Sunday, January 28, 2007

My side of the stretcher continued

So I've been awake since 0530. It's Sunday morning, not a usual work day for me as in theory, I am a Monday-Friday, 0800-1700 type. You know.. no weekends, no holidays no nights. And I'm awake this Sunday morning because I woke up thinking about work (yet again) and couldn't go back to sleep. I'm what the frontliners call a "shirt/skirt". I'm the nurse in the office. The one with the "good life" and "huge" salary. The one that wakes up at 530 on a Sunday morning and thinks about how we can "make it better." I've heard many comments about how managers just "go to meetings" and no one knows what THEY do. I hope to tell you a little about that and at the same time, blow off a little steam and in the process, take a little better care of my emotional health.
My work week usually starts at 8am Monday morning. Now one perk to this job is that I don't punch a clock, so if I get a slow start on Monday and get to work at 830, it's ok... I just stay later in the day to make up for it. The down side is that I am paid for 80 hours every 2 weeks. I am expected to put in my full 80 but if I happen to put in 90 or 120, I still get paid for 80. There is no such thing as paid OT in the manager's world. My first order of business is to be sure to greet everyone on duty by name, ask about their children, their weekend, or how their morning is going. Once that is accomplished, it's on to payroll. There are about 47 employees who report to me, and I am responsible for ensuring that everyone goes home on Friday with an accurate paycheck. So that means spending an hour or so in front of the computer checking each staff member's time card and making corrections when badges have been forgotten, clock ins and outs have not been recorded, shift trades have been made etc. That's comparing the schedule to time cards, making calls and waking up someone who worked Sunday night to find out exactly when they worked, tracking attendance, call-ins and late arrivals and writing up disciplinary actions for same.
Between this activity, I am answering the phone, new "high priority" email, and questions from anyone that may pop into my door way. My office is inside the department itself, so I am in the thick of it and have the benefit of all the sounds and smells that go with a busy Emergency Department. Toddlers screaming in protest at being held down to get stitches, the splattering of vomit on the floor from the drunk patient "sleeping it off" on a hall stretcher just outside my office door, the aroma of diesel fumes from the ambulance parked in the drive that wafts down the hall and into my office, cardiac monitor alarms signaling impending death, ambulance phones announcing yet another arrival. It's a virtual auditory and olfactory buffet. There is room enough in my office for me and one other person, and then it's an invasion of personal space. Every inch of desk an shelf space is taken up with sheets of paper or notebooks of some sort, and yes I am known for being "organized."
With payroll done, I'm ready to tackle the rest of the day. It might go something like this.....
9am :Meet with staff member who has been counseled for being late. This is an intelligent person, a professional. He can start the most difficult IV, triage with 99% accuracy, knows who is sick and who is not, can predict a given diagnosis by simply looking at a patient and hearing their chief complaint and yet he cannot get to work on time. Go figure.
915am - Answer the phone. The person on the other end of the line asks, "Are you in charge of the emergency room?", and right away the hackles on the back of my neck stand up, because I know this can't be good. So I listen to this person's complaint about how she's been having this weird pain in her side for about six months and she came to my ED last night at 2 AM and she didn't see the doctor for 3 hours. ("A person could die out there in the waiting room"). And once she did see the doctor, he was "rude" to her when she told him she was allergic to everything but Dilaudid and he "didn't do anything" for her. Although when I pull her chart, I note that she waited in the waiting room about 10 minutes, saw a doctor in 30 minutes, had complete lab work, a CAT scan (all normal), IV fluids and was given medicine for pain and nausea. Once I listen to the complaint and assure her that I will "investigate" her concerns. I am required to enter this information into our hospital complaint database and am expected to thoroughly investigate the issue.
The investigation of the “issue” may involve checking the ED log to get a snapshot of what might have been going on in the department at the time this woman showed up with her “EMERGENT” problem. Once I have the information from the log, her ED record and have reviewed it all, I track down the nurses’ on duty and get their take on the deal. I document all this in the database and refer the whole mess to the medical director. I ask him to call her back and let her know that her medical management was “appropriate”. All this takes me about an hour.

I have a meeting at 10 am and I am late because of dealing with the complaint. The meeting is with our quality director and regulatory compliance officer. They have a new standard we are required to meet and they want the ED staff to “trial” their new process. The process involves having the ED staff complete a time-consuming, detailed, and onerous form, getting signatures from the doctor and the patient, making a copy of the completed form AND faxing the form to the referral doctor once the patient is discharged. All this adds about 15 minutes of time to the patient’s total ED stay and slows down the discharge process. This in a department where we are expected to move patients in and out in a timely manner AND keep them happy and satisfied as if they had stayed at the Ritz. I look at the form and note that it contains far more information that is required by the new standard. Immediately I can see several ways it could be improved and easier to complete. I negotiate with the regulatory and quality “police” and am able to get them to agree that the ED staff will only have to “start” the form with the minimal required information. YES! A small win for ED but a win none the less.
And that isn’t even half my day gone. The rest of my responsibilities still loom over me like the Grim Reaper. There’s only one of me and my poor assistant manager who has to work 36 hours of clinical shifts per week and still manage to meet her responsibilities.

So what does a “shirt/skirt” nurse manager REALLY do? What is it that THEY spend their time with? Here’s the list….. (Including but not limited to..)
Rounds-STAFF- I am expected to meet once a month with each of the 47 staff members that report to me. That means being here at 6am, 11am, 10pm, and maybe on Saturday or Sunday to catch the weekend staff.
Rounds-Patients- I have a goal to round on patients every day just to let them meet me and know that I care enough to ensure that things are going well with them.
Rounds –Other- I am supposed to meet monthly with other managers of other departments, anyone who is my “customer”. Doctors, ambulance personnel, x-ray, lab, inpatient nursing unit.
Staff Reward/Recognition- Write thank you notes and think up new ways / gifts to appreciate those people who actually do their jobs.
Staffing/Scheduling- Getting the schedule posted every month. Making sure every one got time off as requested and that we keep the request process fair. Making sure there are enough bodies on duty every day to take care of the number of patients (semi-unpredictable) that show up at the door. Making sure that we don’t have too many bodies and sending people home when things slow down. Calling nurse B to come in to cover a shift when nurse A has called in an hour before the start of the shift because she’s been sick on her previous two days off. Shuffling bodies around when someone has made a trade and now we have too many nurses working Friday night but we are short 2 nurses on Saturday. Oh and yeah….If we are too short, below core staffing, and there is no one else to work, I get to put my big girl scrubs on and come on in to work.
Patient Complaints- see above tirade. Thankfully these seem to come in “clumps” and there’s really not that many…especially not many that directly involve nursing.
Patient Satisfaction_ monitor our “scores” on a week to week basis and try to come up with new and different ways to trim 5 minutes off of our wait time or keep people happy and occupied while they are waiting.
Fixing/Buying Stuff- making sure the ice machine works, the cardiac monitor is sent for repair, new instruments are purchased, the supply cabinet is appropriately stocked, budgeting for new stretchers, requisitioning capital equipment, searching for the vital sign monitor that’s “been missing since last week” and no one bothered to look for it or let me know.
Quality Improvement- Are we doing what we are supposed to do? How can we do it better? Audits audits audits. Rapid cycle improvement. Plan Do Study Act……ad nauseum.
Staff Evaluations- these are supposed to be done every six months. Right…my assistant manager and I do well to get them done on time once a year.
Staff Competency- We don’t have a department educator so guess who gets to come up with ways to document that staff members are competent to do their jobs every year? That would be me.
Staff Licenses/Certifications- Checking that everyone that is supposed to have a license or certification actually has one that is current and unexpired and nagging people for verification of same.
Policy and Procedure- Write new ones and review and revise old ones.
Mediation/Refereeing- Serving as the crying shoulder, counselor, mentor, conflict manager of anyone who feels the need to vent
Meetings- Oh yeah….that’s all THEY do. Well that’s a lot of it. Disaster planning, decontamination training, hospital management meetings, staff meetings, charge nurse meetings, patient care meetings, nurse leadership meetings, practice council meetings, quality, safety, administrative, infection control…..the list goes on and on. Some times we actually get work done in these meetings, but most of the time I spend sticking up for the interests of the department and attending out of raw FEAR that someone will come up with some totally outrageous, unrealistic and ridiculous idea that will make the daily life of the poor ED nurse HELL.
Vision- And at the end of the day, I’m the one that is supposed to have a vision, a mission, goals and objectives for the future of my department and my staff. And it all has to be in writing and it has to be kept up to date and current with documented outcomes, data and graphs. Good grief! The truth is I DO have that vision and mission. I want my department to be the best Emergency Department there is. I want us to take care of patients as if they were our own family members and not take all day to get it done. I want us to be educated, state of the art, cutting edge. I want us to be competent, friendly, caring and compassionate professionals. I want all this and more and what I know is that most of the time we really ARE ALL THAT. And I know that it’s not me but our staff that makes this happen on a daily basis.


Kim said...

Excellent post!!!!!!

My manager still oversees the whole shebang but there is some delegation of the routine tasks:

In my ER, the scheduling is delegated to one nurse for each shift.

Two nurses have the responsibility of keeping the time cards in line with the scheduling(one on PMs and one night shift).

Competency is tracked and handled by a Clinical Nurse II on the day shift.

We have staff nurses that sit on the committees for the Med Reconciliation and standardized transfer forms, so we have some input there.

Of course, the ER is full of nurses who have been there 20 years or more, so they know the place backwards and forwards.

Managing is a job that I would never be able to do - you get it from the staff nurses AND you get it from Administration on down! Kudos for the managers! : )

EDMGR said...

Well I have to own up and be totally honest. When I re-read this is does sound a little like I'm trying to do it all myself. NOT SO! I have a great staff who do take some of the load off by serving as reps on some of these committees and we do have to divvy up a lot of jobs. I just have to be the one to make sure it happens 24/7 and still somehow make sure we get our patients taken care of in the midst of all the regulatory and administrative hoopla.

girlvet said...

I think I play a part in you deciding to do the blog. I think it is great and unique. I will love hearing what a manager does on a daily basis. Because I gotta say, a lot of us, like it or not, don't know. How big is your hospital?

EDMGR said...

Girlvet- yes your comments played a part but your voice is just one of many singing the same song, so I thought it would be good to start the blog. I was a staff nurse for 18 years before assuming the manager role so even though I've been away from the bedside since 98, I still remember what it was like. Also, I still have the priviledge of getting to go out and help our staff when it's busy or if I just need a patient care fix. Our hospital is small- 66 beds. Our ED is 15 beds and we see 36,000 per year.

Mary Lu said...

Hi there BossRN:

Husband is a Director of Pharmacy at a medium sized SoCal hospital. I printed out your post and his comment was... I could just take her post, change a couple things add a couple committee meetings and my research work, and include the fact the job has given me an ulcer-- and we've got the same job. He commented may be he should start his own blog...

Good to see some one's posting something about what managers really do. He, like you, gets paid for 80, and ends up working about 100. Some days it really sucks when he can't extract himself before 9 PM.

Mary Lu