Scatter my ashes here...

Scatter my ashes here...
scatter my ashes in the desert...

Friday, November 9, 2012

The Paradox of My Profession: An Apple a Day...

I'm going off on a tangent here today, but bear with me. I read this article today in one of the email newsletters I get daily on happenings in the world of medicine.

This is a blog about ultrarunning, and I am convinced that nursing is also ultrarunning. Nurses who can't imagine what it's like to run 50 miles at a stretch don't realize that they are doing it every single day they work. I get less exhausted by running for 12 hours than I do by working a 12 hour shift.

I really love what I do to pay the bills. I'm a nurse, I came to it later in life, started my first nursing job at age 42, and I'm now in my 7th year of nursing. For a little over 2 years, I have been working in a hospital-based outpatient clinic where we give infusions, which are intravenous medications that run over a period of time. Those include everything from antibiotics to blood transfusions, IV fluids, special medications, biotherapy, and chemotherapy. We give injections, start IVs, change wound dressings, maintain IV access devices like PICCs and central lines. We also administer sedation for bone marrow biopsies done by oncologists at the bedside. Patients come in for appointments that range anywhere from 15 minutes to 12 hours.

I feel fortunate to have landed in a hospital where for the most part, employees are treated very well, and working conditions are better than I would guess 99.9% of the other places I could be working. Things are not perfect, but no job will ever be perfect. I think mine is about as perfect as it can get, even though there are days when I question my sanity for going into this profession at all.

Health care is changing, I am glad to see that enough of the general population values health care to vote in the interest of reform. I don't believe that most people have even wrapped their minds around what this means to them, having access to the health care system, because they have had to do without it for so long. Anyone who uses the term "Obamacare" is usually using it derisively, and I think they are fools. I would personally like to see an entirely not-for-profit health care system. When you see on a daily basis, the consequences of people not having access to basic health care, preventive services, and mental health resources, you would see how desperate the need is.

So what does it mean to be a nurse? Perhaps the word "nurse" is misleading, it is tied to an image of a white-clad, lamp-wielding Florence Nightingale changing linens on a bed or an angel holding someone's hand. Maybe we need to change the name of title of our profession to something else.

The title "nurse" does not mean I am a self-sacrificing, altruistic angel. I am a highly skilled professional.

I clean up shit, puke, blood, and pus, but I also know what to do if your heart stops beating, you stop breathing, or start bleeding profusely. I keep doctors from making mistakes that will get to you and kill you. I am the one who sees, hears, and can evaluate your overall state of health and well-being because I spend the most time with you.

I'm the one who makes sure I wipe down the siderails of the bed you just touched with your hands after the last patient didn't wash their hands after using the bathroom. I'm the one who has to chase the housekeeper down to clean up blood, urine, poop, or whatever other infectious body fluids you leave behind, and if the housekeeper doesn't do their job, I have to make sure it gets done.

I'm the one who calls the doctor, sometimes in the middle of the night, and risks getting yelled at because I want to make sure you get the right dose of medication, whatever you need for your comfort and well-being, and save you extra doctor appointments.

I'm the one whose license is at risk because it's so easy for doctors to blame us if something goes wrong. We're considered an expense, and expendable, while doctors are considered to be the revenue generators. No one ever considers that people come to hospitals for nursing care after the doctor cuts them open.

I spend hundreds of hours, many of them unpaid and unreimbursed, each year keeping my skill levels and education up, so that I am aware and informed of the latest research in health care, which benefits you. I don't have guaranteed hours at work, I can get sent home if we're not busy enough to keep every one of the nurses running their tails off, and I am constantly having to make more and more sacrifices regarding pay and benefits in my job.

For all this I am paid not much more than an auto mechanic or truck driver. I didn't go into nursing because of the pay. We don't get paid very well for the level of responsibility we assume and the skill level we acquire. Our benefits aren't all that great, though these days just having good health insurance is a huge thing. It's not an easy job, ever.

I work 12 hour or longer shifts, most of which is spent on my feet and running for something for you. I might not get to go to the bathroom for hours, or have anything to eat or drink. I rarely get a break in those 12 hours, everytime I think I can put my feet up someone needs something from me.

I rarely get to sit down and take a full 30 minute lunch break off my feet over that entire shift, without it getting interrupted or cut short by a doctor's phone call or a patient's need. We don't get another 15 minute break during the day either, though we might be entitled to it under labor laws for a 12 hour shift. If we need to go to the bathroom or grab a snack we have to rely on the good will of our coworkers to watch our patients for us, in addition to their own, in order to take time away.

If it's the end of my shift, and I'm tired, you giving me a hard time or talking to me condescendingly is not something I'm going to take kindly to. I might have helped a family with a dying person just before I saw you, or called a code when someone had a reaction to a drug, or spent cumulative hours on the phone with doctors offices and their uncooperative secretaries just to get an important detail taken care of so that my patient gets the best and safest care possible.

So if I'm 11 hours into my shift and I don't laugh hard enough at your stupid joke or I forget to bring you that extra package of crackers or warm blanket that you could easily get up and get yourself, get over it and be glad you're only here for a day or two instead of hooked up to a machine that breathes for you and a tube in every orifice and your body being turned and your butt being wiped every two hours by the six nurses it takes to turn your big inert body and keep you from developing pressure ulcers and blood clots.

Could reimbursement changes possibly result in changing nurses working conditions? I've always felt that 12 hour shifts are insane. However, nurses need to work long hours because we are so undercompensated for our skill levels and the responsibility we assume. I believe that if the nursing profession would reform itself and advocate for its members as professionals, instead of highly skilled, overworked, glorified angels who are paid marginally.

Twelve hour shifts do not allow a person to adequately recover from a stressful day. The body needs rest, nutritious food, sleep, personal time, and family time. You go home 13 and 1/2 hours after you left the house and even the slightest need for attention from your family feels like another demand on you, you've been serving people all day long and you're exhausted. And exercise? Who has the energy to exercise after a day like that?

If nurses were compensated adequately so that they didn't have to work long hours and so many days that they burn out, then nurses would be able to deliver even better care. We're always looking for ways to be more efficient and less wasteful of resources. When people are tired they are not as efficient. When the nurse goes to work feeling exhausted, the nurse is not going to operate in as efficient of a manner. Mistakes are more likely to happen, and errors are more likely to get missed.

Doctors have a huge responsibility too, and we are expected to carry out their orders. We have to scrutinize every one of those orders though, because our job is to ensure patient safety, so we have to check the orders and make sure they are appropriate for the patient and their condition or diagnosis.

If something doesn't look right, if the order isn't legible or or we can't understand the order, it is our professional responsibility to question the order. We call the doctor to ask. Sometimes we get yelled at for doing that, but we have to be thick-skinned and know that we are doing the right thing for the patient.

Not too long ago, at the end of my shift, I caught an error where a doctor ordered 200 times the normal amount of a medication that we rarely give. I wasn't familiar with the medication, it was something I'd only given in ICU before, not in an outpatient setting. I didn't know it was the dose that was wrong, I just couldn't make sense of the way the order was written, and I called the pharmacist to ask if it made sense, and she saw the error.

So then I called the doctor, and had to get a new order. I stayed late because I needed to wait for the doctor to call me back so I could make sure the order got fixed before the patient arrived the next morning. I had to see it through, or it could have been the patient's life, not to mention my butt and my license.

You can see how if a nurse is having an off day, how easy it would be to miss some little detail, yet we are expected to be on top of things, and mentally sharp, for entire 12 hour shifts, with little break to restore ourselves. And when you work 12 hour shifts day after day that becomes more difficult as your fatigue builds up.

Some people think that nurses just sit on their butts and surf the internet all day. There are a few nurses who try to do that and get away with it, unfortunately they set the rest of us up with a bad reputation.

There are a lot of overweight nurses too. But I would say that our working conditions contribute to that as much as anything else. And the nurses I work with who are overweight, work just as hard as anyone else. I would say they probably end up a lot more tired after work.

Stress causes you to secrete more cortisol, a stress hormone, which can contribute to the development of insulin resistance, which leads to weight gain amd worse health problems.

Gulping down a hamburger or some fries and chicken fingers is easier to do when you're short on time than crunching on a salad, that takes more time to eat, and provides less energy. Nurses are rushed. They don't get to eat slowly. I bring an apple with my lunch every day, and the apple is what tells me what my day is like. I consider myself lucky if I have time to eat my apple.

What gets me about nursing is the working conditions. Even if you work for what's called a magnet hospital, as I do, nurses work damn hard and most people don't even understand what our job is, and they ask us for all kinds of inappropriate things, and they expect it from us, which makes our job more difficult. And by cutting back on ancillary staff, like nursing assistants, as management often does, it makes our day more rushed and stressful.

We keep getting asked to do more and more, little extra details, changes to documentation that take longer, working with fewer staff on hand, taking more and sicker patients, getting compensated less for anything we do above and beyond, such as professional certification.

We are expected to do that on our own time and at our own expense. I spend a lot of time studying for my oncology certification. I don't get paid much extra for having it, either. I get paid $500 for the first year then $250 a year there after for maintaining it. And some hospitals don't even pay a cent to their nurses for it!

Averaged out over the roughly 1500 hours a year I work, that's 33 cents an hour extra, BEFORE taxes, the first year, and thereafter I get 16 cents an hour extra. And if I worked full time, the average amount would be even less! Meanwhile, my professional nursing organization insists that certified nurses get paid $7 more an hour on the average. I'd really like to see what drugs they're smoking.

And I keep up my advanced cardiac life support which isn't a requirement of my current job, but I feel that I'm giving drugs to people that could have unintended consequences, such as sedation during a bone marrow biopsy, especially to people who are older and have multiple health problems, so I think I should know how to rescusitate a person beyond simple CPR. And just recently I was informed that I will have to pay out of pocket to do that, another job perk taken away.

I feel sorry for nurses who don't have magnet hospitals to work for, like I do. Non-magnet hospitals can completely abuse their nurses on the job, forcing them to work overtime, and their employers get away with it.

So, now we have health care reform moving full speed ahead. The drivers of reimbursement will now be patient satisfaction scores and patient outcomes, all of which have already been linked empirically to nurse working conditions.

Twelve hour shifts are insane. If we were compensated for what is expected of us, we wouldn't have to work so many hours that we burn out. We could work 8 hour shifts, and few enough of them that we wouldn't burn out, and we'd arrive to work sharp, rested, exercised, well-nourished, and restored by adequate sleep.

Nursing is an expense, but where is the nursing profession in advocating for better working conditions and compensation for nurses? Who is saying that we need to reform nursing, and attitudes toward nurses, and the way we look at and pay for nursing care as a delivered service?

Nursing schools should assume some responsibility for getting things unstuck from the dark ages. They have direct ties to professional organizations. Yet many nursing school faculty haven't worked the floor in years, and haven't a clue what it's like anymore.

They teach the same material year after year when working nurses are constantly being educated on the newest equipment, medications, techniques...and health care is becoming increasingly delivered in ambulatory settings, yet nursing schools still insist on sending their students to the floor for the majority of their clinical experiences. And, might I mention, their hackles raise when suggested they do it otherwise.

Yes, we're in the business that calls itself Health Care. Yet nurses, and other health care workers, are living a reality that delivers neither health, nor care for its own members. It's a paradox. We're in demand, but no one wants to pay for us. tell me...are you glad that nurses exist? Do you think we're compensated adequately? Do you think we're insane for being in this profession?


SteveQ said...

Per your last three questions: 1)Yes. 2)No. 3)Maybe.

wildknits said...

Amen. Such a close to the heart topic to me that I can't even adequately comment on it.

I am an RN. I work in a clinic that serves primarily uninsured and underinsured patients.

I spend each day not only addressing my patient's medical needs, but also act as a mental health counselor, social worker, and often the only person in their life that takes the time to listen or care.

It can be exhausting and is made worse when my work limits my time to refresh by being outdoors.

While I work with a great set of providers, demands on the limited RN time is increasing and while the providers see our value, this is not being translated to hiring more RN's. This is directly related (I feel) to the fact that our time is not billable.

Ah, so much more could be written....

Alene Gone Bad said...

Thanks for your comments, Steve and Lisa.

Lisa, there is so much more to be said and written. I really feel like the professional nursing organizations do nothing to promote or improve the welfare of the nursing profession, especially for those of us in the trenches.

I see an incredible amount of apathy on the part of working nurses, they seem to be so beaten down and exhausted by their jobs that they don't want to expend one more bit of energy after their shifts are over. And I can't blame them for that, it's a vicious cycle and sometimes I get paranoid and feel it's by design, intentional. It's like "I paid my dues, now you have to" is the mentality.

Now that all eyes are on health care reform going forward, I think this might be the opportunity for nurses to push for change. I see very little action on the part of the leadership in our profession, who claim to speak for us.

I feel it's unsustainable for any human being to work full-time or nearly full-time at the intensity that nurses are expected to maintain at work, for very long, without suffering phsyical and mental health consequences.

A whole other blog could start here...