Текст книги "The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital"

Автор книги: Alexandra Robbins

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The Nurses

A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital

Alexandra Robbins

Workman Publishing

New York

To my family, past and present, with love

Contents

Prologue

Chapter 1

What It’s Really Like to be a Nurse:

The Joy and Heartbreak of the “Secret Club”

Chapter 2

Crossing Doctor-Nurse Lines:

How the Sexy-Nurse Stereotype Affects Relationships with Doctors and Patients

Chapter 3

Who Protects the Nurses?

Taking Care of People Who Punch You in the Face

Chapter 4

When Nurses Bully Nurses:

Hierarchies, Hazing, and Why They Eat Their Young

Chapter 5

Burnt to a Crisp:

How Nurses Cope–and Why Some Crack

Chapter 6

The Stepford Nurse:

How Hospitals Game the System for Patient “Satisfaction”

Chapter 7

The Code of Silence:

Painkillers, Gossip, and Other Temptations

Chapter 8

Don’t Get Sick in July:

Nurses’ Secrets–What Patients Need to Know About Their Hospitals and Their Health

Chapter 9

What Makes a Hero:

Why Nurses Do What They Do

Chapter 10

What You Can Do:

Advice and Inspiration for the Public, Patients, Families, Nurses, Aspiring Nurses, Managers, and Others

Wall of Heroes

Acknowledgments

Notes

Prologue

Four hospitals stand within a fifty-mile radius of a major American city. On the surface, they are as different from one another as fairy-tale sisters.

Pines Memorial Hospital is a pleasant-looking cream-colored building with a sixteen-story tower and broad, welcoming windows overlooking a quiet tree-lined suburban avenue. After decades of independence, the neighborhood’s favorite hospital was bought out by Westnorth, a large healthcare corporation, which is slowly diluting the local flavor. With 190 beds, Pines Memorial serves a highly educated, wealthy population with a large percentage of academics, retirees, and nursing home residents. Because it is close to a major highway, Pines’ emergency room, which has approximately 60,000 visits per year, often treats victims of major-impact car accidents. Nurses joke that the hospital should be called Highway Memorial, because the risks of the highway are far more relevant to the medical staff than the quiet red pine forests outside of town.

Several miles away, South General Hospital occupies a mostly gray edifice curved away from the road, as if to shield its inhabitants from the gang violence that occurs frequently nearby. The Level-1 trauma center—

designated as such because it has the resources to treat every stage of injury, from prevention through rehabilitation—has 300 beds to serve one of the most indigent areas outside the city. South General’s ER sees 95,000 ER patients annually. The reputation of “The South” is like that of the proverbial kid from the wrong side of the tracks, hoping to keep up with her peers, but unable to overcome the disadvantages of living on the poverty-stricken south side of town.

Forty-five minutes west, in a peaceful corner of the city, Academy Hospital, proud and prestigious, inhabits several white-pillared, brick structures that wind around courtyards and patios, reflecting the storied architecture of its surrounding university campus. With approximately 425 beds, Academy treats a ritzy demographic of young and middle-aged residents in the nearby million-dollar homes and the students at the elite university. The Academy ER treats fewer than 45,000 patients per year, partly because it simply does not have the building space to expand its emergency department walls.

And Citycenter Medical, a longtime teaching hospital, is split between two dusty beige high-rises, perhaps representative of its dual personalities: a stalwart institution with top-notch doctors and an ER so poorly managed it is considered dangerous by many of its own staff. A 390-bed Level-1 trauma center, Citycenter has an emergency department that is crumbling beneath the weight of the 85,000 annual patients it does not have enough nursing staff to treat properly. While Pines Memorial treats more blunt force, multisystem traumas because of the car accidents, Citycenter’s traumas are typically isolated injuries, such as gunshot wounds. Easily reached by public transportation and in the heart of a densely populated city, Citycenter is a destination of choice for homeless people, drug-seeking addicts, and the uninsured.

In each of these disparate institutions, pale blue curtains shroud pods of frightened people. In each, seasoned healers perform routine procedures and medical feats behind bleached sterile walls. And in each, tracking invisible undercurrents through hallway mazes, nurses connect doctors to patients, carrying out copious orders in synchronized steps, entwining themselves intimately in convalescents’ lives.

Chapter 1

What It’s Really Like to be a Nurse

:

The Joy and Heartbreak of the “Secret Club”

“Emergency nurses practice in an environment that has been called permanent whitewater, where constant change, challenge, and crisis are the reality. Amazing stories occur each day and some of these stories may never be acknowledged or written.”

–Emergency Nurses Association, Award Recognition Program

“In the hospital, we’re truly a family and we have fun together. ER nurses have the raunchiest jokes, foulest mouths, and grossest stories. Because we’re working in such close proximity there are always inappropriate jokes, comments, and teasing. Occasionally it escalates to a one-night stand between a nurse and doc, but mostly that happens off hospital grounds.”

–an East Coast travel nurse

“It’s like high school, except for the dying people.”

–Sam, a new ER nurse

MOLLY

  PINES MEMORIAL, August

Molly raced toward the nurses station, dodging other fast-walking staff, weaving through stretchers lining the corridors. Traffic was stopped ahead; another nurse pushing a patient bed had gotten stuck because the halls were barely wide enough for two stretchers to pass each other. Molly had no time for this. No one did. The Pines Memorial ER was overloaded with patients, many of them moaning in pain or calling for the nurses who scurried through the brightly lit department.

After ten years as a nurse, three of them at Pines, Molly had learned to tune out the voices, and the cacophony of constant monitor chirps, high-pitched call-bell dings, and low-toned beeps of alarms from patients not her own. She didn’t even notice the smell anymore, a blend of cleaning spray, urine, and, depending on the number of intoxicated patients, alcohol.

Molly ducked under a stretcher, scooted in front of the traffic jam, and helped the nurse lift the bed slightly to extricate the wheels. When the nurse smiled gratefully, Molly flashed a thumbs-up and hustled to the station.

There, Erica, the senior charge nurse, caught her eye. “I’ve been trying to call a Code Purple for hours, but Charlene won’t budge!” Erica said. Friendly and smart, Erica struck just the right balance for a manager: She was firm but fair, and the nurses respected her. It was unusual for her to be rattled like this. A Code Purple—closing the ER to ambulances and rerouting patients to other hospitals—meant less profit for Pines Memorial, which would explain the administration’s resistance. But the ER desperately needed relief.

Charlene, the nursing supervisor, stomped into the nurses station. Erica urgently called out to her. “Charlene! We need to call a Code Purple.”

“No way,” Charlene said, shaking her long blonde hair.

“Every room is full. Everyone has more than the usual number of patients. Even the hallway is full. We don’t have beds to move these people to,” Erica insisted. “Where are we going to put any other ambo patients who come in?”

“I’ll get back to you.” Charlene left the room.

Erica shot a worried look at Molly.

The medic phone rang. Medic phones, which kept Emergency Medical Services in touch with hospitals, resembled walkie-talkies attached to police scanners. As Molly pressed the radio button, the other nurses nearby groaned. “What’s this one going to be?” one nurse sighed.

Molly answered the call. “Pines. Go ahead.”

A medic’s voice crackled over the speaker. “We’re bringing in a seventy-two-year-old male. Working code. Five-minute ETA.”

“Crap,” Molly muttered after she released the button. No time to waste. A working code meant that CPR was in progress.

“We have to make room for a code, y’all,” Molly said, in her unmistakably Southern drawl. Erica didn’t have time to reply before the phone rang again.

Molly reached over and hit the button. “Pines.”

“Medic forty-two en route to your location with a fifty-eight-year-old female in respiratory distress. We have her on BiPAP.” Bilevel positive airway pressure was a method of assisted breathing. The patient probably would have to be intubated.

“What’s your ETA?” Molly asked.

“Ten minutes.”

Erica summoned Charlene again. “Charlene! We’re getting two working codes.”

As the nursing supervisor during a shift when higher level administrators were not in the building, Charlene had the authority to reroute ambulances. But today, she appeared to be more interested in impressing the higher-ups with an enormous patient load than in making sure the patients were safe and the nurses were able to do their jobs.

Charlene gave Erica a long look. “Okay, you can go on purple.”

“Can you fill out the justification form? I have to prep for the codes,” Erica said, already moving toward the supply closet. To call a Code Purple, the ER had to list the number of patients in the ER and waiting room, the longest wait time for patients, and the number of beds available. Charlene would have to explain the financial loss to hospital administrators.

Charlene backed away, palms up. “Oh no, you’re the one who has to justify this closure.” She turned on her heel and strode off.

Erica looked at Molly in disbelief. Molly fumed. This place is exploding, she thought. We’re expected to work at max capacity with no breaks and no acknowledgment or assistance from administration.

At least it was a weekday. One of the more ludicrous hospital policies dictated that on nights or weekends, the nursing supervisor had to page the administrator on call to get permission for a Code Purple. That administrator could be anyone on senior management, including IT or finance personnel. A major medical decision could be made by someone with no medical training whatsoever. At Molly’s previous hospital, the finance director was on call on a day when the ER was flooded with new arrivals. Focused on billing as many patients as possible, he had refused to call a Code Purple even when the physicians insisted that the number of patients was unsafe. A patient easily could have suffered or died because the staff was so busy checking on others. Eventually, an irate ER doctor yelled at the administrator until he agreed to divert the ambulances.

As Erica texted “Code Purple” to the staff and notified EMS and hospitals countywide, Molly and three other nurses scrambled to make room for the incoming patients. They lifted people off hallway stretchers and into standard chairs dragged in from the waiting room. They moved patients from rooms into beds in the hallway. The patients hated being in the hallway because it was a fish tank: Everyone could see you, hear you, rush by you, and knock into your bed. But the nurses had no other choice.

The first code, the 72-year-old man, would be Molly’s. She wheeled a crash cart into a newly vacated room and paged the respiratory therapist on call: “We have a Code Blue coming in. ETA three minutes. And another patient coming in on BiPAP.”

Molly opened an intubation bag to check that it contained all of the necessary supplies. She went to the medication room to retrieve the drugs needed to paralyze and sedate a patient before intubation, in case they would be needed. She set up the cardiac, blood pressure, and oxygen monitor, then visited each of her four patients to ensure they had easy access to a call light. “I’m about to be tied up for a long time with a critical patient,” she told them.

The double doors at the ambulance entrance opened. Two medics raced down the hall, pushing a gurney on which another medic kneeled, rhythmically pressing all of his weight onto the patient as he performed CPR.

The recorder nurse, who documented the proceedings and kept track of time, guided them into Room 5, which nurses had cleaned only seconds before. Molly was glad to see Clark Preston follow them. Handsome and flirtatious, brash and irreverent, Dr. Preston was loved by some nurses and hated by others. Molly thought he was funny—and decisive, which was important in a code.

When the medics entered, the group quickly arranged themselves on either side of the gurney, hoisted the patient onto the ER stretcher, and whisked the gurney out of the way. As Molly hooked up the patient to the monitor, a technician started an IV.

One of the medics addressed the room: “Seventy-two-year-old male. Witnessed cardiac arrest while eating dinner at a restaurant. En route he was given three epi, two atropine. We bagged him because we were unable to intubate.” Bagging referred to a plastic mask attached to an oxygen source. Squeezing the ambu bag caused the mask, which covered a patient’s nose and mouth, to force air into the lungs.

The respiratory therapist had the intubation supplies ready. “Give me a 7.0 tube,” the doctor said. He intubated the patient, and said, “Molly, listen.”

Molly ducked under the medic, who was still performing CPR, now standing on a foot-high step stool. She reached under the medic’s arms with her stethoscope. She squeezed her head beneath the medic, and listened to the patient’s torso for air movement; air in the stomach meant the intubation tube was in the wrong spot. Then she listened to the lungs.

“Equal bilateral breath sounds,” Molly said.

The respiratory therapist attached a CO₂ detector, bagged the patient, and watched. “Positive color change on CO₂ detector.”

The clatter of the gurney carrying the second critically ill patient echoed from the hallway.

“Secure the tube,” Dr. Preston said. “Let’s run an ISTAT.” The tech quickly drew blood to test whether the patient had a chemical imbalance that could be corrected.

“When was the last epi?” the doctor asked.

“Four minutes ago,” said a medic.

“Give another round of epi. Let’s give two amps of bicarb and an amp of calcium,” Dr. Preston said. “Hold CPR.”

The medic stepped down from the stool, trading positions with a new tech. Because CPR was physically strenuous, CPR providers switched off with every pulse check, two to three minutes apart.

Molly quickly felt the patient’s femoral artery at the groin. “I don’t feel a pulse,” she said.

“Continue CPR,” Dr. Preston replied. The tech resumed compressions. “Bring me the ultrasound machine.”

Dr. Preston swiped gel on the patient’s chest. “Hold CPR,” he said. He passed the ultrasound wand over the patient’s heart.

“I do not see any cardiac activity. What is the total downtime on this patient?” he asked.

“We worked him for forty minutes prior to arrival,” said one of the medics.

The recorder nurse reviewed her clipboard. “We’ve worked him for twelve minutes.”

Dr. Preston looked around the room, making eye contact with each of the four staff members. Not all physicians did this. The staff appreciated that Dr. Preston treated them like part of a team. “Total downtime: almost an hour. There’s no cardiac activity. Does anyone have any other ideas?” The group agreed that they had tried everything.

Dr. Preston removed his gloves. “Time of death: 18:04.”

Erica stepped into the room. “Clark, the next one’s ready.” The doctor, nurses, techs, and medics dispersed.

Molly was left alone with the deceased. When she turned off the monitors, the room went startlingly silent. Dealing with patient deaths like this usually didn’t bother Molly; she didn’t even know this gentleman’s name. She imagined the deaths were much more difficult for floor nurses, who took care of patients for days, weeks, or months.

This was not to say that each death on a nurse’s watch didn’t mean something to her. Births and deaths, miraculous saves and sudden tragedies—all were expected outcomes in the microcosm of hospital life, and their frequency both intensified the experiences and desensitized the staff. But deaths were still sacred to the nurses, who were committed to respecting and preserving the dignity in dying.

Molly unhooked the patient from the monitor. He was still warm. She tidied the room in preparation for the family, trashing the plastic wrap from the intubation supplies and the empty glass medication vials. The room looked much more chaotic than the procedure had been. ERs had specific protocols, and everyone on staff worked from the same playbook; if the heart has this rhythm, give this medication; if the heart has that rhythm, shock the patient. Although they had not been successful this time, the staff had worked smoothly together.

Molly thought about how strange it was that she knew this man was dead, but his family did not. She tuned out Dr. Preston’s instructions in the next room, where he had plenty of assistance. She could have followed the action, but just because this man had died didn’t mean he wasn’t her patient anymore. There were still things she could do to help him. Molly wiped the man’s face and closed his eyes to make him presentable for his family. Families usually wanted to see the deceased one last time. Molly liked to make the patient and the room look serene.

Moments later, the registration clerk came to tell Molly that the man’s family was waiting in the private family room. When Dr. Preston was finished with the other patient, he came to get Molly, wearing his white lab coat. He usually shunned medical coats, but Molly had told him once about a report that people believed doctors wearing white coats were more trustworthy and professional. He had donned the coat for family notification ever since. The moment he left the family room, though, that coat came right off.

When Molly and the doctor opened the door, the family members were seated and crying. “Did he make it?” one of them asked. This was almost always the first thing a family member said. Molly had difficulty avoiding eye contact with the family; she couldn’t let them read her sympathy. She kept her eyes trained on Dr. Preston.

As usual, Dr. Preston started at the beginning. “When EMS picked up your father, he wasn’t breathing and his heart wasn’t beating,” he said matter-of-factly, his bright blue eyes sincere. “So they started CPR and transported him to us. When he got here, he still wasn’t breathing and his heart wasn’t beating. We put in a breathing tube, continued with CPR, and gave him medications to try to restart his heart. I’m sorry to tell you that we weren’t able to do that. Your father has died.”

Dr. Preston offered his condolences. After a few beats of silence—rarely did a family say something right away—it was Molly’s turn. “Do you have any other questions for the doctor? I’m going to stay with you and let you know what happens next.” The man’s widow and her daughter shook their heads. Dr. Preston left the room.

Doctors and nurses told the family together so that after the doctor left, the nurse could deal with the emotional breakdowns and walk the family through the next steps. Many doctors first explained how they tried to save the life, before revealing that they were not able to, because, Molly said later, “It’s easier for them to have that gradual letdown. Once you say, ‘He’s dead,’ they’re not going to hear anything else. We want them to know how hard we tried.” Doctors specifically used the words “dead” or “died” so that loved ones couldn’t misinterpret the message.

Molly’s nursing school had offered no instructions on how to talk to the family; her psychology rotation covered only mental illnesses. The one official rule Molly had learned was that staff first had to notify the next of kin before letting nonrelatives know. When a patient collapsed in the workplace, coworkers often sat in the lobby for hours without knowing the patient was dead, because the ER staff couldn’t tell them before locating the family.

By watching physicians like Dr. Preston, who presented the news well—and, equally as helpful, those who did not—Molly had learned what the bereaved needed to hear at this crossroad. Many nurses hated this task. Molly didn’t mind it, particularly when she was paired with a doctor who was not good at it. She considered it her responsibility to soothe and assist the families, much as she had done with the patient.

Molly sat down next to the widow, who sobbed on her shoulder. Families usually wanted some physical contact with the nurse. Molly typically put her hand on a shoulder and let the person guide her from there. If the family member needed more comforting, she would lean into Molly’s shoulder or reach for a side hug. Molly remained quiet during these interactions. At this point, people didn’t want to hear, “It’s going to be okay.”

When the woman’s cries subsided, Molly spoke gently. “Next, you’ll need to contact a funeral home and let the hospital know which home you’ll be using. Your husband will be in our mortuary until you make that decision. Take all the time you need. Whenever you make that decision, Registration will make the arrangements to have him transferred over there.”

The widow looked up at Molly, still stunned. “Next week he was going to help drive his granddaughter to her first day of college,” she said.

Almost every family told Molly something specific about the deceased, as if subconsciously trying to prolong his life for just a moment longer. Molly always tried to come up with something positive and personal to say, so that the family would know that the hospital staff saw the deceased as a human being rather than a patient. “He must have been so proud that his granddaughter is going to college,” she said.

The widow and the daughter both nodded, smiling through their tears.

As soon as a nurse on the 7:00 a.m. to 7:00 p.m. shift got off work, she was supposed to “give report,” a recitation of her patients’ status for the incoming nurse. Molly already had been working for more than twelve hours without a break. She hadn’t even eaten. Nurses at Pines almost never got time off for lunch. There was rarely a chance to go to the cafeteria, break room, or simply outside for thirty minutes. Only once in the past two years had Molly been able to leave the department for a break. The usual scenario involved eating while working at the nurses station, which was an Occupational Safety and Health Administration (OSHA) violation.

Hospitals were required to give nurses breaks, yet the constantly short-staffed Pines nurses never had time for them. Technically, nurses were prohibited from bringing food or beverages to the nurses station to prevent them from contaminating patient labs and vice versa. Priscilla, the nursing director in charge of supervising every nurse in the ER, let the OSHA rule slide because the odds of getting caught were low. When The Joint Commission—the governing body and accreditation group for hospitals—sent inspectors, they had to check in at the front desk. Immediately, a hospital-wide page would announce, “Pines Memorial would like to welcome the TJC inspectors.” Molly said the announcement meant “Hide your food!” She explained, “After the announcement, we have about ten minutes before the inspectors get to us. It’s so obvious, like, ‘Warning! Mayday! All the stuff that shouldn’t be out—hide it!’”

Priscilla let many rules slide, actually. She seemed to try to look out for the nurses as best she could, which couldn’t have been easy because she also had to enforce the new policies thrust upon them by the Westnorth Corporation, the giant healthcare system that had taken over the hospital six months earlier.

At 7:20 p.m., the charge nurse assigned Molly to put a Foley catheter in an obese paralyzed patient, a somewhat time-consuming procedure that required assistance. Molly walked to the nurses station, where five nurses were giving report to the oncoming shift. “Y’all, can I get a little help in Room 3 with the Foley?” she asked. The nurses ignored her. They didn’t even make eye contact with her.

These weren’t generally uncivil nurses; they were just busy. The outgoing nurses were determined to give report and go home, and the incoming nurses didn’t want to be bothered with someone who was not their patient. The nurse Molly would give report to was already working on a trauma patient. Molly knew that if her friend Juliette had been on duty, she would have been at Molly’s side in a heartbeat.

Molly looked over each of the nurses with her piercing green eyes. A tall, striking brunette, she was hard to miss. Five people were ignoring her—and she was not a quiet person. She had hoped that one of them would sense her frustration and offer to assist. But she would not badger them into helping her out.

Typically, many of the nurses at Pines worked well together, giving aid when needed, knowing they were in it together. Erica, for example, was constantly assisting her coworkers at bedside on top of her supervisory duties, as she was today. Ever since the buyout, however, the atmosphere had changed. The morale was as low as Molly had ever seen it. People were just too tired and angry to help each other out. The staff knew why Pines had allowed the buyout: Independent hospitals across the country were having trouble turning a profit because new insurance guidelines made getting reimbursement for medical care more difficult. Westnorth had instituted several changes that angered the nurses, including cutting their weekend overtime pay and slicing vacation accrual in half.

One of the worst new policies forced nurses to pay for parking at the hospital while techs and physicians could still park for free. The nurses who didn’t want to pay for the covered garage would have to park at a satellite garage that was a shuttle bus ride away from the hospital. To catch the bus, nurses would have to get to work thirty minutes before their shift began and wouldn’t get back to their cars until at least thirty minutes after their shift ended, effectively adding an unpaid hour to their workday. What kind of company wants to make money off its employees like that?! Molly had wondered, dismayed.

The hospital takeover had directly and indirectly affected patient care, too, which was evident when Molly ended up struggling to insert the Foley alone. The procedure took longer than it would have if another nurse had helped to lift the obese patient. ER staffing was supposed to be determined by the number of patients who came in. The number had increased drastically enough to justify an additional staff nurse for every shift, but Westnorth had refused to hire anyone. Consequently, waiting time to get into the short-staffed ER had increased from an average of thirty minutes to three hours.

That night, on the drive home, Molly cried with frustration. She was known as being thick-skinned rather than a crier. She was so tough that once while playing pickup basketball, she tripped and broke her arm, but waited hours before going to the hospital because she was having too much fun to stop playing. Now she cried because the once tight-knit hospital no longer seemed to care about the welfare of its nurses, and her usually co– operative coworkers were so worn down that they “acted like I was invisible.”

As Pines Memorial’s treatment of nurses deteriorated under Westnorth, Molly had toyed with the idea of leaving the hospital. Earlier in her career, she’d worked as a nurse for an agency that assigned her shifts at different hospitals. As an agency nurse, she could choose which days she worked, and the pay was slightly higher. To return to the agency, where she was a nurse in good standing, all she had to do was fill out paperwork and send in her latest certifications.

Molly had stayed at Pines because she enjoyed learning from her experienced colleagues. But lately, there had been too many days like today. That night, she called Priscilla and left a voice message about the day’s events. “I have gone home angry and in tears more in the last two months than I have in my whole career. If I leave work angry again, I will not come back.” It may not have been the best way to let her boss know that she was close to quitting, but she was too frustrated to care.

The next morning, Molly, the designated trauma nurse, was able to focus exclusively on her patients without having to deal with politics, or so she thought. A middle-aged woman had multiple injuries from a car accident, and the operating team would have to repair her ruptured spleen. Molly’s job was to keep her stable in the trauma room until the OR was ready. As Molly connected the patient to a monitor, a nurse sitting at a computer called out from the nurses station.

“You’re going to love this one, Molly,” she said. “Now we’re going to have to pay for fancy uniforms!”

Molly froze. “What?” She breathed deeply. She had a patient to take care of. “Just a minute. Let me finish what I’m doing and I’ll come over.”

While Molly continued to work on the patient, the other nurse read aloud the policy, which administrators had posted on the employee website without notifying the ER nurses. All staff would now be required to wear a standard uniform. But only the nurses would have to pay for the uniforms out of pocket.

“What about the doctors and the techs?” Molly asked.

“Nope,” the nurse replied. “They’re covered.”

That was the last straw. It wasn’t the uniform, specifically. It was what the uniform expense represented: Pines didn’t appreciate its nurses. Furthermore, management gave employees little motivation to work hard. Hospital employees weren’t held accountable for their actions, and the supervisors were either too wimpy to enforce important hospital rules (Priscilla) or played favorites (Charlene). Too frequently, certain nurses and techs called in sick, then posted vacation pictures on Facebook. Or they were unprofessional: Lucy, the laziest tech in the unit, had refused to do lab work on patients she deemed too “gross” to touch. As Molly said, “There are no consequences for poor work ethic and no rewards for good work ethic.”