excellent article in sundays NY Times

  1. 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 and
    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
    on TV.


    ''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
    his nose.


    ''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
    bedside?''



    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
    medical skills.


    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
    does.''


    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
    too exhausting.''


    ''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
    bitter yet.''



    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
    probably will.''


    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
    field.


    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.
    •  
  2. 15 Comments

  3. by   sjoe
    Excellent.
  4. by   RN-PA
    I echo sjoe's "excellent"! Thank you for posting it.

    Is there a link to this article? I'd like to print it out, but the formatting here makes it somewhat difficult to read.
  5. by   Sleepyeyes
    BEAUTIFUL!!!

    I want to HUG this reporter. Failing that, is there an email addy for her?



    Edited to note:

    Found the link!

    http://www.nytimes.com/2003/03/16/magazine/16NURSE.html

    but no email addy. Says she's a contributing writer.
    Last edit by Sleepyeyes on Mar 17, '03
  6. by   dingofred
    Outstanding article.
  7. by   oramar
    That is not a bad day at all. Even though it sounds so busy. No patients were particularly demanding. Nobody crashed or came in or out of the unit. No ER or direct admission arrived announced or unannounced on the floor. No unit director showed up demanding that everyone go to a one hour inservice. They did not pull the CNA to sit with a suicidal patient on another unit. One good thing about daylight is that their are not a lot of visitors around. The small hospital I last worked used to assign ICU and stepdown nurses to code team. In the middle of the day you could find yourself spending a few hours on another unit struggling to keep a person you never med before in your life alive. Seems like they had logistic and housekeeping staff. Yeah, not a bad day at all. Sounds like a good place to work.
  8. by   RN-PA
    Thanks for the link, Sleepyeyes-- Makin' a copy now!
  9. by   Katnip
    Why not just write to the NY Times? I truly applaud this reporter.
  10. by   BrandieRNq
    This is only a usual day, day after day after day. I suppose this is what the article was about. It would be nice to see the EXTRODINARY days we experience way too often. I am quite sure it would more than most people could comprehend. Patients/families would be disgusted and amazed if they only knew, although it is so incredibly overwelming that I think most people would say "yeah, right. That's impossible." If only they knew.
  11. by   Repat
    It's a start, isn't it? I agree, if the reporter attempted to follow me this weekend, the article would have been a bit more dramatic. Sounds like those nurses even got to take a break! However, maybe some of the 'big hitters' in the media will try to keep the ball rolling and let people know what it's really like out there (although who of our employers would allow a reporter to follow one of us?).
  12. by   RN2B2005
    This is why I subscribe to the New York Times Sunday edition. I might not be able to sit down and read the whole paper until Wednesday, but the articles are always well-written, and the topic matter always interesting.
  13. by   -jt
    To e-mail a letter to the editor, write to letters@nytimes.com

    PS
    I just found out that writer came from this BB!

    See her comments about it at:
    http://allnurses.com/forums/showthre...mes#post374942
  14. by   anitame
    Here's what I sent to the editor:

    As a registered nurse working in a hospital, I want to commend Sara Corbett for her informative and very well researched article "The Last Shift." It is an excellent representation of a typical day in the trenches and is a perspective most people will never see. Thank you publishing this article that is so very different from all the other "nursing shortage" articles usually visible to the public.
    Sincerely,
    Anita **** RN

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