December 20, 2006, 7:39 pm

When Men On the Chessboard Get Up And Tell You Where To Go


Okay, let’s all have our hot cups of tea around the newborns!

Hmmm….look at the ages of the nurses. I’m not sure how old this ad is, but there are two things that catch my eye.

One, there isn’t a single nurse in this photo who looks under the age of thirty.

I guess we’ve been an aging workforce for awhile now.

And, out of seven nurses, there isn’t a single guy.

Unless the baby is a boy…..


Once upon a time there was a nurse. An emergency room nurse.

Let’s say they are a “friend” of mine.

They pride themselves on their nursing care and their ability to document that care.

A few years ago, this nurse found xanadu in the form of a particular emergency department.

And it was good.


The waiting times were short.

Their nursing colleagues were experienced.

The doctors were top-notch.

This nurse was able to give excellent care to their patients.

And it was really good.


One day the hospital administration decided to have their nursing professionals punch a time clock.

Such a sight to see a bunch of professionals crowded around a digital read-out waiting for the precise moment to swipe their badge.

You see, if they punch out one minute too soon, they will lose 15 minutes of pay.

It would be funny if it weren’t so insulting.

The nurses protested having to punch a timeclock.

Were they not professionals?

Nobody cared.


One day hospital administration decided that a written report would be faxed to the receiving unit on all admissions.

My “friend” thought this was a great idea! They loved to chart, you see. They were wierd that way.

Besides, the report was not part of the record but it gave plenty of room to give a narrative of the patients ER stay. Yes, it was a bit of additional work but the reports were thorough and my “friend” could clearly see the benefit.

But then the hospital administration decided that the same report had to be used for all admissions and transfers in house. A committee was formed. Much feedback was given and the emergency department representatives did their best.

The resulting form had virtually nothing to do with the emergency nursing. It did not fit the needs of my “friend” and their colleagues.

Now it was hard to give a thorough written report. This truncated, sketchy report form became part of the permanent record.

There was much protesting by the nurses.

No one cared.


JCAHO recommended that hospitals implement a medication reconcilliation form.

Hospital Xanadu was one of the first to try it.

They made their emergency department nurses responsible for starting it.

First it was just a list.

Then my “friend” had to add dosages.

Then they wanted the dosage regimen.

Finally they wanted the date and time of the last dose.

It put a severe strain on Hospital Xanadu’s emergency department.

My “friend” once had to do three pages. Twenty five minutes of just writing down medications and dosages and times and dates on a patient who had twisted their knee.

The nurses verbalized strongly that medication reconcilliation was the responsibility of the admitting physician.

No one cared.


Ah, but wait!

Hospital Xanadu’s emergency physicians were told they would have to reconcile every single medication on every single patient before they left the emergency department.

They did not protest, for they had the power to just say:


And that was that.


My “friend” no longer feels they can give the nursing care and document that care to the standards now set for the emergency department. The one that once felt like Xanadu. The one that now makes nurses feel they are operating in a vacuum.

My friend feels, even at their best, they are operating at 75% efficiency, maximum.

Their morale is quickly depleting, even as they take their own advice to minimize burn out.

A group of nurses can protest loudly. A group of doctors can just say “no”.

Who has the power here?

It sure as hell isn’t my “friend” or any of their nursing colleagues.


I’m afraid my “friend” is becoming militant and is of the age where they are not shy about letting the world know it.

Of course, my “friend” could find another job, one with computerized charting or one that lays the medication reconciliation at the feet of the primary/admitting physician, where it belongs.

Meaning my “friend” could leave Hospital Xanadu.

They could even tell the hospital administration why they were leaving.

And no one would care.


  • jen

    December 20, 2006 at 9:36 pm

    and no one would care………..seriously, longevity is not rewarded and administration does not care. we do med reconciliation at triage and it takes a LONG time. We must have triage completed in 5 minutes and we are audited on it. It’s all on computer, and we love it, but still EVERY SINGLE DAY things are added that take nurses AWAY from the bedside. This isn’t what I was taught in school……..reality has totally set in after a few years and it’s not very pretty. I LOVE my hospital, in fact people come from all over the USA to get care there. My co-workers totally rock and are soooooooo smart, but administration makes it hard. I want laura gasparis to be my best friend, seriously i want to grab a margarita or two with her. My hospital also has the timeclock rule, you should see everyone line up…….it’s insanity…………whatever…….i clock in when i walk in and nobody has ever said a thing to me.
    can we please make it so that i can be at bedside a little more than the computer? um, i would really like to treat the WHOLE person, since that is WHY I went to school.
    sorry this is so long. excellent post girl!

  • Airway Control

    December 20, 2006 at 9:43 pm

    In a newbie, inexperienced sort of way, I feel your pain. As a nurse with only 15 months experience, these hoops are the only ones I’ve ever jumped through, and sisnce the beginning, I’ve often wondered why I must jump through these hoops and not go around them.

    Though I am against them in general, especially for white-collar jobs, Unions are perhaps the best answer for these types of problems. Doctors can say no because because they essentially act as a union; nurses just bitch and moan (me included) because that’s all we can do, because our managers (nurses with one foot and their whole brain in administration) simply nod their heads and agree to whatever administrators suggest we do. Without unanimous support, or at least a unanimous front, Nursing will continue to bow at the alter of hospital administration.

  • Jon

    December 20, 2006 at 9:57 pm

    I think your “friend” must work where I do or somewhere just like it, cause I’m going through the same things.

  • #1 Dinosaur

    December 21, 2006 at 3:53 am

    Are you sure those doctors could “just say no”? ER staffs have been fired/outsourced before, and will again. Sounds like the administration should be nominated for the glass belly button award. (Having one’s head so far up one’s ass, one needs a glass belly button to see out.)

  • Annemiek

    December 21, 2006 at 5:22 am

    That med reconciliation is the biggest waste of time. On admitted patients it is now the floor nurse that has to do it, but that is usually when the family has left, and it is nearly impossible to do. Or patients come with their 2 page typed list of meds, but we can’t write see attached list: we have to write it all out on the form. With all the change of missing something or writing it wrong.

  • George

    December 21, 2006 at 5:29 am

    Very real article. I suppose it is happening everywhere when money and not patient become important and the administrators have no idea what medicine and health care(not in the financial aspect) is all about.

  • Peggikaye

    December 21, 2006 at 6:27 am

    My gut twisted as I read that article. One of my best friends, and blogging buddies … a nurse for 30 years …for one hospital group …in one office for 18 years … health problems came up …and bye bye …without them even blinking an eye.

  • Candy

    December 21, 2006 at 7:02 am

    Maybe it’s time the patients started to bitch about this — all of the extra measures in hospial Xanadu and others are increasing wait time geometrically. The bottom line is payment (we all know reimbursements drive healthcare); patients need to stand up and say “We’re mad as hell and we aren’t going to take this anymore!”

    Just like all the labor saving devices were supposed to help office workers save time and become more efficient (uh, huh), all these little things that get in the way of patient care have sucked the life out of healthcare delivery instead. I don’t think a union of any kind has enough juice to tackle this. We all have to look at the beast in the eye and say “Are you freakin nuts?” and drag nursing care (and healthcare) back to where it’s supposed to be: at the bedside.

  • dribear

    December 21, 2006 at 7:41 am

    I certainly do not envy nurses, but always appreciate the extra work that they have to do. Mostly on the doctors behalf.

  • Chele

    December 21, 2006 at 7:50 am

    On one hand it is nice to know that we do not suffer alone…but on the other hand, its a shame what nursing has come to. I love my job in the ER (even tho it is the lowest paying hosp in the area), I love my collegues (even tho they are all leaving because they are fed up), and I love my docs…well not anymore because all the good ones have left. Add that to a dirty, no supply having, long wait ER with angry, frustrated and sometimes just downright mean patients, docs ordering every test under the sun just because they can…i don’t know why I stay. Somebody smack me!

  • susan

    December 21, 2006 at 9:12 am

    again, i say blessings on you, kim and all you who comment here. i could go on about the er where i worked but it’s all been said in your blog and these comments. may you all have a wonderful year in which the shithead administrators get their heads out of their arses and see the light. oh, yeah, and pigs will fly.

  • Janet

    December 21, 2006 at 10:22 am

    Kim, you should be active in the union. It’s the only way nurses are going to be able to change things. A well-placed strike or two will get their attention.

  • Susan

    December 21, 2006 at 11:34 am

    We go through the same crap at our ED. All the doctors have to do is sign the darn med reconciliation form, and we have to chase them down to do that! And if the form is filled out, except for the MD signature, we get crap from the floor. Now we just write up the med list with no dosages unless we know we’ll be admitting the patient.

    And since we’re starting computer charting, we now have to do this all twice – once on paper and once in the machine!

    What a monumental waste of time!

    Whew – now I feel better. Thanks.

  • geena

    December 21, 2006 at 12:34 pm

    It’s the same way in most places. We have computerized charting, but it’s certainly no panacea. ER RN’s do med reconciliation at our hospital… but when they find out that the patient will be admitted, they just save it for us to do when we admit in CCU (or the floors, etc.)

    I know they’re busy, but so are we! Regardless, it certainly isn’t the physician putting it all in 🙁

    Such a shame for that hospital to lose such an excellent nurse. It’s happened in our unit, though.

    It happens all the time.

  • universalhealth

    December 21, 2006 at 2:18 pm

    Professional practice groups – take back nursing. Self-governance isn’t given to nurses – it comes from nurses. Read my posts about PPG’s on my blog. I know I harp too much, but if you can ignore my bad writing and crabby curmudgeon style, I think you’ll like the PPG concept.

    A single nurse just can’t say no – but an entire organization of nurses can – and can negotiate the practice conditions.

  • Amie

    December 21, 2006 at 5:53 pm

    The doctors do have the power and that is because it comes down to the almighty dollar. They bring it in, so they matter. See what matters here? That is why they don’t mind seeing experienced RN’s go and train new ones. It was said that it is cheaper to train new ones than keep the old

  • Erica

    December 21, 2006 at 11:08 pm

    Kim, I think your ‘friend’s’ Hospital Xanadu’s administrators must be the same set of suits and clicky-heel people that run a certain hospital in the Rockies. My ‘friend’ works there and feels the same ‘how will they shit on us next?’ pain.

  • tbtam

    December 22, 2006 at 2:26 pm

    I can’t believe they make the ED do the med reconciliation! I can understand when a patient has been admitted for days why it is necessary, but for an ED visit?

  • Shodan

    December 23, 2006 at 5:10 am

    Forgive me, but as a layman I think there’s a clear need for med reconciliation. I can’t speak to whose responsibility it is, but SOMEONE treating me ought to have some idea what I’m taking. Stuff interacts….

    At my most recent trip to the hospital, for a stroke (I’m typing with one hand)the med reconciliation took about 2 minutes. Why? EMR – system wide throughout KP. The ED nurse sat at the computer in the treatment room and asked, “Are you still taking this? What about this? Anything else?” And she was done. No hassle at all. And unhurried, happy nurses.

    From my side of the bed, EMR is a great part of the solution to a lot of issues I read about in the medblogs.

  • Mama Mia

    December 23, 2006 at 9:15 pm

    I’m sorry…did you say something? It is hard to hear you when your voice is so small!

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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