March 8, 2017

The Customer Service of Nursing

So you've been waiting forever and a day and you feel like your nurse isn't doing what you need or isn't doing what is in your best interest? I understand, I've been there. My family has been there too, and I'm going to tell you what I've told my loved ones. If you want or need assistance, you have to speak up (figuratively, not in volume - no screaming or yelling please) and speak to the appropriate parties. Your suggestions and complaints must be heard by the right people. The hospital setting is massive, with intertwining departments, and varying levels and administrators. I won't lie, like all professions, there are some good individuals, and sadly, there are some people who shouldn't be in health care. Meaning, you might get a caregiver that truly isn't concerned with your wellbeing. And if you do, you need to get your complaints or suggestions elevated to someone who does. For example, I could be upset with my state senator about a particular state policy, but if they had no control over said political process or its execution, my anger is in vain. If you want prompt, swift change, you need to present your concerns to the movers and the shakers. Here is my advice on how to get that done in the fastest and calmest way possible.

Nursing Aides
Okay, let us begin with the nursing assistants (NAs), certified nurse assistants (CNAs), and nursing technicians (NTs). These people are the workhorses of the floor. You have probably seen them running around making sure everyone is out of bed, clean, and moving around. These individuals will help you with your activities of daily living (ADLs), such as eating, bathing, dressing, toileting, and ambulating. Think of these people as your "person." They are there to help you with minor things (non-drug, non-medical judgment related). Please understand, they often have high patient ratios, for example, 10 to 30 patients per individual. They will help you, but understand there could be a lengthy wait. This is due to inappropriate patient ratios, which is a national concern. Please understand this doesn't occur at every institution. Each institution has different ratios and staff, depending on the acuity of care. Currently, where I work, we have no aides. So I, the nurse, have to absorb this role, in addition to my other responsibilities. If you have a medication issue, a time-sensitive matter, or would like to relay a message to your provider, you should escalate your concern to your nursing caregiver (mentioned next). The individuals mentioned above will not be able to help you in that regard. The nursing aides will be able to relay your request, but the execution of these advanced orders will be done by your nursing caregiver.

Nursing Caregivers 
Your nurse is the individual with one of the following titles: Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN), or Registered Nurse (RN). This type of caregiver can administer medications, contact your health care providers with any changes in your condition, monitor your health, and keep you safe (physically, pharmacologically, and emotionally). Nursing is a state regulated profession and nurses have a scope of practice that they operate within. Within the state’s scope of practice sits institutional and unit-based scopes of practices. A scope of practice is a set of rules regarding what the nurse can and can't do. One major principle is collaboration. A nurse cannot make an independent, unilateral decision and then, execute said decision without a provider. Every action or inaction performed by a nurse is an order approved by an advanced practice provider: Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Physician Assistant (PA), or Nurse Practitioner (NP).

For example, let's say you would like ten milligrams of morphine instead of the five milligrams of morphine you have been receiving during your admission. The nurse can relay your request to a provider, but morphine is a medication and nurses don't have state authority to alter medication orders. Nurses are only authorized by the state to dispense the orders given by your provider. The nurse's entire program is dependent upon the parameters of care, medical plan, and provider's directions. All of these three elements are created and altered by your health care provider. Nurses and providers (MD, DO, PA, NP) are tightly knit groups of people working in your best interest. We communicate often and want what is best for you, but each of us have a role and we operate within that role - we have to legally. Just because you only see the nurse does not mean the nurse is making all of the decisions.

If your request is for medications (e.g., you want more pain medications), the nurse will call the provider for you and forward your request. The approval or denial process is an independent factor from the nurse's role. They will provide you with the final decision (once the provider informs the nurse of the answer), but the nurse isn't the decision-maker in this example. If you would like your room changed or a diagnostic tested completed, the process is the same. The nurse will convey your message to the appropriate provider and remind the provider continuously (escalating your issue when necessary and within the organization chart), but the decision is that of the health care provider. If you aren't satisfied with your nurse's performance or the decisions being made about your care, you then can escalate your concern to the charge nurse.

Charge Nurses
The charge nurse is an individual who is the manager of the floor. You ever go to a fast food restaurant, get bad service, and ask for the manager? The charge nurse is that "manager" (manager for that shift anyway). The charge nurse, often called "head nurse," supervises the unit, manages bed assignments, and collaborates with nursing management and executives. If you need a different nurse, or if you feel your nurse is neglecting their role, this is the person with whom you need to communicate. A simple, "Can I speak to your charge nurse please?" will do. No need to yell or scream. The charge nurse will come in, and this person has the proper leadership skills to get what you need done. If the charge nurse isn't assisting you in a manner you deem appropriate, you can escalate your concern to the Nursing House Supervisor (NHS) or Nurse of Duty (NOD).

Supervising Nurses
The Nursing House Supervisor (NHS) or Nurse on Duty (NOD) are individuals who work throughout the entire hospital. They are not regulated to a certain unit or floor. They are the worker bees of the hospital, making sure things are running appropriately. These nurses usually have extensive bedside nursing experience with an executive background and education. These nurses are the official problem solvers, and the buck stops there (usually). They are often called to confirm that proper sequences are taking place and that resources are functioning accurately. These individuals manage all things nursing and have the knowledge base to present new approaches to problems. Use these individuals to assist you and your family members in finding an appropriate solution.

And that's it, we are done. You have just been given four tiers to nursing escalation.

Nursing Aides ---- Nursing Caregivers ---- Charge Nurses ---- Supervising Nurses

You don't have to yell to be heard or for action to take place, you just need to know the "who." Knowledge is power, and now you can take this power and make sure your concerns are heard by the right people. I know health care can be arduous and annoying. But please understand, we (caregivers) want to help but we are limited by institutional protocols, health guidelines, and state laws. We are also limited by provider orders and medical plans. Health care is a structured system with various faults and gaps. Always advocate and always communicate your needs and concerns. If we don't know, we can't fix the problem.

Please Note: This is for inpatient (hospital) setting escalation. Some institutional titles may vary.