Print this article

E-Mail this article

 

About the only thing that hasn't changed much in the last 10 years of medical/surgical nursing is the walking.

Danette Kodet, RN, can vouch for that. During a recent shift on the medical unit at University of California, San Francisco Medical Center, Kodet spent much of her time scampering between patients' beds, the nursing station and the medication center, as she cared for five patients.

In a mint-green sweater and thick-soled orthopedic shoes, she moved through the halls like a racewalker.

She administered painkillers and antibiotics through IV lines, documenting every drop. She tracked down an aide to get valuables from security for a patient who was leaving the hospital. She stopped an intern in the hall to tell him that a patient suspected of sabotaging her medication was meddling with the IV controls again.

She went over transfer documentation that had not been completed on a patient being moved to another hospital, as the intercom paged her again and again, announcing the arrival of a new admission.

The new patient was an elderly Chinese woman who spoke almost no English and had a mass behind her aorta. As an aide taped the new patient's IV bag to the wall, Kodet ran from room to room looking for a spare IV pole.

Tremendous changes in hospital health care have transformed the med/surg unit so much that, except for the walking, nurses from 15 years ago probably wouldn't recognize it. Nurses such as Kodet now care for patients who-five or 10 years ago-would have stayed in intensive care.

These nurses routinely use technology and techniques once reserved for the sickest patients in the hospital and administer complex medications that were unheard of a few years ago. They see an increasingly older patient population for shorter lengths of time-sometimes a few days, sometimes a few hours-and send them home stable but not fully recovered.

Today's med/surg nurses must be care coordinators, medicine and disease experts, team managers, forensic experts and educators, as well as bedside caregivers. They supervise unlicensed assistants.

They juggle orders from numerous physicians. They work with pharmacists, technicians, social workers, case managers, home health agencies and therapists. Many work on specialty units, such as orthopedics, oncology or neurosurgery, which require specialized training and knowledge, as well as on general med/surg units.

The sheer physical intensity of med/surg nursing, coupled with a higher patient load and a perception that med/surg is a bottom rung on the acute care ladder, make it difficult for hospitals around the country to find med/surg nurses.

Many students prefer to bypass med/surg for more glamorous jobs in specialty nursing. But nurses such as Kodet, who can't imagine themselves anywhere else, and med/surg supervisors and educators say med/surg nursing has become its own specialty, with its own requirements and rewards.

"If you can do med/surg, you can do anything," said Marlene Roman, MSN, RN, a med/surg clinical nurse specialist at North Broward Medical Center in Pompano Beach, Fla., and Coral Springs (Fla.) Medical Center, and president of the Academy of Medical-Surgical Nurses.

In what some consider the good old days of med/surg nursing-say, 1980-patients came to the hospital a day or two before surgery and often stayed at least six days after the procedure. Nurses had time to do leisurely workups. They talked to patients about what to expect, answered questions and soothed fears.

If they were caring for six or eight patients, two might be fairly stable and independent and waiting for surgery, two might have just come from surgery and the others would be in various stages of recovery. The med/surg nurses might deal with basic IV drips, catheters or suction machines, but never the tubes, central IV lines and monitors that they do now. Those were reserved for ICU along with epidural drips and IV-push pain medications, said Kathy Reno, RN, executive vice president and chief operating officer of clinical services at Northwest Community Hospital in Arlington Heights, Ill.

As patients recovered, nurses explained how they could care for themselves and educated them about their general health. "You had time to build a relationship with your patients," Reno said. "You got to know their families, hear their life stories."

On the other hand, many of the patients who nurses now care for would not have survived in 1980, Reno said. Many of those they cared for in 1985 would never see the inside of a med/surg unit today. They would be treated as outpatients or with medications.

So patients who used to be in the ICU now are in med/surg units, while patients who were often hospitalized in a med/surg unit now are treated as outpatients, Reno said. Even within med/surg units, most hospitals have tried to break down their patient populations into smaller groups, such as orthopedics or end-of-life care, to improve nurses' expertise and knowledge.

Many of today's hospital patients are older, with a variety of chronic conditions. By 2010, about 40 million people-more than 13 percent of the population-are expected to be 65 or older.

Most older people live at home, with only 1.3 percent of those aged 65 to 74 and 6 percent of those aged 75 to 84 living in long-term care facilities, according to a report on changes in med/surg nursing by Marilyn Fetter, Ph.D., RN, and Cecelia Grindel, Ph.D., RN, published in Current Issues in Nursing.

"In the last two years, I have seen so many more 90-year-olds coming from home and being discharged to their homes," said Candace Upham, clinical director of med/surg services at Northridge (Calif.) Hospital Medical Center. "I'm seeing competent, fit, capable people in their 80s coming in even for knee surgeries."

But often, med/surg patients have competing, complex conditions such as heart disease, diabetes and hypertension. They are not necessarily sicker with a particular illness than they were 10 years ago, but they are more likely to have many illnesses, especially as they age, Upham said.

The economics of managed care, new medicines and new technologies such as noninvasive surgery have contributed to increasingly shorter hospital stays. Gallbladder patients used to spend five days in the hospital, said Grindel, an associate professor at the Georgia State University School of Nursing.

"Now they don't stay overnight," she pointed out. Open-heart surgery used to mean a seven- to 10-day stay, she said. Now, it's down to four.

Most nurses agree that the shortened stays usually are better for the patient. No one wants to spend time in a hospital. But short stays, coupled with increasing responsibilities, have all but cut out time for teaching and talking to patients and their families.

This means nurses must spend more time on discharge planning-making sure the patient has proper information, arranging for home care, working with case managers and obtaining discharge orders from each physician who treated the patient. In some hospitals, it's not uncommon for at least one-third of med/surg patients to turn over in 24 hours, making discharge a big consumer of a nurse's time.

"We used to not even count a discharge as an assignment," said Lynn Dow, MSN, RN, nurse educator for the med/surg division of nursing at UCSF Medical Center. "Now, it's become one of our busiest times. If people go home on a weekend, it's a nightmare."

Sheila McCarthy, RN, a med/surg nurse for 11 years at Massachusetts General Hospital in Boston, said she's kept in touch with some of her patients for years, exchanging letters and receiving invitations to visit them. But lately, she's had to skip lunch to make time for tasks such as answering a family's questions or having a bedside conversation.

"Sometimes, I feel like I'm not doing for the patient like I should do," she said.

Not only are med/surg patients more complex, so is the technology used to treat them. Most med/surg units have centralized IV pumps that deliver a variety of medications, from antibiotics to blood thinners to painkillers.

Many have computerized admitting processes and procedure manuals. Some are going completely paperless, with all orders entered on computers and scanners that tell nurses what medications a patient needs. A few have ventilators and telemetry monitors on their med/surg units.

The improved technology is great for patients and in many ways makes their jobs easier, nurses say, but it's one more thing they have to keep up with. Unlike an ICU nurse, who has time to watch monitors while caring for one patient, a med/surg nurse cannot spend more than a few minutes looking at a machine, Kodet said.

Most hospitals, some of which had all-RN staffs on their med/surg floors, now use a combination of RNs, LVNs and aides, with the RN in charge, on their med/surg floors. This was common practice in the med/surg units of the '60s and '70s. These assistants still are a godsend when they are well-trained and know how to work as part of a team, med/surg nurses and supervisors say.

But they need to be coordinated and managed, said Frankie Phillips, MS, RN, president of the Dallas chapter of the Academy of Medical-Surgical Nurses, who works at the Dallas VA Medical Center. They can't assess symptoms or respond to possible problems the way RNs can.

"They can draw blood," she said, "but it takes a nurse to put it all together."

Besides delegating responsibilities to assistants-something many nurses still have trouble doing, Roman said-med/surg nurses often become designated care-team leaders, regardless of whether they want to be.

Today's typical patient might be an 85-year-old with a hearing impairment, living alone, who fell, hit her head and is experiencing dementia, said Fetter, assistant professor at the Villanova (Pa.) University College of Nursing.

The nurse must deal with an internist, a neurologist, a gerontologist, a social worker, a therapist, technicians taking her to rehab and family members from across the United States who just found out their mother wasn't sure what day it was.

"The nurse really becomes the management center for the patient because somebody's got to keep track of who's doing what," Fetter said.

Med/surg nurses are the backbone of any hospital, administrators and nurse educators agree. But that backbone is getting older, wearier and straining under the weight of increased responsibilities. Med/surg nurses can be responsible for anywhere from five to 12 patients, depending on the hospital, the shift (night shift ratios usually are higher) the number of unlicensed assistants available and the number of unfilled RN positions.

Med/surg nurses have long considered themselves the workhorses of acute care. They are the ones most likely to refer to themselves as "just a nurse," Grindel said, more so than nurses in critical care or emergency departments.

In the past, new graduates looked at med/surg as a place to spend a couple of years learning basic skills before going on to something more exciting-usually critical care, emergency care or pediatrics. Some discovered they preferred the variety and patient contact that med/surg offered, and decided to stay.

Now, nursing administrators and recruiters say, the nursing shortage has forced hospitals to recruit new graduates straight into the specialties. "It's harder to get young nurses interested in med/surg," said Karen DeLevan, senior recruiting consultant for Texas Health Resources and president of the Texas Association of Healthcare Recruiters.

Many hospitals say they are having difficulty hiring med/surg nurses, filling in with travel nurses and registry nurses as best they can. Some facilities have had to increase RN patient loads or even close beds.

To attract new nurses to med/surg units, hospitals, nurse educators and nurses themselves need to look at the profession in a new light, said Fetter, editor of MEDSURG Nursing.

"There's enormous responsibility in this role," she said. "We need to make the work more attractive and more desirable. We need to reinforce that it's a specialty, to strengthen its status."

Upham said she recently hired seven new graduates by pitching her med/surg unit as a place to get a solid foundation for the rest of their careers. UCSF Medical Center offers a summer internship program where nursing students work as aides, then return as graduates to a place where they feel comfortable and welcome.

Many hospitals are implementing mentoring programs and hiring clinical nurse educators to make new graduates want to stay.

Med/surg still is the place where hospital nurses are most likely to spend time with patients and to see them get better, Roman said. "I think it really makes nurses feel good when they can see patients being discharged after seeing how sick they were."

Med/surg nurses also are playing an increasingly respected role in start-to-finish patient care, said Annette Levitt, MS, RN, nurse manager on two general med/surg units at Massachusetts General.

For example, she said, physicians at her hospital recently readmitted a patient with a variety of problems. The man had spent six months on a different med/surg unit in the same hospital, where the nurses got to know him and his family well.

After the patient was readmitted, nurses on both med/surg floors talked to physicians about transferring the man back to the floor where he was known, even though it might inconvenience the physicians. The physicians agreed. The patient was transferred.

"The staff nurses felt empowered," Levitt said. "They are the ones who made the difference. These were med/surg nurses who took it upon themselves to put the patient where he belonged. That's the kind of thing that a med/surg nurse can do on a general unit."

For Kodet, the greatest reward of med/surg nursing always will be the patients:

The man who amused himself by shooting sputum through a tracheal tube.

The cystic fibrosis patient who nicknamed her "Danutty" and for whom she cared until he died.

The homeless man with beautiful blue eyes, whom she insisted take advantage of all the hospital comforts he could before returning to the street.

"That's what makes med/surg interesting. You can really see the effect that you have on them," Kodet said.

She laughed and threw up her hands. "At least we make them feel better."