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.'' 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. __________________________________ Do you Yahoo!? Yahoo! Calendar - Free online calendar with sync to Outlook(TM). http://calendar.yahoo.com --- URG-L Pour modifier votre adresse de courriel sur URG-L, envoyez un avis a [EMAIL PROTECTED] en indiquant votre nouvelle adresse ainsi que l'ancienne et le nom de la liste.
