Several months ago, I handed in my letter of resignation at the women's health clinic where I'd worked for more than 16 years.
The letter said, in the words behind the words, that in a few weeks I would no longer drive each morning through the suburban streets, listening to Morning Edition on National Public Radio; no longer park my car in the basement of the gigantic hospital lot and walk up the cement stairs, stepping over cast-off Band-Aids and crushed-out cigarettes, following the signs that said, "Women's Health Center." I would no longer unlock my office door, greet my staff, and peer into the crowded, noisy waiting room. I would no longer know which of our patients would be blessed by successful pregnancies or negative Pap tests and who would be cursed by blighted ova, infections, or suspicious findings. It was easy enough writing the letter; it wasn't so easy leaving the job.
I've always found great joy in being a nurse. As a new graduate, I worked in intensive care, surrounded by monitors, ventilators, and central lines, the mechanical great grandmothers of the complex pumps and lines I see in the ICU today. Then I became head nurse on the oncology floor, the place where I learned when to bow to death, making way when he slipped in the door. Oncology, like the ICU, was a body place, a place of skin and blood, a world of intimacy and urgency where, if you weren't prepared to use your mind, your hands, and your heart, you wouldn't make it.
After several years, I returned to school to become an NP, which was still a new specialty. For the next decade I worked with pulmonologists and cardiologists in a subspecialty practice, then in family practice, and finally in 1991 I took a position in our local hospital's women's health center, an outpatient clinic for the uninsured and the undocumented.
Here too, I was working in a place where the body and the spirit were everywhere in evidence. Our patients were the poor, the women who could barely scrape together the rent and the girls who lived in cars or flitted from man to man to stay alive. They might speak English or Spanish or Farsi or Vietnamese; they might have only one pair of shoes or they might come in wearing spangles and heels. Whether my patients were abused women, abandoned mothers, or struggling addicts, I tried to accept them as they were. I especially remember Joanna, a young woman who confided that she had been abused as a child. Our ongoing clinical relationship helped her find counseling and physical and emotional healing. I believe that I helped my patients change their lives.
Then, about four years ago, other things began to change. There was increased pressure from insurance and managed care to cut costs and increase documentation, pressure that slowly filtered down to the clinical level in the form of budget reductions and cost-saving strategies. The expectation of upheaval was in the air. Which caregiver among us hasn't felt those strange vibrations?
If a floor nurse left a position or retired, that job was not always refilled. A few floor nurses, burned-out, resigned to pursue other careers. Expectations shifted, and every nurse had to do more work in less time. For a while, though, our little outpatient clinic seemed immune. We had a small staff and often seemed to fly below the radar.
Then the nurse midwife in our clinic was let go. We were all stunned. How could this happen? she asked me. The next day, my supervisor called me into her office. Our conversation went something like this:
"For years," Pat said, "you've been the go-to person in the clinic. I'd like to offer you the position of clinical coordinator. You're already doing most of the job."
I didn't answer right away. Why ask me to do what I already did?
"That's okay," I said. "I like seeing patients. I like doing what I do now." Pat smiled. "We'll talk again," she said.
The following week, her smile was gone, her manner formal. The offer, she said, wasn't actually optional. Either I became the manager of the clinic or in three months she couldn't guarantee that I would have a job at all.
In my mind, I saw a silent parade: all the good nurses being marched away. All the nurses who really knew how to tend patients hustled from the bedside and yoked instead to paperwork and computer screens. All the experienced nurses, the ones who could recognize the stroke, the heart attack, the malfunctioning valve, the impending skin ulceration, the cyanosis, the swelling, the about-to-happen tragedy-all those nurses now overwhelmed, too busy, too focused on numbers and forms to minister to the patients. Was this my fate?
I took the position. Like other nurses, I needed the paycheck, the benefits, and most of all, the opportunity to serve. There were nods and handshakes all around. Then the weeks rolled into months and, little by little, my new job began to change.
I could no longer see patients. Budgets, scheduling, reviews, special projects, and hospital-wide initiatives filled my days. I put away my stethoscope, my white lab coat, my little notebook of facts and medication dosages. Patients and patient care receded until the concept of caregiving became only a pinpoint in the distance. Like other managers, I cut budgets and asked more and more of the already stressed nurses I had once worked alongside. Was this serving patients, supporting my staff, or upholding the words of my Nightingale pledge? Could I even call myself a nurse?
Then I noticed something else.
Writing has always been my avocation, what I love to do when I'm not working, and often my writing involves my nursing. But as my months in management became one year, then two, I realized I had stopped writing-during all that time, not one good poem and only rarely a finished story or short essay. The spiritual dryness I felt in my management role had invaded my writing life as well. Divorced from the immediacy of caregiving, I was cut off from the experience of story, from the human images and events that inspire me as a writer.
I handed in my resignation and soon began a new job in a new institution. This position offers less money and less flexibility, perhaps even less time to write. But I am, once more, where I want to be-with patients, doing what I've been trained to do, doing what I love.
I know no job is perfect; I will certainly miss the best parts of my time in the women's clinic. But I've learned some valuable lessons: I am, first and foremost, a nurse, in the old-fashioned sense of that word. I'm a tender of patients, face to face and skin to skin. In order to maintain this essential connection, I had to dispense with my clipboard and my portable phone, my calendar of budget meetings and deadlines.
I also learned that as nurses, we can sometimes become deadened to what we are doing. Whether we are staff nurses or clinical coordinators, we can become acclimated to stress, discomfort, compromise, and an ever-widening gap between us and our patients, one caused not only by insurance pressures but also by the steadily increasing demands of technology. Instead of taking care of patients, we manage their charts. Soon we begin to think that's what nursing is all about; we forget why we went into nursing in the first place.
It wasn't easy to start over in a new job after all those years. But the rewards have been worth the risks. Once again, I can pull up a chair and sit down next to the exam table. Once again, I can look my patient in the eye and ask, how can I help you?