How Can We Help?
System strengthening
Beds.
Clinicians often regard bed shortages as due to a discrepancy between bed numbers and population, whereas administrators recognise a further factor – average length of stay. Reducing length of stay is commonly seen as a solution with doctors being exhorted to discharge earlier. In fact this is often a counter-productive strategy as it leads to re-admission and the creation of a larger pool of patients who might be sorted out quickly and efficiently in hospital, but who are being managed as outpatients, often to the frustration of both patient and doctor. Having too many patients in this situation also leads to bigger outpatient clinics, with less time being given to individuals, and consequently even slower resolution of problems. On each patient in the ward, each time you see him or her, consider the following:
*Unless a test is batched (e.g. TSH) most laboratories process specimens the day they are received.
** For instance, for a patient occupying a bed while sputum is collected, plan to be looking at 3 sputum results at most 3 days after admission.
***Some patients for whom discharge comes as a surprise will develop new complaints on the day of discharge.
Broken resources – rural hospital equipment.
Doctors in smaller hospitals are often expected to get involved in equipment ordering and repair. Malfunction of basic equipment such as blood pressure machines, ECGs, ophthalmoscopes and defibrillators is a perennial problem, and often generates attitudes among staff of ‘I couldn’t do it because the machine was broken’.
Prevention is better than cure – dropped ophthalmoscopes don’t bounce. The same applies to sphygmomanometers.
If possible change the working environment – a sphygmomanometer perched on the edge of a desk in outpatients is bound to fall – acquire a wall-mounted one. In the ward, consider mounting diagnostic sets onto trolleys – most hospital workshops love the challenge – and get sphygmomanometers on wheels rather than ones that nurses have to balance on overloaded patient lockers.
Budget for breaks when ordering equipment. Instead of buying one state of the art ECG machine, buy two smaller ones with fewer features that can go wrong.
Order standardised equipment in use in other hospitals in your area. Repairs, spares and ‘software’ (e.g. ECG paper) are more likely to be available.
Burn out (Yes, you are a scarce resource!)
Occupational stress is common in hospital staff[1] and its early recognition and management may prevent premature departure of extremely useful colleagues.
Recognition
Context – under-staffed, over-worked.
As seen by yourself, e.g.:
- Difficulty making decisions and then ‘moving on’.
- Excessive feelings of guilt about mistakes.
- Feelings of ‘not coping’.
- Mood changes (irritability and depression).
- Inability to ‘switch off’ when away from work.
As seen by others, e.g.:
- Punctuality issues.
- Unwillingness to take on extra work.
- Increasing complaints about how unsatisfactory the work situation is.
- Withdrawal from interaction with colleagues.
Management
This is easier said than done. In these situations most of the group are under strain, so lightening the burden of one person is difficult.
Think about dropping sections of the workload that aren’t really core functions.
Get away from the hospital environment completely at regular intervals.
Pace yourself better – you can’t sprint a marathon.
Think about doing things differently in your environment – medical school role models teach ways of doing things that work for themselves – emulating this isn’t always appropriate.
Discussion groups may help but sometimes the stress imposed by the extra time needed may not seem justified. An occasional debriefing session is a compromise.
Look for ‘little rewards’ – setting up a nurse-run chronic care clinic can lead to potentially lasting improvements in health care in the area.
Delegate – it doesn’t all have to be done your way, by you.
In most areas of hospital medicine workloads are high. At least in the resource constrained environments, you know that most of what you do is very relevant.
Don’t sweat the small stuff!
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Thomas LS, Valli A. Levels of occupational stress in doctors working in a South African public-sector hospital. South Afr Med J. 2006;96:1162-8. ↑