It is 10:00 p.m. on Thursday evening. In four months I will be a first-time mother. Presently, I am manager of a thirty-four bed oncology unit in a community hospital. Eighty percent of my staff are first-time hospital nurses. I have had a short tenure, and I am uncertain if I will return after the baby is born. I would like to finish well.
Tonight I will work with the night shift. My goals are to open communication, to stand in solidarity with this hard-working core that keeps the unit together after dark, to educate, remind and observe.
Currently nursing is experiencing a shortage. When I first heard this about two years ago, I couldn't believe it. Today I know it is true. Just two years before the news of an impending shortage, I accepted a per diem job so that I could get my foot in the door at the hospital. Hospitals were merging, and nurses were being laid off. The market was tight, and many new graduate nurses were accepting positions in long-term care. I hired several of them this past year, each one eager to get some acute care experience. Now each is anxious for more help and some relief from high demands and shrinking resources.
Management scurries around, attempting to rethink the nursing care model, inject pride in the profession, promote high nursing standards and professional accountability and stay afloat fiscally. I am an idealist, and I like promoting ideals. I have been frustrated since this is not an ideal time for my profession. I know that nursing has experienced this kind of pressure before and perhaps even emerged in response to a mushrooming demand for physical care and human compassion during crises larger than a booming, then plummeting, economy.
Although in the U.S. no war motivates us to service, many nurses are war-torn and battered by the nursing crisis. Nurses are often called upon to stay extra hours or an entire shift. Many are burdened with more patients than they can manage effectively with dignity and satisfaction. We are pushed by the market to deliver competitive customer service in an effort to retain the local hospital's market share, with limited resources to get it right the first time. Nurses are challenged by an informed, and increasingly sick, consumer who demands more information, more expertise and more caring. Newly graduated nurses come with less clinical experience and a view of leadership that has abandoned service and mentorship.
I appreciate the influence of business on health care. I have advocated shorter lengths of stay so the hospital can remain fiscally solvent. I have evaluated and disciplined staff for excessive use of sick time, which exerts its toll on the annual budget. I have waited months to replace necessary equipment, fixtures and furniture. I have reduced hiring and struggled for minimal safe staffing and then increased hiring again. I have lost many nurses to the other local hospital that offers increased wages, weekend incentives and access to gym facilities. I have listened to them say they simply need more money, more flexibility and greater benefits for what they do.
The market economy also influences the quality of work generated and the attitudes that accompany this work. One struggle I have faced has been what, at first glance, seems to be an unmotivated, undedicated, selfish work force. I have often been surprised by the lack of concern about professional standards, the outright unwillingness to participate in unit-based improvements or to assist with staff coverage for vacations and sick time, and the ongoing demand for more pay for less work.
I believe this is influenced by a burgeoning technology sector where young men and women earn large salaries with even larger compensations, such as cars, phones, offices and other amenities. The success of the information age has influenced the expectations of the service sector, and we cannot keep up. I advocate for my nurses. I call them to something greater than themselves, but we are tired.
I start my time on the night shift explaining why I am there and what the staff can expect from me. Previously, one of the night nurses has expressed frustration over an interaction with a new nurse who often challenges the equity of her assignment. They are both working tonight.
I check in with the evening nurse in charge. She tells me that she does not make an assignment because there has been conflict at 11 p.m. when the night nurses arrive. She prefers to see the night staff work out their concerns about the patient assignment. Next I touch base with the night nurse who raised the concern. She shrugs her shoulders and smirks, telling me dismissively that it is not a problem. I don't believe her; I hear her telling me that she doesn't expect the problem to be resolved. We talk a little longer about the assignment and the role of the charge nurse.
Unexpectedly, she becomes more heated in her comments and seems angry. She tells me that if she wanted to have responsibility for the whole floor she would be in management. She expresses that it is unfair for staff nurses to be in charge without compensation. She also tells me that it is unfair for her to have a busy and complex assignment and to be expected to be concerned about staffing. She asserts that she is primarily concerned about her license and secondarily will address concerns that affect the charge nurse. She reminds me that other floors do not do this and that in other places nurses are paid extra to be in charge.
I start to feel defensive and yet want to be available for such concerns. I feel angry that she has not expressed this previously, that she doesn't own her concerns until pushed to do so and that she is adamantly and defiantly stating that she will not accept what I see as professional responsibility well within the realm of the RN. She is one of my better nurses too, and I feel sad and discouraged. I want to go back to the comfort of my office and the known challenges of the day shift.
I wish I had more management training and knew how to handle this better. Instead of listening, I offer a defense and a dictum about the role of the professional nurse. I tell her that compensation is being discussed and that I am working on solutions for night shift staffing. I remind her that one of the three nurses scheduled for tonight called in sick, which seems typical when the census is low and undermines my effort to resolve their staffing concerns.
I remind her that the night shift has put down my proposed solutions. I am hurt. I tell her that management is not equivalent to leadership and that leadership is needed at the staff nurse level. I invite her to continue to tell me of her concerns and to be a part of defining the solutions. I imagine she does not believe my offer. Certainly, if I were genuinely concerned, I would have listened and not defended. What am I defending, anyhow? My efforts, my shortcomings, myself? A strained and torn system? The ideal. I am a nurse too.
As expected, the night nurse arrives, and no conflict arises because I am watching, and she wants to succeed in this new position. The night routine begins, and I restart an IV and audit the charts for our three cardiac-monitored patients. I review charts for completion, and I e-mail staff who didn't complete the restraint checks for one patient. I answer call lights and get a cup of tea for an anxious patient with a grave prognosis. I answer the phone and accept an admission. I report the admission to the reluctant charge nurse and help her decide which of the two nurses will take the patient. Again she shrugs her shoulders, and states she will just take the patient. She doesn't want any conflict.
I encourage her to make the right decision and appropriately assign the patient to the other nurse who has a heavier but less complex patient load. We talk briefly about equity in workload being greater than equivalent numbers. I talk with the night supervisor, assist a nurse with rhythm interpretation and help to settle and admit the new patient. I spend a few minutes with the night nursing assistant. I would like her to receive some additional training so I can justify her not floating when I hire a second full-time aide. She has worked on this unit for over ten years. I would like to reward her longevity. She agrees that a second aide would be a great help. I am relieved.
I leave about 3:15 a.m. Now I have many things on my mind and wonder if I will be able to sleep. I am worried that I put too much strain on my pregnant body, and I wonder how I will balance these dual vocations of nursing and motherhood. Most of my friends and staff tell me nothing is more important than this new life I am nurturing and will welcome in a few months. They assure me I will be transformed, concerned for nothing besides the new baby. I am not sure.
For ten years I have invested my time and energies to understand nursing as a legitimate vocational calling. I have desired to maintain a call to professional service, not professional ambition. I want to instill this vision in others. I would like to see nursing restored to a valued public service with intelligence, reasonable compensation and enduring compassion and dignity. I wonder about the impact on the ever-increasing shortage of nurses if one more nurse steps down. I know that my service will not make all the difference, but I know it makes some difference. I sleep, and then awaken to talk over the night with my husband before he leaves for the day. It is 10:00 a.m.
We talk about the strain on nurses and the resultant lack of leadership. I wonder how to develop leaders in an age of self-service. I wonder what is fair and reasonable. I wonder what I can do next week to assist the night shift. I wonder if nurses can be recruited to such difficult demands. I wonder how nurses have kept going all these years and wonder what we are lacking today to motivate and invigorate the profession. I wonder how nursing will navigate the waters of business and health care and retain a compassionate service sector.
Two thoughts help me day to day. First, I think of Queen Esther and how God put her in a difficult position "for just such a time as this" (Esther 4:14). Second, Jesus said we are salt and light in the world (Mt 5:13-14). Salt slows down the rotting process. Light reveals problem areas and effects change. I want to be salt and light in nursing. I care deeply about nurses and about supporting positive structures where nurses practice. In doing so, I hope that I can faithfully represent Christ in the world.