen. Whereas, as I'm sure you know, if we say a damn word about anything, everyone just yells "Goddamn rich bastards out on the golf course" etc etc.
    Thank you for providing such an interesting blog where it's possible to bring up such a controversial topic.

  3. Hi Ellie,

    I have had the same experiences with the same type of nurses that you're talking about, particularly in the UK. I've also worked in NZ, and can see where you're coming from.

    But I don't think it's neccesarily the fault of the nurses on the shop floor. I think there are big problems with buraucracy at a higher level. I know ain't no angel from blogging with him, and from the biology and medicine forum where this blog started. I know he would jump at the chance to start cannulating and taking bloods and doing ecgs if someone made it easy for him. It's made easy for docs. One of our seniors shows us. We have a few tries, and then we're let loose on the public. He's already mentioned catheters. I can imagine the paperwork and "consultation groups" that particular idea is going to generate. It's probably going to take a couple of years to role it out. Whereas I learned by doing 2 catheters in med school. I'm sure I'm no more skillfull with my hands than ain't no angel, but I don;t have the same hurdles in my way.

    The poor nurses have to go on IV courses, or ECG courses to do these tasks. They also have to be qualified for a certain amount of time before they're allowed go on these courses.

    If I took ain't no angel aside and taught him how to cannulate, and he put a cannula in a patient, he'd get in trouble from his bosses. I get praise from my bosses if I learn how to do a procedure quickly, with minimal supervision.

    I do worry that initiative isn't rewarded enough in the nursing profession.

    I do also accept that there are nurses who will pass the buck out of laziness. Just this week, a nurse made a drug error on one of our babies. She didn't tell me. She just told the nurse manager. Both of them wrote in the notes "registrar to inform parents". Buck passing at it's best.

    But I think (and you seem reasonable enough to see that this is probably the case) that most of us do the right thng most of the time.

    Dr. Thunder

  4. Unfortunately, Dr. Thunder, there I have to disagree with you.
    A specific example:
    The last place I worked in Ireland, we had a young patient with a Hickmann line. On all the wards in this particular hospital, nurses were trained to take bloods from Hickmann lines. However, this one young nurse who was always very hostile to our team for some reason, refused to do it and repeatedly called me to take bloods from the Hickmann line. She would not administer any drugs through it either. She told me "nurses don't take bloods from Hickmann lines".
    Her ward sister overheard her-and started giving out like mad to her-and tellingly, the nurse in question went straight away and took the bloods, with no trouble, as she knew how and had done so many times.
    I have SO many examples of this from Ireland, and so do my colleagues. What I don't understand is why? I'm not trying to start the old "nurses vs doctors" thing. Some of my best friends from school are nurses. However, they are nurses who do the things they are trained to and so they have no answers for me either. Many wards, though the nurses there are trained to do ECGs, and CAN do ECGs, refuse, and say "nurses DON'T do ECGs". Not nurses who aren't trained and signed off etc-of course I understand that, I would never ask someone to do something they don't feel comfortable doing as that's both unprofessional and dangerous. But the ones that admit they can just say "We don't".

    This is a topic everyone always avoids, and says "just don't mention it" and so I never do, but the chance to find out why, really, these things happen, would be nice. To a certain extent ward protocols are or should be standardised, but they either don't seem to be, or there is a culture of "I don't do that" that needs to be addressed. And one plucky intern last year who asked to see the ward protocol outlining what was and wasn't done, suddenly got the ECG done. Why?

    I don't understand why this happens to such a degree in Ireland and nowhere else. I have noticed a higher level of hostility and unwillingness to cooperate with female NCHDs among Irish nurses, but I sometimes wonder in this day and age if that's really all it is. The whole system seems rotten to the core in Ireland, and this is just one symptom of a sick health service, but instead of the inevitable hostile responses it would be nice if one person could just give us an honest answer. I always try and do what I can, if the phlebotomists haven't taken bloods, I don't say "it's not my job", I do it, if a patient asks for a drink, I don't say "it's not my job to get that" I get them one. It only takes a minute. The patient doesn't know who is supposed to do what, and just wants to be reassured and feel better. And this should happen in a sensibly organised environment where everyone just does what they can, instead of what they decide is their job. Ain't no Angel talks about bureaucracy, and its impact on his work, and as a frontline health service provider, paperpushers deciding what he can and cannot do must be a nightmare for him. But, although he just wants to care for his patients, any way he can, he IS in the minority there from what I've seen. Surely addressing the root of this problem would be better than tactfully not talking about it?
    Are nurses in Ireland so demoralised that a burned out, angry "that's not my job" is all the response they can muster up? If so then we should hire more, redistribute their workload and utilise their valuable skills rather than have them washing out bedpans and making beds, which these "not my job" protocols have them doing currently. In the US a trained RN would be doing ECGs, INTERPRETING them, putting in lines, ABGs, and feeling generally valued. (And paid pretty well too!)
    I'm not advocating ALL aspects of the US healthcare system, but there is no denying that nurses there are a respected and valued skilled resource. And in Ireland they seem to be at once an incredibly protected but not well respected one. Docs are neither protected nor respected, and look what it has done to us. But nurses, with all the power their union has, could they not do something about their end of things? If they wanted that payrise, surely they could come up with a nationwide protocol of tasks that every fully qualified RN would be able to perform, by say, 2009? In exchange for a payrise and a delegation of menial tasks to auxiliaries and care assistants? My friend who went back to nursing as a mature student, studied Physiology, Anatomy, biochemistry, etc etc and studied damn hard. Why shouldn't she be able to perform an ECG and interpret it? why should this work and skill be wasted on making beds and changing pads? Why should we be forced to delay clinics or ED referrals or reviewing sick patients because someone doesn't value her skill and years of hard graft enough to allow her to stick some stickers on a man's chest and press some buttons? She has two degrees under her belt. And she makes beds? The problem from what you're saying appears to go deeper then just attitude, it's a lack of respect from higher up for qualifications and experience and not utilising highly trained workers as they should be utilised.

    Ireland is just bloody screwed up. I'm glad to be out of it.

  5. I know I sure ain't making any friends here- but the only way to change difficult situations sometimes is to ask why are they happening in the first place. This strange combination of being protected and having power but also not being valued has put nurses in Ireland in the strange position of feeling happy to refuse to do more relevant, skilled and interesting work, and keeping them in roles that do not reflect the extensive training and expertise they have worked for. Their managers must realise this? I've seen, for every four that tell me they don't do something, at least one or two that are so dissatisfied with the level of work they are asked to do that they leave and do midwifery, or GP practice nursing, or sometimes just plain leave altogether. Hospital medicine is short of nurses. So why aren't we addressing this problem? Some of the most satisfied and fulfilled nurses I know, are, believe it or not, A&E nurses, because, despite the stress, they are fulfilling the role they trained for. They use their medical knowledge to triage, some suture, they all cannulate and take bloods and interpret blood results. I don't think this is coincidence.
    And actually, my friend's sister, who is also a nurse, was fed up with ward nursing too. I was incredulous, as she is such a good nurse, and I asked her why. She couldn't qualify why, but just felt fed up.
    She went and worked in Australia, doing all the things she refused to do at home in exchange for bedmaking, and loved it all. I don't think she's coming back! Is this the problem?
    Please don't hate me!

  6. hate you???

    I don't hate you at all. In fact I kinda love you. I say get your arse back over here and me and you will go on Thelma and Lousie style rampage until we get things sorted!
    (only not 2 girls in a cadillac, more a man and a a honda civic)

    Its terrible that you've had these experiences in Ireland as a Dr. But i knkow all too well what your talking about.....and you've hit the nail on the head there, nurses are on one hand protected but also totallt disrespected and wasted.

    I've entertained serious thoughts about getting out of nursing altogether, mainly because I'm sick of being told no no no. Its that or I'm off to work in the states!

    More of this on the next post!