Wrong! This kind of thinking gets us in trouble! When we don’t recognize how complicated the work is, we can’t (or won’t) provide staff and resources to get it done properly and on time. Repositioning a patient seems like a simple process and when family members or leaders see that it hasn’t been done regularly, or there is a pattern of pressure sores they may think that staff are lazy, stupid, or negligent. Solutions are focused on training in repositioning or a beeper system that reminds nurses to turn patients every two hours. But if lack of knowledge or forgetfulness aren’t the problem these won’t be effective solutions. In fact they perpetuate disconnections between staff and leaders and consumers and healthcare professionals.
A first step towards meaningful solutions lies in understanding the problem. As leaders and consumers understand the complicated work of nurses and nurse assistants they can have collaborative problem-solving conversations that will lead to effective solutions.
So What Makes Repositioning More Complicated?
- Often requires two staff members to boost a patient up in bed and turn him/her.
- The two staff members must be available at the same time in the same place. This may mean waiting for someone to get back from their rest or lunch break or finish what they are doing for another patient. (During an 8 hour shift with two nursing assistants, there will be 1.5 hours of meal and rest breaks where only one assistant is available.)
- If several patients on a unit require repositioning, then two staff have to be available at the same time every 2 hours for each of these patients.
- The bed must be raised to height that prevents back injuries for staff, (and returned to lowest position afterwards to prevent patient injury).
- If the staff start to reposition the patient, but s/he seems to be in pain, a nurse must be notified.
- The nurse can assess the patient and provide PRN pain medication if ordered. (PRN pain medication is often suggested by nurses, families etc and ordered by physicians and nurse practitioners to help minimize pain There are all sorts of different medications and schedules that can be ordered).
- If the nurse finds that the patient is suffering from pain she can go back to the med cart and follow the process for administering medication. She may need to finish what she is doing for another patient, i.e. administering medication, changing a dressing, reviewing a lab result or a multitude of other things.
- If there is no PRN pain medication ordered then the nurse will have to contact the physician. Once the physician orders medication or possibly other testing, the nurse must transcribe the order and actually obtain the medication. This may be as simple as using a stock medication such as tylenol that is readily available or as complicated as getting a prescription for a controlled substance such as Morphine. This can involve multiple phone calls to physician & pharmacy, faxes, documentation and reviewing the patient’s chart. We may have to wait for call backs or be put on hold.
- If the patient has been incontinent of feces or urine, then they must be cleaned first. This will require getting towels, linen and bathing supplies.
- If the supplies are available they may be obtained fairly quickly, but if not a phone call to laundry or trek to supply closet may be necessary.
- Any of these steps may be interrupted by an alarm warning that an unsteady patient is getting out of bed, or an IV pump isn’t working, or a resident with dementia is trying to leave a locked ward.
- Is there a respectful culture where staff are working well as a team?
- Do staff have delegation skills necessary to ask for help and do they trust help is available?
What else might be going on that complicates this picture? Having enough skilled nurse or nurse assistant’ hands available to facilitate repositioning will decrease waiting, help ensure supplies are available, minimize interruptions, and decrease a sense of “rushing” with all care. This should decrease falls, decubitus ulcers, and using medication to control behaviors such as restlessness or combativeness that are associated with being ignored or treated as an object on an assembly line. Outcomes will be better for patients and staff!
As leaders, consumers, and direct care staff engage in authentic dialogues, we’ll gain mutual understanding and become aligned in improving healthcare. Until then, ineffective solutions will keep up the appearance of problem-solving and frustrate or cause harm to patients and providers! Here are a few related blogposts: