dear nursing students

what you should know before your heart is on the line

Healthcare is a business. 

It’s best you understood this unfortunate truth now. I didn’t. I was idealistic, hopeful, and optimistic. I went to nursing school believing I was called to be the hands and feet of altruism; subsequently, I sacrificed health, money, time and sleep in its pursuit. 

I am now struggling with the existential friction that comes from following that call directly into the mouth of a business structured not around purpose, but profit. Soon you will struggle too.

When you graduate you’ll be pinned. You’ll get your hands blessed and your boards passed and you will be proud. You will endure a grueling, stressful first year of work and feel like you’re lost in a fog. Eventually your eyes will adjust, you can see through the clouds, and somehow you will no longer be drowning. You will be swimming. It is then you will see what you were blind to before: healthcare is a business. 

You will start to feel it. 

Healthcare is a business, so you will often be short staffed. You will not be paid what you feel is reasonable. You will not have the support or supplies you feel are appropriate. You will also not be able to change it, as businesses aren’t run according to what you feel. You will begin to feel powerless. 

You will be taken advantage of. You are kind, hard working, and compassionate. Your work ethic does not allow you to stop doing your job; your workplace is aware of that. This is why you will continue to work short, get paid less than you deserve, and feel entirely, utterly replaceable. Because, to a business, you are. Nurses come dime a dozen and someone will fill your position as soon as you get frustrated enough to quit. Or you’ll go back to school, where you’ll feel like you have the control- the chance to provide the care you planned on. 

You’ll feel like the business cares more about customer service than anything else; this will start to sting. 

You’ll find patients who consider you waitstaff, hospital stays akin to hotel stays. This will feel wrong too. 

You’ll hear older nurses say it wasn’t always this way. You’ll see younger nurses lining up to take your place. 

You’ll be asked to do more jobs than your job, and jobs you aren’t prepared for, because that’s the way it’s been done. It was the norm, the standard of what was acceptable, and it shouldn’t have been. You’ll be expected to suck it up and keep working anyway.

You’ll get stressed. You’ll get burned out. You’ll be too tired to fix it. 

Your co-workers will become the reason you show up. They will see you through marriage, divorce, birth, death, and life. They will become your family. You will even find colleagues and doctors and managers who listen to you, try to help you, try to help nursing, and you will be grateful. Eventually, though, they too will come up against the impenetrable wall that is business.

You’ll still get to care for your patients; you’ll cry with them, laugh with them, talk with them, heal them. But there will be a day when your heart will get tired and the rest weighs too heavy. Your optimism will be met with a budget; you will be broken. You will want to leave, but you can’t, there will be no where else to go, because the rest of the system is broken too.

The choice, then, will be yours. You can clock in and out, care for your patients, laugh with your friends, and ignore the rest. You can try to fix what you can, wherever you can. You can reduce your hours, change your career, or move hospitals. Either way, as long as healthcare is a business, nurses will filter through as fast as their profit-producing patients. Eventually the business will wonder about their front-line turnover, but there will be no need for a fix; the ones who spoke up will already be gone. There will be another new nurse, another fresh face, and the cycle will continue.

I wish I knew how to break it.

nurses are going to burn out (or worse)

we are getting tired

The original version of this post was shared in early April, though I was asked to remove it by my workplace as they investigate potential privacy concerns. While it is challenging to thoroughly discuss the nurse’s experience without also discussing his or her patients, I have attempted to modify this piece to satisfy their needs; they advised me that sharing an edited version would be acceptable. I will also mention that, at this stage in my workplace’s management of COVID-19, not all of the following processes are still in place and are no longer of concern. However, I leave the post as intact as possible, as it is my continued belief that nurses should feel free to share of their experiences, past or present. It is my primary hope that in re-sharing this sliver of my experience someone else will feel comfortable enough to share theirs as well. It is only through open communication that nurses will be able to collectively advocate for improved workflow and, ultimately, improved care of their patients.

All too frequently, nurses are torn between customer service and nursing service, that endless rolodex of patient complaints and notes on our failure rolling through the back of our minds. We waste precious moments at the wrong bedside more often than we should, on more days then we should, unable to shake the conflict.

This day is no different. Once again, I find myself torn between a patient wiggling about in her stretcher, clamoring for my attention, and the guttural, maternal sounds that precede birth that echo across the hall.

I’ve been frozen in place two moments too long, the “patient experience” administrator who came around last week clouding my judgment, who wanted to make sure we were specifically asking every patient if they were “comfortable.” The endless supply of warm blankets and ice chips and phone chargers wasn’t enough evidence of our care, nor were our assessment skills, medication administrations, therapeutic conversations, education and advocacy. No matter, we aren’t scoring well enough on patient satisfaction. Using these buzzwords will hopefully remind our discharged patients that we did, in fact, care about them. Today this well-intentioned administrator hovers over my shoulder, whispering she’s uncomfortable in my ear, and I don’t know what to do. 

The spell is broken when a doctor pokes her head through the curtain asking for my help. I snap out of it, frustrated, and march after her. We messily deliver a baby who’s decided to slide into the world on the wrong unit, and what should have been a calm, straightforward birth has become a loud, crowded, hurried mess in a room without the privacy of a door, without the right physician, and without the right supplies. Births like this happen all the time, where nature gets the best of our attempts at organization, but it never gets less overwhelming. Not down here, anyway. The same thing happens the following week: one upset patient, one delivering patient, and a handful of frazzled nurses. 

Some days don’t feel this hectic. Some days our little OB-GYN Emergency Department is full of less pressing complaints, like those patients looking for STD testing or management of morning sickness. Some days we are urged along more quickly by pregnant women seizing, bleeding, or worse. Some days we have the staff. 

More often, especially lately, our nurses get sent home early because the budget doesn’t allow for them. This is fine on easy days, stressful on others.

Today is looking like one of those less-fine days as we consider the pandemic creeping through our city. We sense its approach and are growing concerned because now, on top of normal pregnancy concerns, we are starting to see pregnant women with respiratory concerns. And, unlike the adult ER on the other side of our hospital, we don’t have a separate unit to place our respiratory patients. Of the beds we do have, only two have doors. Our unit was simply not built for things like this. 

We are left with both practical and theoretical questions. Where are we supposed to put down the masks and shields we’re meant to be re-using? Why does it feels like those hacking coughs are blowing straight through the curtains? We’re confused; the PPE charts make it look like we don’t need shields and gowns until our patients are considered “Persons Under Investigation” for COVID-19, but we don’t feel comfortable waiting for the moment it’s official to start wearing protective gear. We’re also wondering why we can’t do any testing. At first it was because the Health Department wasn’t testing at night. Now it’s because we are only testing inpatients. We’re concerned for the patients we’ve discharged home; they might not be sick enough for admission, but they were certainly still infectious.

All these things run through our minds and our mouths when we have patients show up looking for COVID testing; their physicians sent them here, but they probably shouldn’t have, we aren’t testing anyone. Nevertheless, they are here, they must be evaluated, so who gets the room with the door? Which nurse is going to take care of the sicker looking one and who is going to pick up the rest? What do we do when too many sign in for one nurse to handle? My coworker dons and doffs gear, adjusts monitors, empties bedpans, then helps me juggle the influx.

As she’s handling masks and gowns and shields we chat about the rumors that staff have been taking protective equipment home. We discuss the new “PPE Steward” who comes around distributing packages of gear every day. Meanwhile, somehow, patients who have no respiratory complaints are wearing masks and gloves because they’re scared. How did they get those items? Do they know how to use them correctly? Don’t they know there’s a shortage? I’m scared. 

All this confusion is starting to make a stressful situation seem downright unmanageable and I’m sure it’s only going to get worse. I get a headache, realize I’ve forgotten to eat, and notice I’m starting to get irritable. Nature laughs again as, of course, this is the moment my performance evaluation is due.

At the end of it all I had concerns of my own- I didn’t like the inconsistent communication about daily guideline changes. I didn’t appreciate that we care so much right now about using the word “comfortable” when we can’t get straight what masks we are or aren’t allowed to wear. I don’t like that my “goal for the year” is to obtain a new nursing certification; I obtained a more challenging one at management’s request last year but now the “hospital initiative” is to have a different one, which feels like an unfair use of my time. Mostly, I’m tired of working short and I don’t think we are paid well enough. 

Somehow I make it to the end of the shift. I clock out and eat cold mac and cheese on the ride home. I strip in the garage then eat two bowls of cereal, half a bag of Cadbury eggs, bite off all my nails and watch four episodes of Girls. Eventually I fall asleep, wondering if this is what burnout feels like or if this is just a symptom of nursing in a pandemic. Maybe it’s both. Either way, none of it is good. 

This crisis has only begun to highlight those pre-existing systemic weaknesses nurses face on top of this threat to our health and that of the public. We are lost somewhere between strained nurse management and corporates who don’t understand patient care. I am left wondering who to rely on. I am dreading what comes next, because nurses are caring for the sick. We need to trust someone will be caring for us.