The Good, The Bad, and The Lazy

Over the past year we have gained a good dozen or so nurses fresh out of school.  Some of them rock, some of them tread water just bobbing above the surface, and some take laziness to a whole new level.  Like other ERs we have standing orders, and 90% of the staff use them.  Unfortunately when you come in and you are following a person who  is in the other 10% who doesn't, it can make for a really rough chaotic shift-- not to mention the pissed doctors, patients, and loved ones of the patient.
Yesterday I walked into a disaster.  One non English speaking pt was going to the OR, three had beds, of which one had been called for an ultra sound 3 hours ago and was never sent, and one was waiting for a CT that was ordered 4 hours earlier.  Perhaps my favorite surprise was my altered mental status patient from a nursing home that had an assessment done but the nurse said he never actually went in to see the patient who had been in the ER for 2 hours ( how did you assess them if you didn't see them).  And the icing on the cake not one standing order was done, no OR check list either.

When I asked why the standing orders weren't done for a woman who was sent by her provider for an incomplete miscarriage, and why her assessment didn't include a GYN-OB assessment or history the nurse said "I just didn't do it" not a great answer since she was on her way to the OR.  Just when you think things can't get worse that same non English speaking patient was consented on an English consent form, without a translator or a witness-- stupid new resident!
This of course lead to a call to the residents' attending and a very good lesson for that new resident.

For the first 3 hours of my shift one of my fantastic co-workers helped sort out the mess that had been left.  When our charge came over to get the scoop on why earlier CT, ultra sound, and the OR called all sorts of pissed,  5 nurses in our little section of the ER enlightened her to the track record of a particular nurse I had followed.

Through the course of the evening when things settled down we had some time to discuss the trends each of us were seeing amongst some of the newer nurses.  One had said that a new grad nurse had a patient with a cardiac history come in for chest pain and the nurse did none of the standing orders.  She had not even started an IV.  I had a very similar experience with the same nurse who told me that a resident told her not to do anything.  When I asked her which resident it was she "couldn't remember".  Which was funny because the residents didn't recall that conversation with her.

As we chatted about the possible ways of opening our new co-workers up to the concept of completing standing orders we thought about the ways that would impact them the most.  If you stressed the urgency of the matter to them would that shift them into gear?  One suggested writing up the nurses, while another suggested having them walk in the shoes of the patient.