Karen Sanders, Senior Staff Nurse at North Bristol NHS Trust, describes the moral challenges of working in a busy Emergency Department. This is the first of a series of stories we'll be presenting on The King's Fund's site on the issues that staff face in trying to ensure a positive patient experience. The views given in this article are of the author and do not necessarily represent the views of The King's Fund.
Imagine the scene. You walk onto a shift in a busy Emergency Department (ED) and take over as the nurse in charge.
You are primarily concerned with the overall safety, management and care of the department, its patients and its staff. However it sometimes feels that your unwritten role is to watch the 'tracking' system and ensure that no-one stays in ED for longer than the 4-hour target.
Not so long ago, when a doctor asked for a patient's vital statistics you would have heard the ED nurse say, 'BP 120/60, Sats 100 per cent, pulse of 60'.
Today you will hear that same nurse say '3 hours 40 doctor and it's not looking good on the bed situation! Discharge or home?'
No longer is there time to form a decent therapeutic relationship with the patient, or to use the 'medical sixth sense' to explore exactly what it is that is wrong with patient when the nurse says 'I don't know what's wrong - but they’re just not right'.
The hospital is full, with not a bed to be found, and some of the sickest and most complex patients are at the 3 hour 40 mark with no forward destination. You have 20 minutes to find a home - for all of them.
The managers are also watching the tracking system, so are the site managers and the main receiving wards, who all start to call you asking for your plans. You become harassed, so you start harassing the doctors for plans; they then ring x-ray departments and labs and harass them; who in turn produce a list of tasks with which to harass the nurses.
You now have a department at fever pitch - phones ringing, people shouting, computers flashing, ambulances arriving, people crying, relatives frantic for information and people trying to 'out sick' each other to get seen quicker. Worse, there is a real possibility of a 4-hour breach and it will be your fault.
A manager calls through and demands to know why a sick child is still in your department, when a bed has already been identified? Then something above us appears to crack! A senior doctor overhears this conversation, snatches the phone from you and takes over the call.
He rants that he will make a decision on when to move this sick child and he will tell the frantic parents all they need to know before he can be safely moved. He slams the phone down in front of a startled department and turns to you and rages:
'I still care about my patients and I will not be rushed into any dangerous decision-making. My patients and the care of them are my ultimate priority and not your ridiculous computer screen!'
You stand there. The staff all stand there, while we all take in what has just happened. That doctor has just done what you should have done.
You should have stuck up for your patients; you should have put patient care first. You should have given them time to recover before whisking them off their stretchers to wards, or forcing them into clothes and cars before they are ready. You should have the time to make people a cup of tea before they go. You should soothe the frayed nerves and check they have keys to get in their house and food and company when they get home. You should be checking these patients are safe for discharge. You should make sure they are clean and not covered in blood. You should make sure they are pain free and have follow-up appointments arranged.
This is what you should be doing. You are a nurse.
In those few seconds of outburst you realised what you have become: poacher turned game keeper. You have been bashed about the head with your own integrity and there is a guilty conscience beneath those wounds.
Are you ashamed at what you have become? Recent nursing literature says that nurses are experiencing a 'moral distress', and you have become that distressed nurse.
Karen Sanders, Senior Staff Nurse, RGN BSc (Hons) Nursing BSocSc (Hons) – Frenchay Emergency Department, North Bristol NHS Trust
Are the government targets scuppering the caring attitude of nursing? When should we say enough is enough?!
Denise Samphire - UCLH London
Please see my personal view in the BMJ - very similar theme. (Rawlinson N: Harms of target drive care - a personal view. BMJ 2008 337: 237). Yes target driven care has attracted resources, and the environment is better. But it has also radically changed the way we practice. Emergency care is less fulfilling. Unless we can restore the joy of emergency patient care our specialty will fail, as it will no longer attract trainees.
Many thanks for your kind comments. I read your BMJ article with great interest and found myself nodding along in agreement with many of the issues you raise. I am especially interested in developing the concept you raise about the "Joy" of Emergency Care and the ability to attract new Emergency Care professionals.
"Joy" as a concept of Emergency medicine is a dimension that I had not considered until recently, when new Nurses in the Emergency Department have remarked that they feel they are "processing" each patient as a product, which needs to be sorted efficiently and quickly to their end destination, but there is no time built into the system to care. No time to understand or truly perfect the management of the presenting complaint or issue. With speed instead of care as the central focus, who will want to work in this area? How will there be any development of skill? Where will greater knowledge, expertise and evidence come from? Will research continue to be carried out?
It is argued that you can have speed and care, I would however beg to differ. You currently cannot drive at more than 30mph on residential roads because it is impossible to proceed at speed with care. Speed causes accidents and carelessness.
There is a new support to retain the 4 hr target so we need to decide do we want our ED's run with speed or care and as you rightly point out, will this attract anyone who will want to work in this environment?