The Gap Between East Coast & West Coast Nursing

ArticulateRN, MSN, RN

Tupac or Biggie? Shake Shack or In-n-Out? Coastal rivalry aside, it doesn’t take a CVICU nurse to surmise that the way of life between east coast & west coast nursing is markedly different. As a former travel nurse who worked my way from Atlantic to Pacific, it is my observation that hospitals on the east coast (read: any state outside of California) could learn a thing or two about work culture from the Golden State. I liken east coast nursing to an abusive relationship that you didn’t realize was so bad until you got into a healthy one. I’d always heard that there was a place where nurses were treated with dignity and respect, where they were valued members of the healthcare team. It’s called California. When I moved there, I met other east coast defectors like myself who’d come to the same realization: it’s possible to be treated like a human as a nurse. There’s a reason people say California is where travel nurses go to die, and in my experience workplace happiness came in the form of approachable management with less influence of corporate oversight, thereby lending staff adequate resources to provide quality patient care.

Budget-First

In South Carolina, no matter what decision needed to be made for our unit, budget was always top of mind. In the PCICU, we asked our manager for a resource nurse to help admit OR cases. Scoffing that a free-floating nurse was a senseless waste of resources, he shut that down before we could make an argument. The audacity to ask for an extra set of eyes on a critically sick infant fresh out of open-heart surgery to adequately manage hemodynamics, ventilation, and pain while updating worried parents!

One year, when we hit a milestone of “100 days CLABSI free,” our unit was awarded a sum of money to use however we pleased. Management set out a suggestion box to decide how we would spend the CLABSI cash, and I racked my brain on what would better our workflow. In a bleak reminder of how limited our resources were, the nurse next to me announced she was requesting a Silent Knight. Did it really take three months of “don’t infect someone” bribe money to get a pill crusher for the unit? I laughed. Who needs a pill crusher when you could mash together the handles of trauma shears to get the same powdered ascorbic acid? Imagine my delight years later when I discovered that every room in the PICU in California had its own Silent Knight!

Human-Second

I watched the pandemic unfold from the comfort of Northern California, adorned with proper PPE and safe patient ratios, but I counted my blessings because I had a pretty clear picture of what my life would be like if I’d still been working back east. There are plenty of examples out there of how nurses were treated like sacrificial lambs during the pandemic, so I won’t disturb you with death rates of nurses serving the front lines. I won’t give an award to the nursing unit with the highest rate of N95 reuses, or depict images of nurses donning garbage bags as protective gowns to keep a highly contagious virus off of their clothes. I’d rather take you back to pre-pandemic days where nurses silently suffered through consistent gaslighting by hospital leadership.

I’ve passed out in the middle of interdisciplinary rounds from hypoglycemia. I’ve risked patients self-extubating to step away to pee because no one was around to keep an ear out. Nurses are accustomed to putting their basic human needs second, so none of this is news. In a less extreme example of inhumanity, I’d like to illustrate a time when hospital leadership failed to support its staff well before the pandemic, in turn putting patients at risk.

I was working a Saturday day shift when historic floods shut down the metropolitan area. While it is typical for this town to flood, in this instance there was no traffic allowed onto the peninsula, as regulated by emergency services. My mom works at a hotel near the hospital, so I was able to stay there with her the night prior to my shift. Her management had anticipated the storm and created a plan, booking rooms for their staff before their shifts. In the morning she drove me as close to the hospital as we could get, but when the roads became impassable, I got out and tried to walk, only to come upon waist-deep water. In a panic, I rushed back to the car and called the hospital to see if they were doing anything to help us get to work, or if I should plan to swim. When I finally got on the line with a hospital supervisor, my concern was met with “just get to work.”

We pulled into a gas station and I saw a truck with a passenger who appeared to be in scrubs. I got out of my mom’s car and knocked on the window. “You going to the hospital?” I gambled, hopping in with a stranger who was driving his wife to work. Arriving to my unit on time, I found out that several other nurses were late because they’d been afraid to leave their homes. One of our nurses had a military husband with a big truck who took it upon himself to run shuttles to deliver PCICU nurses to their patients. Thanks to our Valiant Knight, we were fully staffed. My patient that day was a 1:1 in a dangerous heart rhythm who needed bedside cardioversion. We prepared for the procedure with emergency drugs and equipment in case we didn’t get a heart rate back. She lived, and the worst-case scenario was avoided. Management checked in around noon to ask about staffing. “We all made it to work today, in case you’re wondering!” the charge nurse offered.

The California- Everywhere Else Disconnect

I can’t imagine that scenario playing out the same way in California, but if it did, nurses’ outrage would be addressed by their nursing union. The California Nurses Association supports working nurses through oversight on working conditions, wages, and staffing ratios. Not only are patient ratios mandated by law, so are lunch breaks. That’s right, nurses in California turn in their phones to that resource nurse who will respond to alarms and hang meds so that the bedside nurse can enjoy forty-five minutes of uninterrupted rest. If we had those same mandated staffing ratios in SC, I could enjoy the luxury of a 2-patient limit in the ICU. I wouldn’t have to debrief with shame about my 3kg patient who had an emergent re-intubation because I didn’t have close eyes on her due to a triple assignment. With mandated staffing ratios, having a resource nurse may seem more like a standard of care than a splurge.

While idealistic, it’s not realistic to suggest each state form their own nursing union due to inevitable political pushback, especially in right-to-work states like SC. Organizations like National Nurses United have marched on Washington and presented the need for change to policymakers for years. With the spotlight on nurses and our working conditions throughout the pandemic, now seems like our best shot for safe ratios. But I wonder what it will take to treat nurses like humans? Is this in the budget?

The Influence of For-Profit Healthcare

Talk to any nurse who's been around since the early days and you’ll hear a common opinion that nursing isn’t as rewarding as it used to be due to the shift into the for-profit healthcare model. Over time, we’ve shifted our care from patient-centered to “caring for a computer” to meet the demands of the reimbursement powers that be. With corporate oversight dictating our care, budgets in both the for-profit and nonprofit environments continue to tighten; as a result, nurses feel less supported by managers, who balance the line of providing the needs of staff and appeasing executives.

It’s no secret that U.S. hospitals got caught with their pants down when the COVID-19 pandemic began to unfold: most hospitals were only stocked with about two weeks of PPE for their staff, and suddenly had to scramble to acquire more. I was fortunate enough to work in a hospital that advocated for staff and provided us with hospital-grade droplet masks, contact gowns, N-95s, and face shields. When I took care of COVID patients, I felt safe.

Here I am feeling guilty that I didn’t die of COVID or have to wear a trash bag to work, guilty that I got to eat lunch all those shifts. But why is California a unicorn? Perhaps hospitals have better resources because of how funds are managed, or maybe the influence of a nursing union makes all the difference. Either way, the Chief Nursing Officer in California knew my name, and that’s more than I can say for any other state in which I’d practiced.

I’m Not Sure If I’ll Ever Go Back

At the end of 2020, I removed the Golden Handcuffs and moved back to my hometown in South Carolina to be closer to family. I knew what to expect with the hospital system here, so I set myself up for new opportunities by earning a Master’s in Nursing Education. I saw this as my ticket out of bedside nursing, but the reality is an MSN isn't going to save me from the toxic work culture that still exists in the hospital systems here. Yes, I could get a job as a nurse educator with slightly better hours and less physical strain, but I’d still be working with the same leadership that had made me feel as dispensable as a pair of latex-free gloves. As I decide where I’ll fit into the health system in SC, I’m currently observing from the vaccine sites. While it’s no adrenaline rush like the PCICU, I get to sit back with other nurses who enjoy a break from the bedside. I’ve spoken to many nurses in my position, who express the sentiment: “I’m not sure if I’ll ever go back.”

I wish I had an objective solution to a broken system, but all I can offer is my observation from my own nursing experiences. If you’re a nurse suffering burnout, know that I see you and empathize with how you’re feeling. It’s difficult to articulate why you dread going back to a job you once enjoyed, with people who pulled you through the trenches. Instead of complaining “corporate culture sucks” or “management never listens” (all valid points), keep notes of the problems that come up. Write an incident report when a patient codes due to unsafe staffing. If it wasn’t documented, it didn’t happen. At best, we will be heard by policymakers for safer staffing ratios, and at a minimum maybe one day we’ll be treated like humans. Until then, I’ll give an answer to my own question: Christopher Wallace and Shake Shack, hands down.