A CNO Goes Incognito – An Update

Medical-surgical nursing is tough and undervalued. Patient acuity is higher today. It seemed every patient needed pain control, was a diabetic requiring insulin coverage, and needed assistance toileting even if they were continent. These activities often require a second set of eyes or hands to waste narcotics, double-check insulin or help with a bed change. With ratios being stretched, resources are becoming scarce. Much RN time is now spent looking for another nurse to co-sign. In 13 weeks, I called off twice due to physical and emotional exhaustion. Most of my clinical career was spent as an ICU in 1:1 assignments with ECMO, VADs, balloon pumps, and fresh open hearts. Never have I taken more than two patients. I was hired as a traveler on a medical-surgical unit and had not taken a patient assignment in almost a decade. I received one day of orientation, and despite this, I was successful. I see a future where we have no clearly delineated service lines and nurse staffing is flexible. Nurses could be hired at a hospital or system level versus a unit-based model. Well-compensated nurses would cross-train to multiple areas and be expected to go to any part of the hospital on a given shift. Some systems are already piloting this; from a frontline perspective, I see this could be an important innovation. This change would shift the focus from hiring for specific units to hiring for skill sets. We need to motivate and incentivize nurses to increase their skill sets.

Workflow is challenging. The workflow is challenging in medical-surgical units. Once you clock in…. the clock starts, and you are already behind. It’s a race to (1) assess patients, (2) pass meds (3) document assessments. Until these three things are done, items are ignored, and quality is not the focus, i.e., ambulating. These tasks had to be done before I could be a real nurse and focus on complex wound changes, the higher-than-comfortable BP or HR, emotional needs, education, quality best practices, etc. Once complete, the remainder of the shift is driven by tasks. A call light during this time is an annoyance. The non-clinical patient needs, and requests go unfilled if you don’t have help. I would have preferred to have twice as many techs for the first six hours and do primary care for the back half of the shift than the standard entire shift coverage.

Equipment matters. Equipment that is outdated or broken makes the work harder. Computers often needed to be restarted or had a mouse that didn’t work. Phones were left without batteries. Scanners that don’t work are an enormous inconvenience. When not functional, they are ignored, and steps are missed.

Secure communication is a must. Texting is how we communicate in 2022, but many systems still don’t have a safe way to text. Even when it is not considered a valid way for nurses to receive physician orders or share protected health information, it happens daily if a secure messaging platform is not provided. It often starts like this: the nurse texts the doctor, “Next time you come around, stop in room 3204 and look at the foot wound.” “Hey – pressures in rm 3501 have been soft. SBP is in the high 80’s. Just letting you know.” “Are you around? 3108 has been tachy all night. He says he feels fine. Temp 100.1” All of these require the doctor to ask clarifying questions, which inevitably lead to an order via text on personal devices.

The Workstation on Wheels is a terrible piece of equipment. At a recent Cerner conference, I saw a vendor selling the “best WOW on the market.” One of his selling points was that his workstation weighed 70 pounds instead of the standard 125-150lb station and had a low center of gravity, making it roll easily. Our workflows require nurses to be attached to 70 – 150lb of equipment, which is an enormous tragedy. Nurses need to be mobile, agile, and hands-free whenever possible. The medical-surgical unit I worked on was in some phased rollout of the workstation on wheels. They had workstations from various vendors and some decades-old equipment. Imagine being dependent on a tool where people’s lives may be impacted and having options of what is equivalent to a 1990s flip phone versus the iPhone 14. Nurses sometimes came in 30-40 minutes early to write their name on a post-it note and claim one of the new workstations. Those who rolled in right at shift change always got what was left. Many workstations would restart automatically multiple times a shift and take 4-7 minutes to log into the EHR fully; they had scanners that didn’t work, most wouldn’t roll, and would require you to drag them. The workstation was an enormous inconvenience since I worked in a unit with semi-private rooms on nights. Opening a door fully, letting in a ton of light, making noise, and rolling this device past the door to get to the bed by the window was a task. I often opted not to do it. Knowing the risk of not scanning meds, especially in a room with two patients, was a risk I chose over fully opening the door and dragging a large piece of equipment into a crowded room, knocking SCDs off beds, dragging the scanner cord over the patient to find a wrist band. It was a conscious choice that other nurses and I made every shift.

Nurses holding out for higher incentive pay – is ok. The transactional approach of nurses to seek higher incentive pay is interesting. I had been on the CNO side of this too many times. At the eleventh hour, usually within 24 hours of the shift, we offer new incentives to get nurses to pick up the shift. This hospital provided various incentives depending on need, which did require leadership approval: (1) a $550 shift bonus, (2) call-back pay, (3) double time. On one shift during the 7 pm report, the charge nurses told the outgoing day shifters that there was a desperate need for nurses the following day shift. If the census remained the same through the night, we would be very short, potentially leaving a 7-8 ratio in patient assignments the next day. The first question from the dayshift nurses was, “what incentives are being offered?” When they were told that a $550 bonus and call-back would be used, there was a unanimous groan as staff made clear that double time was the desired incentive. The charge nurse reported this to the house supervisor, who escalated it to the CNO, who decided there would not be double-timed support. One nurse commented, “It’s 8 pm. I would have to get childcare lined up for the entire day, and without double pay, I lose money on the day.” Another said, “We just bought my daughter her car; I’m taking a break,” while a third RN said, “If they offer double, don’t tell my husband because he’ll want me to pick up, and I can’t do five in a row.” These were all legitimate responses as they weighed life’s problems. Nobody was angry or bitter or out to stick it to management. The trade-off of committing to a 12-hour shift instead of having a Sunday off wasn’t good enough. This was a pivotal moment, having lived on the other side for many years.

Recognition matters. This travel assignment was always temporary, and I could walk away anytime. The lack of recognition from leadership struck me. I never heard public praise for nurses. New policies or initiatives were frequently rolled out because a provider was upset. Most communication was about individuals not being compliant with I/Os or CHG baths, etc. The communication felt critical. This created a negative culture. At the end of this assignment, I had (1) patients requesting to have me back, (2) leadership asking if I would take externs, (3) nurses asking to work the hallway with me, and (4) the manager asking me to extend my contract. I joined the unit’s fantasy football league, group texts, etc. When I left, they threw me a pizza party, and I received a Starbucks gift card from a charge nurse. Both made me feel wanted and appreciated. I realized that every nurse is a flight risk. If you offer a sign-on bonus, the employee knows the exact date and how many days remain until they hit that commitment date. Nurses have no intention of staying; the temptations are just too strong.

Administering Medication is harder than it should be. Medications scheduled at 2000, 2100, and 2200 are a logistical nightmare when dealing with a heavy patient load and usually minimal help. My workflow response was to give them all together with my initial assessment. This meant the first patient I saw (highest acuity) was always getting some meds >1hr early, and my last patient (healthiest) was getting their 2000 meds >1hr late. It was the only way I could make it work.

There are self-inflicted wounds. Health systems have choices with documentation policies. This facility had a charting philosophy of using within-defined limits for areas within that definition and then using a focused assessment on the impacted key systems. No one followed this, not even me. The healthy 40-year-old with a kidney stone who we are diuresing and straining urine had a neuro, cardiac, and respiratory system within defined limits, but we all still charted full assessments – AAOx4, follows commands, lungs clear x five lobes, on room air, heart regular, s1s2 heard, etc. This was highly time-consuming and likely for no reason. There’s a feeling among nurses to CYA in documenting this, but all the clicks and drop downs required were very time-consuming.

The end-of-shift report takes too long. There’s a push to identify models that allow nurses to take higher patient loads safely. Report on 5+ patients to multiple nurses puts everyone into incremental overtime. Rarely can you get out by the standard “shift end time,” especially when you’re expected to do a bedside shift report and do four-eye skin checks. Every nurse will get out a minimum of 30 minutes later than expected. This increases incremental OT hours twice daily because nurses are following policies. The patient report needs to be completely revolutionized.