March 16, 2003
The Last Shift
By SARA CORBETT
The people of 3 East are sick.
Their bodies, one way or another, are failing. They have kidney failure,
respiratory failure. They have bowels that perforate, bones so brittle
they snap. There's a man in Room 361 who can't stop coughing. Down the
hall, in 350, a woman has been unconscious for four days, and nobody knows
why. These are average people who happen to be ill, and illness has left
them with a cavalcade of needs. They need their pupils checked and their
urine inspected. They need ice chips slipped into dry mouths and gauze
pads pressed against leaking surgical incisions. They need their hair
brushed, their heart rates monitored, their physicians paged. Sometimes
what they need is a simple kind word.
Karen Mitchell is a nurse, and 3 East is her kingdom. For 10 years, she
has worked here, at this ''critical-care step-down'' unit at Mercy
Hospital in suburban Minneapolis, tending to patients who are too sick to
stay on a general medicine floor and yet not so sick that they require
intensive care. In their midst, Mitchell, 40, is a burst of Minnesota
sunshine -- a green-eyed mother of two dressed in nursing scrubs
spiffy white Reeboks. Her blond hair is styled in a no-fuss bob; her
expression is simultaneously mirthful and calm. Visiting patients, she
routinely peppers her speech with affirmatives, from ''Okey-doke'' to
''You betcha,'' as if she finds nothing impossible.
On one hip, Mitchell carries a cordless phone. When one of her patients
hits the call button, Mitchell's phone rings. When another nurse wants a
hand or a doctor is looking for information, it rings again. Some days it
seems to ring for eight hours straight.
On a midwinter Wednesday at 8 a.m., 3 East is hushed and hermetic -- all
carpets and fluorescent lighting -- a place where it hardly matters what
day of the week it is, where hours are measured by flower deliveries and
doctors' rounds, by the arrival of squeaking meal carts and what's showing
''Good morning, Mr. Beaudry,'' Mitchell says to a 78-year-old man
recovering from rectal surgery. ''How do you feel today?''
Mr. Beaudry is sunken-eyed and pallid, an IV tube snaking from his jugular
vein and crumbly scrambled eggs languishing on a tray before him. ''I feel
terrible,'' he says. Speaking triggers a spasm of coughing, which in turn
brings on a tortured moan. ''Terrible,'' he says again. ''And these eggs
are too dry.''
''Okey-doke,'' Mitchell says, promising to return soon.
In the next room, there is Mr. Tempel, recovering from a stroke. Mitchell
delivers a swallow of water and his morning meds, one at a time, naming
each one as she places it in his parched mouth. Her third patient, Mr.
Niemann, is a sallow but polite young man who needs to be prepped for a
liver biopsy, while her fourth -- Mr. Finder, another elderly stroke
victim -- reports that a ''whole bunch of bloody stuff'' just slid out of
''Next time it happens,'' Mitchell tells him, ''just save it in a Kleenex
for me so I can have a look.''
She casts an amused glance in my direction, aware of how unglamorous this
work seems. And how hard. Because of the dwindling influx of registered
nurses, it is getting harder, as well as more dangerous, for them and
their patients. According to the American Hospital Association, the demand
for nurses outpaces the supply by 126,000. Critical-care units in
hospitals are operating with an average of 14.6 percent of their nursing
positions unfilled. Meanwhile, the nurses left to make up the difference
are mostly over 40 and contending with high rates of on-the-job injuries
and work-related stress. As managed care has bulldozed its way through
hospitals, these are the people who have held down the front lines,
providing the bulk of patient care, suddenly forced to ration not just
time but also empathy.
You see it as Karen Mitchell whizzes from room to room, dabbing Betadine
on incisions, administering insulin, checking to see if Mr. Niemann's feet
are swollen, if Mr. Beaudry knows what year this is. She assesses her
patients' health with a lean-and-mean efficiency, spending just a few
minutes at a time in a room. The first time she sits down in two hours is
when she stops at the nursing station to update her patients' charts. She
stirs a packet of instant hot chocolate mix into a cup of water -- ''It
gets me going,'' she says. Earlier, I had asked how she felt about the
nursing shortage, and she had been too busy to respond. Now she swivels to
face me. ''You know, sometimes late at night, I think about this,'' she
says. ''And what I really wonder is, Who's going to take care of me
someday? When I get old, when I get sick, who's going to be there at my
In an era when everything feels accelerated, the image of a nurse hovering
tenderly at a patient's bedside bears the same impossible quaintness as a
doctor paying house calls. While many registered nurses lament how little
time they have to provide what might be termed old-fashioned care --
simple hand-holding, for example -- they also recognize the choke hold of
a stereotype, one that glorifies their compassion yet undervalues their
If profit-driven health care, which brought about nationwide layoffs of
nurses in the early 90's, is largely to blame for creating the current
shortage, the public's perception of nurses as beneficent and mild may be
helping to sustain it. Historically, nurses have been portrayed as saints
and as sex objects -- women both dedicated and servile, treasured but not
necessarily respected. Today, even the most positive depictions of nurses
leave the impression that their work -- along with their intellect -- is
secondary to that of doctors. In cutting-edge medical research or
news-making surgeries, the pivotal role that nurses play is rarely
credited. Part of the problem, says Barbara Blakeney, president of the
American Nurses Association, is that a nurse's work is difficult to
quantify. ''Nurses prevent bad things from happening,'' she says. ''And
it's much more difficult to measure what doesn't happen as opposed to what
Though many Americans actively shop for skilled doctors -- surgeons,
particularly -- they seldom inquire about the quality of a hospital's
nursing care, even though their lives may depend on it. Last year,
researchers at the University of Pennsylvania School of Nursing found that
patients undergoing routine surgery have a 31 percent greater chance of
dying if they are admitted to a hospital where nurses care for more than
seven patients. And a 2001 survey by the American Nurses Association
provides an unsettling closeup on patient safety: more than 40 percent of
responding nurses said they would not feel confident having a family
member or friend cared for at the facility in which they work.
The simple solution -- encouraging more people to become nurses -- has
proved to be not so simple. Nursing's relative invisibility holds little
appeal for a generation of women (and 94 percent of nurses are women) who
consider professional recognition a birthright. After six years of
declines, nursing programs
reported a slight uptick in enrollment last
year, but hardly enough to break the profession's death spiral. As
headlines have long warned, we are careering toward outright disaster: by
2020, more nurses will be departing the profession than entering it,
leaving the health care system -- which will then be stuffed with
octogenarian baby boomers -- with a projected shortfall of 800,000 nurses.
Seeing little in the way of positive change, experts are no longer talking
about a ''nursing shortage'' but rather a ''nursing crisis.''
Suzanne Gordon, a co-author of ''From Silence to Voice: What Nurses Know
and Must Communicate to the Public,'' says that nurses must overturn the
perception that they are ''kind but dumb'' and that their work is trivial.
''People don't understand that if a stroke patient isn't assessed
correctly, if the food's going down the wrong tubes, they may die or be
sent to the I.C.U. If someone isn't helped out of bed and walked, their
blood won't circulate and they could end up with a pulmonary embolism and
die. All of these so-called unimportant tasks are really about life and
death.'' Speaking to groups of nurses, Gordon urges them to shed their
modesty and emphasize their value. ''Let's face it,'' she says. ''The
angel image just doesn't work.''
Back on 3 East, Karen Mitchell's day begins to unravel. It's 10 a.m., and
Mr. Finder's doctor has approved him for discharge. Mitchell photocopies
the small mountain of records he has amassed and then writes up two pages
of instructions for the rehab center where he's going. The phone on her
hip rings: Mr. Niemann's kidney specialist has arrived. The phone rings
again: Mr. Tempel has hit his call button. Mr. Finder needs a wheelchair.
The kidney specialist prescribes a new drug and orders some plasma, both
of which Mitchell will have to find and deliver.
Now she wakes up Mr. Beaudry to give him some pills.
''How are you feeling, Mr. Beaudry?'' she says.
''Not too hot,'' he says.
Back in Mr. Niemann's room at 10:24, she realizes she needs a different
kind of IV bag, and at 10:27, after some frenzied hunting in the supply
room, realizes it's not there. At 10:28, she tracks down a pharmacy tech,
and five minutes later, she hooks up the bag and adds the medication,
explaining that it will lower his partial prothrombin levels. Mr. Niemann
listens intently and then asks if he can have a shower.
She is behind on her charting. She is ''way late'' in delivering yet
another medication to Mr. Niemann to lower his blood pressure before his
liver biopsy. And she has heard there are four patients down in the
emergency room, all of them candidates for Mr. Finder's recently vacated
bed. There is pressure, too, to discharge Mr. Tempel, despite Mitchell's
worries that he is too weak to go home. Her phone rings again with the
nurse's aide on the line: Mr. Beaudry is insisting that the button he
pushes to release pain medication has stopped working.
''First thing in the morning, I can conquer anything,'' Mitchell says.
''But by 11, reality has set in. I give up on the idea that my day's going
to have any organization to it.''
All things considered, Mitchell is reasonably fortunate. She lives in a
state where the nursing shortage is significant but not yet dire, and she
works in a hospital that courts nurses with signing bonuses and flexible
scheduling. On 3 East, the vacancy rate hovers around 5 percent, meaning
the unit is normally short a few nurses. But this is the point: a few
nurses matter. Whereas Mitchell says she is at her best dividing her time
between two critically ill patients, she more often is tending to three or
four. Even under decent conditions, the nursing shortage acts like a slow
bleed, draining the optimism of its hardiest veterans.
Karen Mitchell is careful not to impugn the hospital, careful to note that
she believes her patients get good, if less than perfect, care. And yet
she admits to feeling a deepening fatigue. ''During a hard shift, when I
can't get to everything and I know that patients aren't getting what they
deserve, it's like, Why do I come back?'' Mitchell says as we spend her
30-minute lunch break in the hospital coffee shop. ''What's the point?''
It is an uncomfortable, downbeat moment for Mitchell, one that feels
confessional, like a good soldier admitting to a single treasonous
thought. At first I think she is simply being too hard on herself, but
later I wonder whether Mitchell's guilty despair is a reflection of a
larger symbolic load nurses carry. If nurses are the human face on our
health care system, then when that system is failing -- and who can argue
that it isn't? -- it is nurses who are left to articulate that failure
personally to their patients. The pressure on nurses today is perhaps as
psychological as it is physical, and it's taking its toll. Research shows
that a registered nurse is three to four times as likely to be
dissatisfied than the average American worker. And young nurses tend to
have their idealism quickly dismantled: one in three hospital nurses under
30 reports she is planning to leave within a year. ''Frankly, I'm so sick
of teaching new kids on the block,'' Mitchell tells me, ''because they
just turn around and leave.''
After lunch, I wander into 3 East's break room, a windowless space
dominated by a single long table, where a group of nurses linger over cups
of yogurt and microwaved leftovers. When I remark that the unit seems busy
today, Tina Janiak, a straight-talking, brown-haired nurse who started at
the unit in 1995, laughs. ''This is average,'' she says. ''Sometimes,
especially on weekends, they've got two nurses to 10 patients. It gets to
a point where it's just not safe.''
This sets off a chorus of commentary. ''Every single one of my days off, I
get a call from the hospital, asking if I can come in and work,'' says
another nurse. ''I'm too burned out already.''
''I don't want to be doing this 10 years from now,'' Janiak says. ''It's
''I don't want to be doing it in five,'' says a third. Somebody else
checks her watch. Break's over. One by one, the women adjust their
stethoscopes and shuffle from the room, tossing their garbage into a can
by the door. Until there is only one nurse left, a doe-eyed woman in her
20's who has been quietly reading a book at the far end of the table.
Getting to her feet, she looks at me and shrugs, indicating she has
nothing to add. ''I'm new,'' she says, almost apologetically. ''I'm not
With the hospital nurse quickly becoming an endangered species, poor
working conditions have bred a new militancy among those who remain in the
profession. In the last several years, nursing unions have affiliated with
heavy hitters like the A.F.L.-C.I.O. and United Steelworkers and have
staged work stoppages and strikes everywhere from Long Island to Hawaii,
demanding not only higher wages but also more control over their workload.
In 2001, when Mercy's 628 nurses voted to strike, Mitchell was serving as
3 East's union rep. ''We had nurses who were newly married, who were
expecting babies,'' she says. ''There were two who had just closed on
houses.'' The mood, she says, was ''extremely tense.'' Hours before the
strike was to begin, Mercy Hospital, which is owned by the health care
conglomerate Allina Hospitals and Clinics, reached an agreement with its
nurses -- a compromise that left some unsatisfied. ''We were ready to do
it,'' Janiak says, a touch of swagger in her voice. ''Next time, we
Abandoning hospital patients in order to walk a picket line hardly seems
like something Florence Nightingale would do, but many nurses contend that
patients are better off surrounded by R.N.'s who have not just worked a
double shift and who have the right to refuse a patient they feel would be
unsafe to treat. But speaking out also compounds the basic problem: when
embattled nurses draw attention to workplace stresses, they run the risk
of scaring off young people who might otherwise consider entering the
In an attempt to buff nursing's image, Johnson &Johnson has begun a $20
million publicity and scholarship campaign, extolling both the nobility
and the medical know-how of registered nurses. Congress recently
authorized the Nurse Reinvestment Act, offering loan forgiveness to
nursing students who go on to work in underserved areas. In the meantime,
hospital recruitment has taken on a carnival aspect: in September, a St.
Louis hospital held a one-day phone-a-thon, hiring 75 percent of its
nursing staff by telephone. Other hospitals do their binge hiring in
countries like the Philippines and India.
During our phone conversation, Blakeney, the A.N.A.'s president, can't
pass up the opportunity to deliver a booster speech. She waxes eloquent
about how dynamic and varied nursing is, how it can be practiced anywhere.
And of course she's right. There are 2.2 million registered nurses in this
country. Some administrate insurance plans; some work on naval battleships
or for pharmaceutical companies or for dermatologists. Others teach or run
public health studies or clinics for refugees. But the majority of them
work in hospitals, where their good intentions are often trampled by a
lack of resources. When I raise this point, Blakeney's enthusiasm abruptly
reverses itself. ''I know,'' she says, a familiar frustration seeping into
her tone. ''Nurses love nursing. They just hate their jobs.''
(Embedded image moved to file: pic07618.gif)r. Niemann is back from his
biopsy, pale and drugged up and sleeping in his bed. Mr. Tempel has been
approved for discharge and waits like a schoolboy by the door to his room.
Karen Mitchell pages his doctor so she can go over the medication
instructions she has written up for him. She orders a wheelchair and then
goes to check the color of urine flowing through Mr. Niemann's catheter.
When Mr. Tempel's doctor doesn't call back, she pages him again.
It's approaching 3 p.m. Her shift is nearly done. The canned laughter of a
television game shows floats from an open door. A terminal cancer patient
in Room 354 bellows in pain. Down the hall in 350, where the unconscious
female patient still lies, her 30-year-old grandson puts down his book of
word puzzles and starts to pray.
The phone on Mitchell's hip rings: Mr. Tempel has grown tired of waiting,
and so she goes to help him back into bed. And then she goes to check one
more time on Mr. Beaudry.
''Are you comfortable, Mr. Beaudry?''
''Not at all.''
''On a scale of 1 to 10, how's the pain?''
The patient's lip quivers. ''It's a 9,'' he says.
She will page his doctor and request that he prescribe some Percocet.
Before she goes home to her family, she will empty his colostomy bag,
redress his surgical wound and flush the tubes in his neck with heparin.
Karen Mitchell does not hate her job. She just wishes it were different --
that in this stark and unremitting cycle of illness, in a time when
hospital administrators put ''care'' and ''cost containment'' in the same
sentence, she could be afforded more time at the bedside. Without it,
nursing becomes dehumanized; patients become dehumanized. The concerns of
making money and the concerns of healing have never been easy companions,
after all. Which is why Mitchell sometimes takes it upon herself to
sacrifice one for the other. It's her small act of rebellion, a quiet vote
cast for the future. Every once in a while, when Mitchell encounters a
patient like Mr. Beaudry -- a strong soul having a moment of true
vulnerability -- she will unclip the hospital phone from her hip and pull
out its batteries. And then closing the door, she sits down beside her
patient, just to be near.
Sara Corbett is a contributing writer for The Times Magazine.