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A Typical Day in the Life of a Bedside Nurse, Part 2
For Part 1, click here. It’s okay if you don’t want to, I promise you haven’t missed much. Even the start of the day…
The horde surges out of the conference room, all be-masked and be-goggled, seeking out their partners for report. Our aides find one another because they are matched 1:1, they report to one another and then answer whatever pages come forward and then can attend to patients. The night shift aides saunter toward the break room to hide until it is an allowable time to clock out. They aren’t supposed to and many nurses roll their eyes as they see them all gathering together to gossip and basically take the last 20 minutes of the shift off on a social break.
This is heavier than you might think; pushing it around all day is a workout.
I walk toward the center of the nurse world: the Main Nurses’ Station (they tried to rename it “Clinician Station”, but it didn’t stick). We are supposed to gather there at the end of the shift in order to make ourselves easily found; it is easy to lose people to the never-ending pages, alarms, and the large surface area of the floor itself. We swarm the mobile computers. Previously known as COWs (computers on wheels), they have been renamed WOWs (in honor of some mythical person who was offended when someone referred to the “COW in the hallway causing trouble” or some such). I search for a computer for a few minutes, but quickly give up. Night shift does not like to relinquish their computers. Instead, they prefer to drag them about as a rolling pedestal of belongings. As if it were somehow evidence of their hard work, they will often cling until the last possible moment. Their fingers loosen and relent to unforgiving glares and side-eye by the day shift, enabling us to finally log in. I find one such clinger and pry the confounded thing from her cold, not-yet-dead fingers.
I still have not found a nurse to get report from. This means the beginning of the investigation. I would like to say that I patiently walk over to the secretary and unobtrusively look over her shoulder while she works in order to see who has my assignment. In reality, I’m fairly certain I sound more like an irritated bull stomping through an already chaotic scene. “Hey. Can I see that?!?”
It’s 7:17. I have about 13-15 minutes to find all four (if the night charge didn’t like me) of my nurses for all four of my patients and to hear them give a quick summary of the patient’s name, age, history, how they came here, what happened while they were here, what their status was, what the plan is, and do a bedside assessment to ensure that they are all neurologically still the same. On a good day, I do not have any stroke assessments to do with confused patients. On a bad day, I might have four.
According to studies my supervisors keep saying exist, patients prefer for the nurses to give bedside report. This increases patient satisfaction, as they feel more in the loop and capable of correcting incorrect information. This also increases nursing dis-satisfaction, as the nurses are required to awaken the patient early, declare what they are doing, and then hold a conversation in the poor dozing patient’s room while attempting to be sensitive while still giving out pertinent details. This becomes increasingly problematic in light of difficult family members, possible Adult Protective Services cases, abuse/criminal cases, patients that have been found doing lewd things to the staff, and cases where the patient does not know the results to specific tests but the nurses do. (More on that topic later, probably much later, remind me.) Patients delight in asking complicated questions that we cannot possibly answer at this time. Indeed, we need to just check and make sure they’re okay, give our report and get out so that we do not get in trouble for clocking out late.
I find it hard to believe that patients enjoy being awakened to hear details they do not want to know (or do not understand) when they are in pain, and have their questions dodged while the nurses converse together in front of them.
There might have been a time that this was revolutionary and helpful. I am not sure that time still exists. Instead, we move on…
With oriented patients, it can be tricky. Time is truly limited for report: we have allocated about five minutes per patient, not including assessment. That would be exactly 20 minutes. This presumes that we get out of the morning huddle and assignment process by 7:10. This also assumes that during this time, we have not had to run (literally) to a bed alarm, answer our phones, seek out a nurse who didn’t show up to the main station, and that all of our patients are fairly straightforward with an uncomplicated hospitalization. If the patient is otherwise confused, one can assume that once inside the room, the patient may attempt any number of things, all of which will distract the oncoming nurse and irritate the off-going nurse. Sometimes, our helpful aides come in to start vital signs, happily interrupting our complicated cognitive assessments. Other times, our patients burst out of bed thankful that their waiting finally paid off. They would like to brush their teeth, go to the bathroom, go for a walk, and then be settled to breakfast in the chair, you see.
Unfortunately, I have exactly 4 minutes left with the night nurse and those 4 minutes do not include these different activities.
On my floor, breakfast is also usually served right at this time. Patients begin calling for extra utensils, Splenda, complaining about their orders, or sometimes they insist on seeing the doctor or even being discharged.
Again, the 3 minutes I have left with the night nurse giving me report does not include those activities, so I attempt to explain that the night nurse is very tired and we must do these assessments right now. I attempt to smooth over their frustration by paging the front desk and asking for an aide to come in. I will be honest when I say the following: I do not know how long it takes in the morning. While we rely on our aides for a great many things, they also get right to work. If they do not log into their phones, we can’t call them. If we can’t call them, they blissfully go about their day doing vitals, charting, and then just sitting there, completing education modules (oh, no one escapes them here!). In the meantime, the nurses will even get tracked into the rooms they are in (still trying to get report, mind you) to be told that a patient needs….whatever. Sometimes, if it is a good day, the night nurse will help me to accomplish whatever needs doing. We will quickly change the patient, bring over a toothbrush and wipes and a cup of water. On a good day, we’re a team, it all goes smoothly and somehow we get out on time.
It is rare that we have days that are so good.
Most of the time, we rush from patient to patient doing the best that we can while being interrupted. Ah yes. The family member for 24 is calling. They know that we just changed shifts, but they’re hoping to get an update. Right now. Unfortunately, I have not even laid eyes upon this gentleman. I ask the secretary to defer, with my absolute gratitude. If I am lucky, I can then finish my reports after finding my other nurses and doing my other assessments.
If I have rushed around appropriately or I am on my second shift in a row, I might actually have completed report. Offgoing nurses will tell if they’ll be back that night or if they are off and we all silently pray that they’re coming back so that we can give update report. Update report being the ultimate goal for continuation of care between nurses regularly; the patients’ basics are all known, so it is a chance to give a better, more precise update about what happened during the shift. It is a relief and a joy to find that the nurse will be back.
I hate this phone.
(Disclaimer: This is not my phone and none of the names are real.)
It is now 7:35 am. I rush the night shift away and try to help them wrap things up as quickly as possible. I try to track down the nurse with my iPhone: this is our connection to everything and when busy, sometimes people will just drop them off with the secretary. This is not ideal, but it happens. But today, being a more typical day, one of the nurses tracks me down and drops off my phone as I log into the computer.
7:37 am. First official page of the day. Patient is in pain. I was, literally, just in that patient’s room and just asked if he had any pain. He said no. Night shift told me that they had just medicated him at 6:30. I look into the chart: sure enough, 6:38 am he got his dose of Dilaudid. He received all other medications and nothing would be due for about another hour. I get up and walk over to the room on the other side of the unit in order to notify him that his next medication is due at 8:40 am and show him where it is on his whiteboard so that he can remember. He insists that he didn’t get it during night shift and that I need to do something. I apologize, but tell him that I’m looking at the orders and once I make sure there’s nothing left to give, I’ll call the doctor for an extra dose. In the meantime, could I get him a warm pack or an ice pack? Would he like to be repositioned? No, no, he grumbles. The only thing that works is that one IV medication.
I tell him that I’ll work on it and start the move back to where I left my computer. I sit down and start looking at all of my patients’ labs. It’s now 7:45. I like to be done by 8 am so that I can start assessments and regularly scheduled medications. I am reminded that two of my patients are diabetic and on insulin, so they’ll have to be seen first so that I can give them their insulin. One other patient had an IV antibiotic scheduled at 7:30 am (the worst possible time) and night shift left it for me. I call our resource nurse and beg her to pick up the slack so that I can finish analyzing labs and start my day.
Unfortunately, she’s already in another room with some patient that is screaming. It sounds serious. I tell her not to worry and hang up.
I get up, rush to the medication room and go to the Pharmacy fridge: there’s no antibiotic. Well, I guess that solves that problem, then. I go back to my desk and send a request to the Pharmacy that the medication was past due but never arrived and that yes, I did check the pneumatic tube system. I’m busy so I bend the truth there: I looked in two of the tubes. There’s a third that I didn’t look at because I was busy, but it seemed that none of the medications were up yet for the morning, so I doubted it would be there to begin with.
I navigate away from the messaging and start to focus on my patients’ abnormal labs. My surgical patient’s H/H has dropped after surgery. It’s not awful, but it’s close enough that they might want to transfuse. I should keep an eye on that, look at the trend. She’s not symptomatic at this time, but I should really look and see what her pre-surgical baseline was and what the estimated blood loss from her surgery was. I get an overtime page. My aide has not answered a page in 5 minutes, so it rolled over to me. Apparently the patient “needs help”. This page is vague and does nothing to help me prepare for what I’m about to see when I go into the room.
Seizure pads are essential for safety, thank God they’re cleanable.
I log out of my computer, grab my stethoscope (might as well get my assessment in, since I’m late with everything else already), and hurry over to the room. The confused patient has one leg hanging over the rail and her IV in another hand. There was a bedpan under her, but it seems she wiggled off it or managed to take it out from under herself and her morning BM has been smeared across the bed and her body. It is even under her nails. I sigh.
I walk over to the IV pump, turn it off, take the tubing from her hand, and disconnect everything in the set and throw it out. I wash my hands and put on gloves. I move her legs off the pads on the side rail (intended to protect her in case of a seizure) and try to straighten her out in the bed. I look around me for any wipes. There are none. Covered in…my morning work… I use my elbow to hit the call button and ask for assistance from my aide, the Resource nurse, or anyone within earshot. Thankfully my coworker is walking by and she hops in, pops on gloves, helps me take off the soiled gown, then takes off the gloves, uses sanitizer, and jogs out to the supply room to grab wipes, towels, a basin, skin cream, sheets, and a new gown. We spent the next few minutes cleaning up the patient, rolling her back and forth, tucking and cleaning and removing fabric in ways that even Houdini might be jealous at our sleight of hand. As we move to hike the patient up to the head of the bed, my aide rushes in, forehead already sweating, “Oh! I’m so sorry, I was stuck…”.
We nod and smile. She doesn’t notice the smile because of the mask, but she recognizes the eyebrows when we say, “It’s fine, go take care of someone else!”
We settle the patient into bed, together, ensure the bed alarm is on, take all of the dirty linens and trash out of the room. We sit the patient up to a near right angle and set her up with breakfast. The other nurse rushes out while I whisper, “Hey, thanks…” and she nods as she backs out, rubbing sanitizer on her hands.
It’s 8:05. I’m already late giving morning medications and I’m still not done looking at labs.
I rush back to my desk, take a quick glance at the remaining labs, make a few notes on my report sheets (known as Brains) and shove them into my clean pocket. I pull the desk upward and unlock the wheels. It’s time for meds and assessments and we have to get going. If I’m going to be done charting morning assessments on 4 patients, I’m going to need to be done with medications by 9 am. I’ll be lucky to chart on two, but I set myself to getting it done, regardless.
The mad morning rush begins.
—
Disclaimer: The pictures used in this post are open source on the internet. They bear no resemblance to any people I know or have worked with and are not a violation of HIPAA. Nothing I describe in my day in the life bears an exact resemblance to anyone but myself and all graphics are taken from the internet and never from a facility with which I am affiliated. All descriptions are generalizations of experiences I have had over many years of work and are meant to be generalizations; this is, after all a “typical” day. In nursing, it is rare that there is a true “typical” day, but this is often how these days go as closely as I can approximate.
Published in Healthcare
I was inside enough to fear the need for anything at all during shift change.
Twice the staff, but half of the time to answer calls. It’s something that comes up frequently with leadership: where is everybody? Why isn’t anyone answering pages? It’s because half of the aides are already off the floor, the other half started vitals, and some/most of the time they haven’t logged into their phones yet. Everyone is in a rush to get their work done. It’s understandable. If I helped everyone every time that I wanted to, I would never finish on time. I’d be very popular with my co-workers, but I would never give medications on time, I would never be able to answer the phone for doctors… frankly, I’d get fired for not “appropriately prioritizing and delegating work”.
We’re supposed to do last rounds at 6-6:30 to ensure that everyone is settled before shift change. Pain meds are given, people went to the bathroom, they’re otherwise all settled in. I suspect that night shift does not do this in the morning; I understand that most patients will not want to be awakened since they were probably prodded every 2-4 hours at night anyway. This puts an odd and undue burden on day shift where we walk in and already are behind. This is why people are supposed to stay on the floor and round until 7:28am.
Now, does that happen? No. Will it happen? Probably once someone complains again. People will be better for a while and then it will probably revert. Again, I know I am blessed to even have aides on my unit, so I feel bad complaining, but it is frustrating. On the other hand, I know that I’m exhausted at the end of a shift and I’m sure they are too.
Wow.
I’ve spent enough time as an industrial engineer that I immediately try solving this problem, or rather shift change problems more generally. Unfortunately I’ve also spent enough time in the real world to realize that all my solutions will probably boil down to “more nurses”, which is something that you’d already have if it were feasible.
It’s not just more nurses. It’s more nurses and more aides and people being held accountable. I’ll admit my failings, but I certainly hope that others can too when they are reminded of them. I think we all get tired. With Covid, everyone’s exhausted and ready to leave the moment they give report. Unfortunately, then that leaves the oncoming shift with a crappy burden of trying to solve problems, plan their days, and do shift change type stuff.
And the 6-6:30 rounds usually ends up with somebody calling a code. That’s always a wonderful way to end your shift (not to mention a chaotic scene to come into).
You left out the preop nurse calling for report on the patient having surgery later that day. We always try to call at change of shift. ;)
Now, make sure you update your care plans before you leave for the day or else JC will not like us.
Welcome to my world
Great post.
I’m feeling encouraged to post about a day in the life of what I do.
This is compelling reading, but also a bit scary and disorienting, realizing that if (I guess I should say “when”) the time comes for me to be the patient, I’ll have no real orientation, no warnings about or understanding of what has to be done. TRN’s articles are a must-read.
I did say a typical day in the life of bedside. I should also post an A-typical Day in the Life where a patient comes up, unexpectedly, from the ER at shift change without report to a dirty room and ends up waiting in the hallway with a transporter who doesn’t know what is happening.
But I think that’s a little too real for the masses. I was trying to demonstrate a bit of the work load and a bit of what happens so that people have an idea of what’s happening in the hospital when they or their loves ones are admitted, not scare them!
And 6:30? Sheeeesh. Ours are always at 7 or 7:15 with a neuro change. “But he was totally different at 6:30!!!!” “Well, call the Code Neuro…”
Your world? My world? Our world?
I should point out and maybe the editors can help me with this by adding a disclaimer or perhaps adding to my caption of the iPhone that these pictures are open source on the internet. They bear no resemblance to any people I know or have worked with and are not a violation of HIPAA. Nothing I describe in my day in the life bears an exact resemblance to anyone but myself and all graphics are taken from the internet and never from a facility with which I am affiliated. All descriptions are generalizations of experiences I have had over many years of work and are meant to be generalizations; this is, after all a “typical” day. In nursing, it is rare that there is a true “typical” day, but this is often how these days go as closely as I can approximate.
So, in sum: I have not violated HIPAA, I would not violate HIPAA. I am acting in accordance to the Nurse Practice Act in the state where I am licensed and have violated no policies of my employer.
Please don’t cancel me; it’ll really mess up the staffing ratios.
Ah, the mythical COW. We got told that story, too.
To solve the bedside report problem, I take a full report from the out-going nurse with the chart open at the station. We then go into each room, I introduce myself, explain the plan for the day and ask for questions and concerns. In and out of each room, usually in about a minute.
I start at 3 or 7 pm, so I’m not waking anyone up. I’d push pretty hard against doing that if I were ordered.
(Says the guy who can retire at any time and just admitted he doesn’t take report on sleeping patients.)
The way way my hospital solved that problem is the floor nurses are responsible for coming to get the patients. We do bedside in the ER and they take it from there. That would make your life easier, being away from the rest of your patients during that time.
Of course, I never sent a patient to the floor at shift change without giving report or making sure the room was ready.
Well perhaps I can shed some light on this one. I was working on renovations for a Labor and Delivery department. While there one day doing verifications of dimensions and room identification, one of the nurses complained, remember pregnant women everywhere, that she had gotten in trouble for when, needing more room to work, my interpretation, she curtly insisted, “Get that COW out of here.”
I don’t believe this is a HIPAA violation, but if it is, of course I’ll take it down.
We do that when the ER is overwhelmed and we’re about to start diverting. ER loves it. We hate it. Why? Because then we have to find someone to cover our 3 other patients while we go down and try to find the nurse, etc. Most days, that is a difficult thing to swing on my floor.
Disclaimer added.
Of course, when we have to take a patient to the floor, someone has to watch our three other patients-who are a lot more likely to be unstable.
Meh. 50/50. The ED patients are often DC’d home. So goes the ongoing battle of ER vs. The Floor!
We only do bedside for stroke patients. All others usually get a break nurse to travel with them. Now, if they go to Critical Care, what do you do? Ask them to come get their patients? We go to CCU with our patients to give bedside report.
Ultimately, my personal opinion on report is that with visitors present, it is a possible HIPAA violation and is inappropriate for most of my patient population. When it isn’t, most aren’t up for it at 7am. I’m all for report at the station followed by focused tandem assessment/bed check.
PS
Everyone: it is called “bed check” because we are literally checking to ensure that our patients are still in their beds, upright, safe, and stable. You might be surprised how often at least one of those criteria are not met.
Upright, safe, and stable? I wasn’t that when I got there. I wasn’t that when I got home either. Lots of luck.
I’m guessing it’s like “fast, cheap, and good. Pick any two”.
Well, upright in the sense of sitting upright or appropriately positioned (more correctly). Many of my patients are required to be head of bed (HOB) flat. So during bed check, we ensure that they are that, safe, and stable.
My literal first day of nursing school clinical, my precepting nurse for the day asked me to do the bed check. I’d checked on our people (all fine), but then heard a slight sound from down the hall. It sounded like…maybe a woman? It was faint, so I kept walking with my ear tilted toward the door.
There she was. The last room I checked. Her head was at the foot of the bed and almost on the floor. Her face was red and she looked at me. “thank god! ….I don’t know what happened…” She was completely entangled in the sheets. Thank god was right. It lashed her to the bedrails and prevented her from falling face first at the foot of the bed onto the tile. I managed to help her into bed with the assistance of another nurse.
And this, my friends, is why we do “bed check”.