Even in the best of times, nursing is a terrible job. We get pooped on. Yelled at. We care for a lot of people who are having the worst day of their lives. Unsurprisingly, they’re not always particularly nice or grateful, no matter how kind and gentle we try to be. We cause pain in the name of healing, sticking needles and tubes in places nature never intended, and we spend a surprising amount of time extracting, collecting, measuring, and transporting bodily fluids.
And smelling them, too. There’s a special place on patient charts to note the odors of urine and wounds. You can learn a lot about a disease by how it smells.
This is not a job for the faint of heart or weak of stomach. But some people love it, and I am one of them. The truth is, I’m kind of a chaos junkie. I think most of us hospital bedside nurses are. I like messy things — and what’s messier than people, with their irreconcilable desires and needs? Illness and injury make things even more complicated, and hospital bedside nursing, as a result, requires a lot of creative problem solving. It’s smelly, challenging, and never, ever boring.
But ask any bedside nurse what the worst part of the job is, and chances are they won’t even mention bodily fluids or patients’ insults. The answer I hear most often is the same as mine: charting.
Accurate, timely charting of nearly every patient interaction, assessment, and intervention is mandatory. Arguably, it’s the requirement that matters most to the hospital administration. I’m not being critical here — I get it. Insurance companies pay the bills. They demand documentation. It’s part of the job, and we do it, grudgingly.
There’s a host of other duties we have outside of direct patient care — everything from calming family members and tracking down doctors (who appear and disappear from patient rooms like specters, impossible to catch), to triple-checking odd-sounding medication orders and running around the hospital looking for supplies. Cleaning, disinfecting, spraying deodorizer in the halls — if it needs doing, we do it. And most of us like the variety. It keeps things busy and interesting, and you get your steps in.
But all these tasks, patient care and others, take time, and there’s a limit to how many a nurse can perform in a 12-hour shift. That limit dictates the number of patients we can safely care for. The sicker the patients, the more tasks they require and the fewer the patients we can safely be assigned.
In my experience as a nurse, and from the many fellow nurses I’ve talked to, I’ve learned that most hospitals ignore these essential limits on nurse-to-patient ratios. Legally (except in California), they get away with doing so. We can argue about the reasons — budget shortfalls, staffing crises, “it’s a pandemic!” — but concerns over unsafe staffing ratios have been voiced for decades and are likely to remain until hospitals are forced, either by law or by finances, to accept that nurses are not bottomless pits of cheerful productivity.
There are increased legal and ethical risks inherent in caring for too many patients at one time. Nursing errors become inevitable, and we’re responsible for those, regardless of staffing levels. We’re given no tools with which to mitigate these risks. In the places I’ve worked, there are no “crisis-level staffing” policies or procedures to relieve nurses of any of the burdensome charting requirements or any other duties, no matter how many patients they have, no matter how sick the patients are.
We’re expected to complete more tasks in less time. But a patient who just had a hip replaced can’t be made to walk faster to her commode. An IV antibiotic that needs to be administered over five minutes can’t be administered in two. Good, safe patient care is time-intensive. Reduce the time, and it’s neither good nor safe.
“The problem is, nurses just take the path of least resistance,” my manager said to me recently. We were discussing my safety concerns about the unit. Safety policies and procedures are often designed by nonclinical staff and ignore the realities of patient care. Some are so cumbersome they are impossible to execute. As a result, they get bypassed or curtailed. I had suggested that if a particular workflow were changed to accommodate practical constraints, it would increase safety, because staff would be able to implement it.
My manager disagreed. Hospital policy, she explained, is based on best practice, and nurses need to figure out a way to follow it. Then she smiled, like we had an understanding, and thanked me for my input. I smiled back — what more was there to say? — and finalized my resignation a few minutes later, while my anger was still fresh. I knew that if I waited, the chaos junkie in me would begin eroding my resolve, reminding me how fun and exciting it is trying to conquer the impossible, day after day.
I hear a lot of people blaming the mass nurse exodus on “burnout,” but I think that misses the point. Even in the midst of a pandemic, I loved my job. What I couldn’t stand was the constant administrative pressure to accomplish the maximum number of tasks in the minimum amount of time and the fundamental lie that I should be able to do so without compromising my patients’ safety — and my own.
Clara Yim Bolduc is a hospice nurse. She lives in Maine with her husband and four children.