Warehousing the Undesirables

When I became a nurse--back in the Peloponnesian War--we were told that there WAS no nursing shortage.  Hospitals were cutting nursing positions; the market was flooded with experienced nurses who had been let go.  Jobs were hard to find.

I was single with two small daughters.   I applied at every hospital that had its lights on.  After sitting next to a silent phone for a few days, I decided that I really do like to eat on a regular basis.  So, I filled out an application at a nearby nursing home.

The manager fanned her magenta cheeks with my application, pulled open her file drawer with her foot and dropped the paper in. "You get three days of orientation," she said.  "Start tomorrow."

On my first shift I oriented beside an LPN for eight hours.  The second day I was supposed to be with an RN, but after four hours she had to leave to deal with a family crisis, leaving me to blunder about on my own for four hours.   On the third day of my orientation, my assigned preceptor did not show up at all.

And that was it.  On my fourth day--my fourth shift as a new nurse--I was told that I was going to be the "charge nurse" since I was the only RN in the building.  A nursing home has to have at least one RN.  I was in charge over the LPN's and the nurse's aides.

Those that had shown up for work.

I learned a lot in that nursing home.  It has impacted my nursing practice and my outlook on life.  I worked there for three weeks and five days.  Then, my phone rang.  A hospital nearly an hour away had an opening on their oncology floor.

Like Bugs Bunny in a cartoon, I ran straight through the wall on my way out, leaving a punched-through outline of myself behind.

The people in a nursing home are not called, "patients", because they are not sick in a hospital.  They are called, "residents" because this is their home where they reside. 

The nursing staff turns over constantly.  In the three weeks I was there I saw four aides and one nurse come and go.

Every morning I trundled a medication cart wildly through the halls, madly throwing drugs around like a crack dealer with ADHD.  In nursing school we were taught that medications could be given in a thirty-minute window either side of the hour they were due but NO MORE AND NO LESS.   But nursing home residents are all on about 152 different drugs, so it takes a long time to prepare and administer them all.   If I started shoving medications at residents the very second I stepped across the threshold at 06:58, I was lucky to be finished by 11:00.  When I needed to start the midday med pass. 

It was also drilled into us in nursing school that medications are to be given one at a time.  The nurse is to discuss each pill--what it is and why it is being prescribed.  I tried that.  I explained selective serotonin reuptake inhibitors and betablockers and clotting cascades and angiotensin converting enzymes to a resident who listened in a friendly, interested manner, then offered me a handful of stool from his brief.

It was 08:49 and I still had 37 patients to pass pills on.  I altered my methodology then, and started doing what the LPN's were doing--pawing madly through the MAR, pouring pills into cups, thrusting them at the residents and moving on.

Nursing home residents do not wear wristbands.  It is considered demeaning to put ID on someone in their own home.   This might be good for the residents's self-worth, but it is a a nightmare to the nursing staff trying to confirm who is who.  Lots of the patients are confused or nonverbal.  Often THEY don't know who they are.  Some of them are mobile, wandering up and down the halls and in and out of each other's rooms.

The resident who lived in room 64 was Shirley Buckley.  The second morning that I worked there, I saw that she had 16 different pills due at 09:00.  I put them into a little white paper cup and handed it to the wheelchair-bound woman in room 64.

She took them with a shaking hand, stared at them for a moment, then muttered, "These ain't mine."

I was getting the next patient's medications together.  It was common for one medication cart to run out of potassium and we would steal it from another cart.  I was trying to remember which cart I had stolen the last doses of potassium from.  It's best to rotate.

Distracted, I said, "Yes they are.  Take them."

She shook her head and repeated, "These ain't mine!"

I was opening my mouth to argue when an aide hurried by.  The aide paused long enough to say,  "Now, Melva, you take your medicine!"

My heart skipped twice.  I snatched the cup of pills back.

Nursing homes like to advertise themselves as, "restraint-free".  That sounds nice when you are trying to keep your beds full and avoid a One Flew Over the Cuckoo's Nest- type of image, but a system where staff cannot use actual restraints will result in falls.  Lots of falls. 

Falls are considered very bad in any medical institution.  It is kind of a Catch-22:  the resident cannot live at home safely--very often because they have fallen and been injured--so they are placed in a nursing home.  In the nursing home they cannot be restrained in any way.  Despite the fact that now they are even older and more debilitated, they can't be restrained but they mustn't fall. 

In a very typical human fashion, the staff circumvents this impossible standard by using "restraints" that are not true restraints.  Residents are parked at tables so they can't push themselves up and topple over.  A sheet is tucked around them like a seat belt.  Pillows are wedged beside them snugly to make it difficult for them to stand.

Despite all those efforts, falls are common at nursing homes.  It seemed like not a day went by without someone falling--either out of bed, out of a chair or in the hall.  Unless every resident was kept on a leash by their very own personal staff member, there were going to be falls.

The nursing home had a locked Alzheimer's ward.  Ralph lived there, all six feet four inches of him.  Before he came to the nursing home, Ralph was a soybean farmer.  Now, he was a CIA agent.  He often talked about his years in the CIA as he paced the unit restlessly.

The first day I was assigned to the Alzheimer's ward, I prepared Ralph's medications carefully and presented them to him in a little white paper cup.  Ralph was walking about listlessly. 

"Go away," he told me, waving one hand dejectedly.

In nursing school, we had been heard many lectures about how patients always have the right to refuse medications and how to document the refusal.  I confidently took the rejected cup of medications and disposed of it in the hazardous waste container.  Then, I carefully circled 0800 on the MAR and wrote, "refused" by each entry. 

At 1200, Ralph had several more pills due.  I noticed that he was agitated and pacing wildly now.  He seemed pretty excited.  As I approached with the cup of pills, Ralph threw up his arms and said, "Go away!"

Again, I pitched the drugs and documented, "refused" on the MAR.

By 1600, Ralph was charging around the unit, kicking over chairs and knocking into unsteady old folks.  He saw me approaching him from across the room with another cup of his medications.  He started pawing at the air and yelling, "GO AWAY!!  GO AWAY!!  GO AWAY!!"

Shaking, I walked back to the MAR to start circling.  Liz, one of the LPN's, had heard all the ruckus.  She hurried over and saw my MAR.  She said, "What are you doing?"

I started explaining how Ralph had refused his medications---but she interrupted me.  "You can't do that!  You can't do that here!" 

She took the pills from me, crushed them expertly and mixed them with some vanilla pudding.  In nursing school we were taught that you NEVER hide medications in food or drink.  I watched, astounded by how swiftly it seemed that everything that I had learned was being cast aside.

Liz walked right up to Ralph and slid her arm confidently around his waist.   Ralph, who had been pacing and waving and yelling at an invisible enemy a moment before, froze as her curves pressed against him.

Nurse's Note: A CIA agent's weakness is always a woman.  Remember James Bond?

Liz said in a low, husky tone, "Hey, Ralph, I just made this.  Would you taste it for me and see how it is?"

Ralph stood there like a stunned sheep and docilely ate every bit of the pudding/pill mixture.  Liz gave him her most beaming smile and said, "Thanks, Ralph!" 

He smiled vaguely.  Some pudding was smeared down his chin.

Liz walked away and I trotted after her, chastened.  When she paused by the med room, I said, "Thank y--" but she cut me off.

"Look, I don't know where you went to school or what--" she glared at me like I had just raped her dachshund. 

"Don't do that again," she said.