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Care and Chaos on the Night Nursing Shift

topic posted Tue, April 24, 2007 - 2:25 PM by  Rip............
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In a Search for Purpose,
An Editor Changes Careers;
'He's Asking for You Again'
By JOHN BLANTON
April 24, 2007; Page D7

My war with the clock began the first week.

The patient had a fresh burn starting at the jawline, spreading down the neck, across the chest and shoulders, and down both arms to the fingertips, and it was time to change his dressings. In the supply room, I could find none of the large sheets of lubricated mesh used to cover extensive burns. We were out, I was told. I would have to make do with 3-by-8-inch rectangles.

With morphine coursing through his body, the long, lanky 21-year-old lay chatting as I frantically assembled a crazy quilt of mesh strips, dozens of them, over his wounds. Sweat trickled under my paper cap. By the time I finished setting up supplies and preparing the patient, cutting down his old dressings, washing his wounds and applying clean dressings, 90 minutes had passed.

Not too bad, except that during that time, my other patient lay untended in an adjacent room, breathing on a mechanical ventilator through a hole in his neck. He could have "crashed" at any moment in a life-threatening crisis. As it was, I had missed a blood-glucose check, a set of hourly vital signs, a urine dump and a medication. He, too, required a dressing change. I spent the rest of the night ping-ponging between the two, catching up with one while falling behind with the other, documenting my shortcomings through it all in my patients' charts.

My first months as a registered nurse, it didn't take much to throw me off: a missing piece of small but essential equipment; a medication undelivered from pharmacy; a surprise physician's order. Anything could do it, anything that forced me to stray from the template of nursing duties I had been taught to perform like clockwork as per textbook and hospital protocol. I could handle these tasks, barely, so long as the night conformed to my expectations of a normal shift.

It rarely did. And I operated in a state of continuous low-grade panic, punctuated by spikes of abject terror. The three or four nights a week when I walked toward the hospital to start my shift, I was gripped with a fear-induced nausea. My breathing quickened. Sweat slicked my palms.

Please, don't let me hurt anyone tonight. Please.

In 2002, at age 40, I left my job as a page-one editor at The Wall Street Journal, my professional home of 15 years, to take a giant leap of faith -- in myself. Like a lot of people, I questioned my purpose after Sept. 11, 2001. Jolted from the complacency of a comfortable career, I became convinced that I could achieve selfish fulfillment through devotion to service -- to the individual, to the community, to the vulnerable.

I considered teaching. I considered law, medicine, pure science and research. But my thinking always returned to the nurses I had watched care for my mother a few years earlier, when she lay in an intensive-care unit in her final illness. I marveled at the way they melded an aloof, precise professionalism with a mysterious human (and humane) instinct. They seemed to operate in a purer space, beyond worldly distractions. I would be a nurse.

I enrolled in an accelerated nursing program and after a year that remains largely a blur, earned a bachelor of science degree in nursing. Within three months of graduating, I passed the state licensing exam and was hired to work the night shift in the 20-bed burn ICU of a giant hospital in New York City. I went through several months of hospital classes and floor training, and then suddenly, for less than half the pay I earned at the Journal, I was doing my part to help ease the nation's nursing shortage. It was that simple.

My skills were those of any new nurse. With easily shattered confidence, I could start an IV, administer medications, bathe a bed-bound patient and change linens, change dressings, insert all sorts of catheters and tubes, read lab results and electrocardiograms. I knew to be vigilant against infection, pneumonia, pressure ulcers, medication errors and the many other lurking threats to hospital patients. On the burn unit, pain control loomed large. I also knew, as both executor of treatment plans and patient advocate, to keep a close eye on what doctors ordered. They make mistakes, too.

But in those first months, I felt stupid and slow, and thus dangerous. I hadn't yet mastered the ruthless efficiency of thought and motion that lent veteran nurses the appearance, at least, of enviable ease. Next to my crazed back-and-forthing, they floated around the unit, maintaining a cool composure no matter what crisis erupted.

"Nurses eat their young," nursing students are often told. But my colleagues were my essential backup. They answered my constant questions, offered their help when I asked for it and volunteered it when I didn't. They weren't always nice, but they were good, and they were tough on me, which ultimately made me a better nurse.

The night began with the shift change, from 7:30 to 8. "The arrival of the replacement killers," as one nurse liked to put it. We straggled in, one by one, from the locker room to the nurses' station, crowding around the assignment sheet, groggy from unsatisfying daytime sleep.

Assignments were subject to wide variations. Typically, a critical but stable patient, often on mechanical ventilation, came with a second and even a third patient, in less serious condition, perhaps even a "walkie-talkie" -- alert, oriented and ambulatory, in clinical nurse-speak. If the rooms were spaced apart, I could look forward to spending 12 hours trotting like Edith Bunker back and forth across the unit, from patient room, to med room, to supply room, to another patient's room, to supply, back to the first patient's room, and on and on.

Already thin, I lost weight as a nurse.

Shift change was a noisy time, as day nurses, relieved to be relieved, gave "report" to the night nurses. I was anxious during report. For my patients' sake, I couldn't miss details -- "He may try to yank out his feeding tube," "You may need to bump up the sedation" -- but I was already parceling out the time. Second hands relentlessly swept the clocks mocking me from the walls.

Basic nursing duties were enough to keep me on my feet until dawn: initial head-to-toe physical assessments; hourly vital signs and other monitoring tasks; medications; bed baths and dressing changes; regular suctioning. First thing, I reviewed my patients' charts, checking for any outstanding physician orders that might devour precious minutes -- a blood draw for early lab work, perhaps, or an order to start tube feedings, or, as encountered one night, hourly enemas.

There could be no skimping, no coasting through a shift because of a headache or trouble at home. For 12 hours, I belonged to people whose survival was at stake. A sloppy physical assessment could later explode in disaster if a potential problem -- a bum IV, an incipient pressure ulcer, abnormal lung sounds -- went unnoticed. Rooms required meticulous inspection, too, to ensure that vital equipment was present and functioning: A missing bag mask -- attached to those blue vinyl footballs you see TV doctors and nurses rhythmically squeezing in emergencies -- could cause lethal delays.

Then came 9 o'clock medications -- for me in my early days, 9:15ish at best. Patients received as many as a dozen medications at once: injections, IV infusions and pills, either swallowed or crushed in mortar and pestle, dissolved in water and squirted down a feeding tube with liquid meds. Ointments applied, eye drops administered. For one patient, I could spend 30 minutes just gathering it all together and double-checking it for safety.

Burn care was a nightly abyss to be crossed with every patient. It was a big, messy, smelly job that demanded painstaking attention to detail. We usually helped each other or enlisted a patient-care technician -- the latter a negotiating tactic I began to cultivate after that night working alone without the lubricated mesh I needed. We had to work fast because burns impair the body's ability to regulate temperature; exposure can cause life-threatening hypothermia. And simply moving and turning a patient can cause blood pressure to soar or the heart to jump into a dangerous rhythm.

These were the basic functions, and on an uneventful night, I could just manage them -- the tasks themselves, and the documentation of them. If it isn't documented, the saying goes, it wasn't done.

I wanted to hover over my charges like a jealous hound, alert to the tiniest shifts in their biological function. I talked to my patients, to assess their mental status and their pain, to dispel their fears, to teach them about their conditions and treatments, and to learn details about their lives that might affect healing and recovery beyond the burn unit. But I felt hurried, with little time for the reassuring smile and comforting touch one sees on TV commercials that laud nursing as the caring profession.

Most nights, unexpected contingencies unwound the tight choreography of the shift, diagrammed in hourly increments in the sprawling spreadsheets of patients' charts. I lurched from one task to the next, fulfilling all requirements, but little more.

For a while, the electronic thermometers we used were in short supply, and the shift started with a mad dash to nab one. We made a joke of it, but behind the laughs, I heard the clock ticking. Infection control slows down all movement: Hands must be washed before and after every contact with a patient, and fresh gown and gloves donned every time one enters a patient room, to be discarded when exiting. A thermometer or any other piece of equipment moved from one room to another must be cleaned, too.

Often, it seemed, I came on shift to discover a clogged feeding tube. I had to pull the tube, insert a new one (in the nose, down the esophagus), and then wait for X-ray confirmation of correct placement in the patient's stomach before feeding could resume.

An order for bedside dialysis for a patient in acute kidney failure entailed mastering a contraption that looked like a prop from "Lost in Space" -- a big beige metal box on wheels, with knobby green and red lights flashing, rotors whirring, alarms buzzing. It came with printed instructions. Even so, obtaining the necessary solutions from pharmacy, priming the machine, attaching it to the patient and getting it running took a couple of hours, and then a lot of catching up.

A medication missing from the med room could prompt a trip down dark corridors to the pharmacy and back. Blood sent to the lab went bad before it could be tested, requiring a second draw. Dressing supplies ran out, calling for creative solutions. Patients being taken out of deep sedation yanked out their feeding tubes and IVs and fretted with their dressings. A fire in the city could yield new admissions, to be parceled out among us. And of course, infection or shock or some other problem could turn a stable patient into an emergency.

Regardless of the job at hand, my mind raced through the list of others awaiting my attention, convinced that my own feelings of being overwhelmed compromised my patients' well-being. Twelve hours weren't enough. I finished my shifts breathless, and delivered to the day nurses confused, fractured reports before hopping a train home in the morning rush hour.

So it went for the first six or seven months of my nursing career. The 12-hour frenzies, worry about my patients and paltry sleep bred chronic fatigue. I was often in a fog: At home, I spooned coffee into my cat's food bowl, and mistook toothpaste for shampoo. One afternoon, I leaped out of bed, showered, dressed and noticed only as I was heading out the door that it was 10:00 a.m. I had been asleep an hour, and didn't have to be at work for another nine. A deep ache gnawed at my lower back. My feet felt like ragged stumps. I fell asleep in chairs, on subway trains, in taxis, at movies, at supper tables.

I was vaguely aware, too, that the stringent economies I adopted when I left the Journal were failing. My pay was that of a 22-year-old college graduate. Many nurses my age enjoyed dual-income lives, and were earning 20 years or more of seniority pay. My wages weren't enough to cover bills, including the $400-plus a month I now owed on student loans. My credit-card debt climbed beyond $10,000. Overdraft protection was my friend. I was thankful that on the burn unit, we wore hospital-supplied scrubs.

But though my new career terrified me, tired me and was impoverishing me, it yielded that satisfying sense of purpose that had motivated me at the start. As early as those first few weeks, I could see that even my frantic novice's efforts contributed to a cumulatively positive effect, despite my chronic fear of inflicting harm. In time, the great majority of patients improved. Their grossly swollen bodies returned to supple form. Their wounds closed or were successfully grafted. They relearned to breathe. They talked -- laughed, even -- walked, healed and were discharged. Sometimes, they returned for a visit, shockingly normal in their workaday appearance, neatly dressed and coifed. That was my proof against burnout.

One night, as I was slouching toward the assignment sheet, I heard a voice coming from a patient's room: "I want John! I want John for my nurse! I want John!"

He was 11 years old, burned in a house fire that killed his two siblings. I had cared for him, off and on, since his admission weeks earlier. Now, healing and weaned from ventilation, he was coming to terms with the life he would go home to. His mother poked her head out from behind the curtain: "He's asking for you again," she whispered.

He would be one of my patients that night. But I wasn't hyperventilating and nauseated with worry. In fact, the dread had been absent for weeks.

In those stress-drenched nights, it hadn't occurred to me that I was learning, that desperately navigating the minefield of the shift was making me a better nurse. That I might be the kind of nurse whose arrival cheers a patient -- now there was a thought.

Nursing schools teach about a progression of competence. I was making the transition from novice nurse, focused almost exclusively on the completion of discrete tasks, to a higher level of competence, able to meld immediate duties with a comprehensive view of patients' needs.

I could now change dressings, give meds and perform most other tasks in about half the time I needed in the beginning. The practical result was that the surprise hurdles I had once viewed as disastrous aberrations I now met as part of the job. Hourly enemas? Bring 'em on. That's what nurses do. They deal with the unexpected and set priorities.

I had time to take breaks. My sleep improved. I moved around the unit with greater confidence. Some nights, I liked to gather a comb, a basin, warm water and mild soap and wash a patient's hair; I had never forgotten the blissful expression on my mother's face when a nurse's aide gave her a shampoo in the ICU.

I tidied my patients' rooms, threw out the accumulated clutter of the long stays most burn patients endure. Surfaces shone as pink bloomed on the horizon over Queens. My patients lay clean, well-bandaged and stable, tucked under smooth white sheets amid the rhythmic click, beep and whoosh of ICU equipment. When morning shift change came around, I felt that I should take a bow. I had made peace with the clock, and I was proud to be a nurse.

As my skills grew, my fortunes continued to wither. I was dipping into my retirement savings to meet monthly expenses, and still I bounced checks. With more time to think about matters beyond the job, I began to worry about myself, of all things. I could see no way of ever having enough to resume contributions to a retirement-savings plan -- an alarming prospect for a 42-year-old man.

I was frustrated by circumstances and shamed by my inability to overcome them -- and by what that implied. Sooner or later, I would have to quit. When the time came, guilt was the overarching feeling: The hospital had devoted precious resources to training me, and now I was leaving. But the nurse managers took my departure with equanimity. "Why the hell did you ever decide to go into nursing anyway?" one of my veteran colleagues said.

Within a month, I was again sitting among familiar faces in the corporate office I had known for years, performing a job for which I had a natural affinity. I am paying down my debts and providing for my future.

People often ask me if I consider my three-year foray into nursing to have been a waste, an expensive midlife misstep. The only mistake, in retrospect, would have been not to have done it.

Too frequently, perhaps, I crave a shift -- a one-off 12-hour respite back on the burn unit, a reprieve from the news cycle, the BlackBerry, the office patter about war and Anna Nicole Smith. Despite the stress and complexity of nursing, the framework is simple: nurse, patient, clock.

The craving often hits me on the subway in the early morning or the early evening, when it's hard to miss the one or two passengers wearing scrubs, making their way to and from shift change. I resist the temptation to ask them where they work and about the patients for whom they care. I imagine following one of them off the train, down the street to the hospital, putting on my scrubs and moving into that purer space, beyond worldly distractions.

Earlier this month, I renewed my New York state nursing license, good for another three years.

• Email me at John.Blanton@wsj.com1.


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Rip.............Cor...............Duh
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