excellent article in sundays NY Times

[-jt]

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.

[sjoe]

Excellent.

[RN-PA, RN]

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.

[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.

[dingofred]

Outstanding article.

[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.

[RN-PA, RN]

Thanks for the link, Sleepyeyes-- Makin' a copy now!

[Katnip, RN]

Why not just write to the NY Times? I truly applaud this reporter.

[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.

[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?).

[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.

[-jt]

To e-mail a letter to the editor, write to [email protected]

PS

I just found out that writer came from this BB!

See her comments about it at:

https://allnurses.com/forums/showthread.php?s=&postid=374942&highlight=NY+times#post374942