Friday, February 28, 2014

I don't like your tone

It was such a bad day, even though I have been trying to not let things get to me.

One of the attendants was assigned to do blood pressure on ten patients.  Ten.  Not 500.  Ten.  He did a few and then disappeared from the ward, returned with coffee, and sat at the desk, talking loudly into his phone.  I need the blood pressure readings for medication administration and not just for the fun of it.  I prefer to do them myself and have in the past, which still angers people.  As unchecked patients came for their medications, I called out to the attendant to do their blood pressures.

He went on a rant in the middle of the ward.  "I'm done with that assignment.  You can't give me more to do.  If more patients need blood pressure, you have to do it yourself."

He was supported by the other nurse on the floor, "Leave him alone!  Stop arguing with people and just do it!"  This nurse has never done a blood pressure.  She claims she can't hear and she doesn't know how to use the blood pressure machine.

So I did the remaining blood pressures myself.  The attendant went missing.  Then I was called into the supervisor's office about the attendant.  "Help me understand," she started, already in his favor, "Why you singled him out to do work."

"Everyone had a job at that time.  This particular attendant's job was to take the blood pressure of ten patients.  He did four and then sat behind the desk, drinking coffee and talking on his cell phone.  I don't think it was unreasonable to tell him to complete the task."

The supervisor said, "Put it in writing or this is nothing I can do about it."  No.  We've been down this road before.  Putting it in writing is proof against me that I complain too much.  I did not go to the supervisor about the attendant.  The attendant went to the supervisor because he has the nerve to think that he can complain about being told to do work when he is at work.

The morning raged on with screaming patients, exacerbating the already noisy and chaotic environment.

By noon, the situation had come to a boil and I ended up injecting a patient as she ran naked all over the ward, screaming and cursing and knocking things down.

Another patient decided that we were coming after her next and preemptively punched several staff members in the face until she could be brought under control.

I had psychiatrists and medical doctors crowding the floor to treat people and medicate.  The employee clinic was calling and calling for paperwork from me about all the injured employees.

Where was the supervisor during all of this?  In her office, repeatedly calling the ward, demanding that I come to her office, ignoring my response that she needed to come to the ward immediately.  Then she said one of those lines I can't stand, "You are holding people up."  As if I'm waiting for my nail polish to dry.  I'm busy working and there is too much work piling up for one person to handle.

I eventually flew into her office and found the attendant from the morning with his union rep.  The supervisor launched into her speech, "I conducted an investigation on your unit as well as other units.  The reason why people are unable to do work is because they do not like your tone."

I countered, "He stopped doing work before I even spoke to him.  He purposely stopped performing his assignment so I would speak to him and then he would use that as an excuse to stop working and leave the unit.  This is not new behavior."

The supervisor continued, "Other units have more teamwork.  It is common that more than one person takes blood pressure.  You put all that work on one person.  He told you he had done too much work, so you should have had another attendant step in, but you didn't."

I said, "I can't ask someone else to do his assignment.  They each have their own assignments and will not help one another.  There is no teamwork on that ward."

The supervisor said, "As the nurse, you are supposed to foster teamwork, and you don't, so you can't expect people to do any work, especially with your tone."

I concluded the meeting:  "We have covered this before.  It is all my fault, either because of my tone or my lack of forming a team, so the staff does not have to work.  It is irrelevant that they did no work before I ever worked here and they do no work when I am off.  If this is okay with administration, that this attendant does no work, then that is fine with me.  I don't like his tone, either, so it must be okay that I also do no work, right?"

I walked out.

Wednesday, February 26, 2014

Snake Pit

One of the day attendants (who was a complete pain in the ass) switched to the evening shift and in return, my ward received an attendant who switched from evenings to days.

Remember I can't win.  There are no normal people working here.

The new attendant is late every day, while the prior attendant, in spite of all her flaws, was early every day.  Every day there is no attendant on the floor for a good twenty minutes into the shift.  The first attendant to arrive complains boisterously that he is coming in later the next day.

On one particular day, the other attendants decided that they were not going to do any work until the chronically late new attendant showed up.  Fortunately, the patients are used to the attendants doing little work, so the flow of the ward was not severely altered.

When the new attendant slowly walked onto the ward, she was already an hour late.  I know the trick.  You may wonder why she does not get in trouble for being late.  She will say she was here the entire time and that the nurse (me) lied because she is vindictive and mean.  Her time card will not show the lateness because- ooops!- she forgot her time card (again) and had to sign in at the office.

I don't see a way of winning this, so I just do what I have to get done in spite of the late attendant.

On this day, the attendant, oblivious to my workload, sauntered up to me and launched into a lazy, roundabout soliloquy on why she was late.  I continued working and didn't answer her.  She eventually wandered off.

Later, I passed her in a hallway and I heard her call out after me, "Why didn't you answer me?"

I turned back to her and said, "I didn't hear you.  What did you ask me?"

She lost it.  Screamed her damn head off right next to patient rooms.  "When I speak to you, you stop what you are doing and you listen to me.  Who do you think you are, ignoring me?  You better start respecting me right now or you're going to have some real problems."

I've had it.  Really I've had it.  Every attendant is the same self-righteous, do nothing boss of the nurse.  My previous method of handling such an altercation was to ignore it, keep walking, and hope it would eventually stop happening, which it never did.

On this day, I tried my new approach.  I was so pissed that she was screaming demands of respect at me that I ROARED back and ran right up to her.  She got scared.  She stopped screaming, her body jumped, and she backed up a step.  "Don't you EVER tell me what to do.  Your friends in administration may cover your late, disrespectful ass, but I will make your life on this ward miserable until your buddies can figure out how to transfer you out."

She more quietly tried to retort, "I heard about you that you harrass people."

I shot back, "Well, you didn't listen to the warnings and fucked with me anyway.  Now you'll pay."

I'm not like this.  At least I wasn't in my prior life, before the psych ward.  I want a team of people to work with to provide care for the patients.  Instead, I'm dodging bullets and launching counterattacks.  Administration is corrupt and so are the people I work with directly.  Sitting down with a nursing supervisor to work out the disagreement will blow up in my face, not the attendants.  So I won't do that again.

In my martial arts class, another student told me that whenever anyone strikes you, you immediately strike back.  She said this is called, "Speaking when spoken to" and it shows the other person that you will meet their action with an equal reaction.  This is so different from my prior approach of ignoring the attack and hoping it will stop.  One of the keys is an immediate, powerful response.  Talking about the situation later does not work with this crowd.  They only respond to screams and threats.

Tuesday, February 25, 2014

Your Taxpayer Dollars

One of the interesting and irritating things I learn by working at the psychiatric hospital is how tax payer dollars are spent.  For this post, I'll talk about Supplemental Security Income, or SSI.

Most of my patients collect between $400-$600 per month.  Additional funding is available based on housing costs, if living independently.

People who are disabled but have not worked can be eligible to receive SSI.  In the mental health arena, where disabilities are not always physically obvious, the SSI program can be appropriate for someone with schizophrenia because symptoms start in teen years, before someone is likely to work gainfully, and then becomes full-blown in the early 20s, which usually precludes establishment of a productive working life.  For other mental illnesses, the merits of claims become murkier.

I've had patients tell me, "You're so stupid for going to work.  I just sit at home and collect my money.  It's free."

I've also had patients tell me, "I wish I could work like you.  I wanted to be a nurse, but I got sick.  Nobody will let me work.  The money they send me just covers the rent.  I have nothing.  There must be some kind of work I can do."

On one hand, I am glad that this country has a system in place to fund disabled people so that they do not need to live on the street and beg for food.

On the other hand, we have created a section of the population who could work but instead collect benefits for being "disabled."  They are physically able to make babies that they cannot financially support while they manage to have enough money to spend on drugs, cigarettes, and alcohol that lands them in the emergency department and psych wards on a regular basis.  This is the population from which most of my patients are drawn.

Once they reach my hospital, we have one of two ridiculous and costly scenarios.

In the first, a person is collecting SSI while living with relatives and becomes hospitalized.  While the government is footing the bill for the patient to stay in the hospital, the family continues to collect the SSI checks.  This is understandable in a short-term hospitalization.  The problem is when families outright refuse to allow the patient to return home, even when hospitalization is no longer clinically justified, and they continue to receive the check.  This situation can persist for YEARS because the hospital has to find alternative housing for the patient, which is scarce, and then fight the family to sign the checks over to the new residence.  Without a source of income to pay for room and board, a group home or boarding home will not accept a new resident, so the hospital is stuck with the patient until the monthly check is wrested from the family.  Taxpayers are not only paying for a hospital bed for someone who doesn't need one, but they are also handing over hundreds of dollars a month to a group of people who feel entitled to collect this money no matter what.

The second scenario is when a patient arrives at the hospital without any benefits.  SSI must be awarded in order for the patient to be accepted into a group or boarding home.  Being awarded SSI benefits takes at least a year; sometimes several years.  In the meantime, the person sits in an expensive hospital bed which is not conducive for someone who is no longer acutely ill AND this costs so much more money than handing someone an SSI check each month.

The system is so broken and wasteful.

Necessary Evils

A judge comes to the psych hospital at regular intervals for commitment hearings.  For people whose stay is not voluntary, a judge has to review the case, listen to the patient and any interested friends and family, hear from the doctors, and decide to continue the commitment or not.  The proceedings are informal, given the setting and nature of the topic, but the decisions are real and can only be reversed at the next hearing or by appeal.  I tell my patients to wear clean clothes and not pajamas.  Most patients do not have suits or dresses to wear, which is okay, as long as they look like they knew to put themselves together.  There is always that one patient who insists upon wearing five layers of ripped, soiled clothing with colored markings of "Set me free" written on his face.  Oh well.  Commitment predictably extended.

I was retrieving some of my patients from the little court area when I saw a patient from another ward waiting to see the judge.  He was wearing plush reindeer antlers on his head.  This particular patient is out there, but has listened in the past when I told him to dress up.  I asked the attendant why he was allowing the patient to see the judge in such a state.  The attendant answered, "Job security."

Mean.  True but mean.

The other thing that struck me was that most employees express that they cannot ever loose the job, as if it's an inalienable, God-given right.  At least this attendant understood that he is dispensable.

Meeting Topic: Not you

I was sent to a meeting about policy.  This was a first.  Up for revision:  a patient nicked himself on a razor, so how can we modify the existing policy to prevent this from happening again?

My suggestion:  Stop buying cheap, single blade razors.  And, What does this have to do with policy?

I spent the rest of the meeting making notes (about my shopping lists).

Days later, an idiot nurse confronted me:  "Why did you tell everyone at the meeting that I do nothing and you do all of the work?"

I'm sick of this.  Really, really, really sick of it.  I answered, "I am offended that you listen to gossip and then come to me with it as if it's true."

Idiot couldn't follow this.  She persisted.  "So, did you say that or not?"

I responded, "Did you ask the gossiper if she was even in the meeting?"

Idiot still couldn't follow.  "No," she answered, "I am asking you directly.  Why did you say that about me when it's not true?"

While she was "asking" me why I badmouthed her, she was sitting at the desk, swinging her feet, while I was serving the lunch trays.  She then put the icing on the cake:  "You are not even paying attention to me.  I am asking you something, and you just keep on giving out trays and talking to the patients."

The only thing in my favor is that most of the attendants can't stand this nurse, either.

Monday, February 24, 2014

Lost in a book

There is an attendant who reads several books a week- at work.  The psych ward is noisy and chaotic.  I can't hear myself think, let alone concentrate long enough to write an entire sentence in a chart as I am interrupted every five seconds.  Yet this attendant sits along the wall, his nose buried in his book, while the noise and whirlwind around him swirl on, without him.  Nobody interrupts him because he has trained everyone to not interrupt him:  to get his attention, you have to call him several times, shake him, and then repeat yourself multiple times while he sits there with a smile on his face, repeating, "What is it that you are saying?"

It's hopeless.  His sister is the non-working clerk of another ward and her husband is a nursing supervisor.

Fifteen minutes before the end of his shift, he folds up his book and papers, tucks everything under his arm, and then saunters out the door, waving and saying, "Nice working with you!"

Sunday, February 23, 2014

Different world

The new nurses are quite taken aback by the sexual behavior of the male attendants.  (They are also surprised by their laziness and rudeness, but that's for another post.)  One nurse has already been asked to bear the next baby of a highly prolific male attendant.  (He asked me three babies ago.)  The advanced age of other flirtatious men is very off-putting to the young nurses.  I pointed out to one nurse the gray in an attendant's beard and informed her that he was more than double her age.

The nurses ask, "Didn't they hear that sexual harassment is not allowed?"

Well, no.  They haven't even heard about computers.

Monday, February 3, 2014



Patient had a seizure.  Broke his face open hitting the floor and then broke it some more while the seizure continued.  But this posting is not about the lack of help I got from my staff, such as when I asked two attendants standing nearby to get me sheets and blankets.  Three times.  Finally one of them said, "Me?  He is not even my patient!"

This post is about how the error happened that led to the seizure.

I'm giving report to the ED.  Yes, history of seizures.  What medications does he take for seizures?  Dilantin.  Nope.  Was discontinued and started on Depakote.  500 mg twice a day to 1000 mg twice a day to 2000 mg.  Oops.  Was discontinued yesterday and started on lithium for bipolar.

A review of the chart showed that the Depakote was originally ordered for seizures by a neurologist.  A psychiatrist increased the dosing and wrote the indication as bipolar and not seizure disorder.  When the patient's moods were still cycling daily, the psychiatrist discontinued Depakote- clearly not working for the bipolar disorder- and tried Lithium- which is of no benefit in preventing seizures.  Suddenly withdrawing the Depakote likely induced the seizure.

How could this have happened?  Various higher people wanted to know.

Well, let's see.  Instead of allowing me to concentrate on medications and physical assessments, they have me serving breakfast and lunch because the dietary department is short-staffed; yet I highly doubt that they have fewer than one person working, which is the number of people working on my ward.  I have to do the filing in the paper charts because it's too much for the clerk to have to file in addition to everything else she does (which is . . .).  The medical doctors work overnight, take off in the morning, and then return at 2 pm and write a flurry of orders right before my shift ends.  I have too many doctors descending upon me at once and the incoming shift does not have to take off orders written on my shift- and I do not get paid for staying later because "there is no reason why you cannot complete your assigned tasks in the allotted time."  I am the only permanent nurse on the ward and I work with a floater unfamiliar with the ward and disinterested in working at all.  The attendants will not perform the simplest tasks, insisting that it is so easy that I can do it myself instead of "expecting everyone else to do my job for me."  The supervisor of the day marches in, oblivious to what I am doing and the whirlwind of chaos around me, and launches into a diatribe about how so-and-so is upset and it's all my fault, blah blah blah.

And that is the story behind that error.

Coincidentally, I remember this patient during his last stay because of another error.  He is allergic to a few drugs.  The practice at my hospital is to not fill out any allergy information on the chart, the order sheets, or the medication administration record.  I always fill it out, but most people don't, and I end up filling it in for other nurses and doctors when my name has to go on the page for some reason.  The patient started acting very nasty for a few days.  I reviewed the chart and realized that the psychiatrist had started him on a medication that was listed as an allergy.  I called the doctor and discontinued the medication and the patient cleared up.  The error was not intercepted by any safeguard in place:  the nurse taking off the order, the nurse reviewing the order on the 24 hour chart check, the pharmacy, and the nurse giving the medication.  As far as I know, the error was not caught on any subsequent chart audit.

For those of you who have your wits about you, pay very careful attention to the medications you receive.

Saturday, February 1, 2014

Entry level nurse job

Some observations and questions from the new nurse I trained for two days:

---They just sit there on their phones?  That's allowed?  Why don't they have to do any work?

---That's not a patient?  How could that not be a patient?

---Why is this place not computerized?  I thought every hospital had to be electronic.

---I was warned that the men who work here will try to get me into bed.

---Why did eight people come up to me and ask me if I was on time to work, but that guy just walked in two hours late and the supervisor hugged and kissed him?

---Did she just take a three hour lunch?

---The phone just rings and rings and people sit next to it and don't answer it?

---The clerk yells at you for not filing?

---He just knocked the fax machine over and kept walking.

---I thought everyone starts at 7.  Why are we the only ones here?

---Why is everyone telling me what to do?

---I don't think she likes me.

Good Luck!