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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Текущая страница: 12 (всего у книги 33 страниц)

MOLLY

  November

South General Hospital

Molly was assigned to a patient who had developed a 104-degree postoperative fever after a minor surgical procedure. Molly introduced herself, then started an IV to deliver fluids and medicines. An hour later, when she checked on the patient, the woman was feeling better. In a tired, crackly voice, she said, “Thank you, Molly.”

Molly couldn’t believe it. In ten years, no patient had taken the time to thank her by name. That small gesture made Molly feel important, “not in the world, but to that patient,” she said.

As Molly continued to work at South General, it happened again. But, for Molly, while the patients were preferable to Pines’, the nurses were not. The racial divide was pronounced: The white nurses worked together and the black nurses worked together. Except for Lara, whom the black nurses seemed to accept, South General nurses rarely crossed that line.

As much as Molly liked South General, her commute was ninety minutes each way, which meant her workday totaled fifteen hours. Knowing that South General was not the ideal hospital she sought, she decided to drop the hospital from her agency rotation and pick up more shifts at Citycenter and Academy.

Citycenter Medical

One afternoon, a foreign-born woman came into the ER with abdominal pains and breast tenderness. Women of childbearing age with abdominal complaints automatically got a pregnancy test. Some of the women had no idea they could be pregnant. Others came to the ER because they would rather Medicaid pay hundreds of dollars for a hospital visit than spend $10 themselves for a home pregnancy test. Molly took the urine sample to the lab room and placed four drops onto a pregnancy test kit.

After Molly’s second post-IUI pregnancy test had been negative, she had kept her chin up. But when a third IUI was again unsuccessful, she started to get discouraged. Her follicles weren’t responding well to the fertility medication. The IUIs, lab tests, and drugs already had whittled most of her insurance coverage. If Molly’s next IUI was unsuccessful, her doctor had told her they would have to move on to IVF, an even more expensive process that she would have to pay for entirely out of pocket.

Molly had never been the sort of person to “What if?” but even she wasn’t immune to these creeping doubts. What if the next IUI didn’t work? What if her money ran out? And, worse, what if she couldn’t get pregnant at all?

When Molly returned to the patient’s room, she asked the woman if she could discuss the test in front of her husband. The woman nodded.

“The results were positive. Y’all are pregnant,” Molly said.

The couple immediately burst into joyful tears and hugged, ecstatic. “We have been trying for a while,” the woman said through misty eyes. “I have lost a baby in the past.”

Molly wiped her eyes and, smiling, left the room. She couldn’t decide whether her tears were “sweet tears, happy tears, or jealous tears.” Whichever they were, Molly couldn’t remember ever feeling that way before.

Academy Hospital

In late November, Molly wore Thanksgiving scrubs for an Academy shift. “Oh, would you look at that,” Molly overheard the baby nurses titter, hyperaware that she didn’t bother to follow their trends. Molly didn’t mind the comments; the young nurses probably considered her cheerful animal-printed scrubs the equivalent of, in her words, “the grandma sweater with the embroidered flowers.” The Academy girls wouldn’t be caught dead in printed scrubs. But patients often commented on Molly’s with a smile.

Nurse divisions were particularly stark at Academy. Academy nurses had a “look,” a uniform within the uniform. Most of the nurses were new grads who wore designer scrubs (such as Urbane), North Face zip-up tops, and $120 Dansko nurse clogs. Molly wore her old running shoes for comfort.

The divisions went beyond the clothes, though. The major clique consisted of what Molly called “the cute little trendy girls” who had graduated from Academy’s prestigious nursing school. The Academy graduates were talented, prepared nurses who would not leave any coworker in the lurch professionally. But socially, they distanced themselves from nonalumni.

One of Molly’s favorite nurses was Claire, who had spent two years as a medical/surgical nurse before coming to the ER. Claire was friendly, helpful, and overweight. She had told Molly quietly that clique members weren’t nice to her and made her feel inferior, even though she was more experienced. Two months later, Claire quit. “It makes me sad,” Molly said. “She was big, and being a cute nurse at Academy really equals being part of the ‘in crowd.’ For some nurses, being included like that makes them happier workers and better able to focus on their job, so when they’re blatantly left out, their days are much more difficult. The profession has that reputation of older nurses eating their young, but I feel like the younger nurses were eating their fat.”

At Pines, Molly did not believe that Juliette’s size was the reason the clique excluded her. Juliette was the type of person whom you had to get to know in order to love, and some people didn’t look past their first impression. Juliette could say something completely benign, but her tone of voice could make it sound negative, and her blunt mannerisms could seem abrasive. Molly tried to persuade her to leave Pines and work for the agency instead; the agency would hire her back without question. She thought Juliette would be happier outside of Pines’ strange social bubble.

Molly had befriended Juliette when they were both new nurses. She came to know her as funny, outgoing, loving, kind, and generous. Juliette had a handful of close friends for whom she would do anything, and she often let them know how much she cared for them. She was much softer than people realized. If Molly were to play armchair psychologist, she would guess that Juliette was the way she was because she had a difficult childhood with an alcoholic mother who chose booze over her daughter. Molly believed Juliette had constructed a tough exterior to protect her feelings but at the same time was desperate for approval. It was a combination that unintentionally could come across as simultaneously harsh and needy.

The traits that nettled Juliette’s colleagues were some of the same characteristics that made her an excellent nurse. Juliette was fiercely loyal to her patients, standing up for them no matter the cost. Patients also appreciated that she was straightforward; she told them the real scoop and then did everything in her power to help make them better. It was a mistake to dismiss Juliette without giving her a chance.

Nurse on Nurse

Nurse-to-nurse bullying has been called “a silent epidemic,” “professional terrorism,” “insidious cannibalism,” and “the dirty little secret of nursing.” And it is crucial that the public learns about it—and hospitals eradicate it—because it affects patient care.

Workplace bullying can happen in any profession. It may come as more of a surprise from nurses, who are expected to be nurturing, empathetic, and caring. But the numbers are staggering. In the United States, a Journal of Nursing Management study found that 75 percent of nurses had been verbally abused by another nurse. It is so pervasive that even the American Nurses Association observed, in literature for its members, “Most of us could probably recount at least one story in which we as nurses encountered or witnessed workplace bullying.”

Nurse bullying is a significant problem in many corners of the world, in countries as diverse as England, Japan, Portugal, Finland, Australia, New Zealand, Ireland, Taiwan, Poland, Canada, and, a country with particularly high rates, Turkey. Worldwide, experts have estimated that one in three nurses quits her job because of it, and that bullying—not wages—is the major cause of a global critical nursing shortage. “We are not ‘angels in white,’” a Japanese nurse told me.

One of the most sobering statistics comes from Boston Medical Center’s director of nursing education and research, Martha Griffin, who found that nurse bullying is responsible for 60 percent of new nurses leaving their first jobs within six months and 20 percent leaving the profession entirely within three years. “It is destroying new nurses,” a Kansas nursing instructor told me. “I have five students who graduated less than a year ago who quit the nursing profession because of this behavior. It makes me very sad.”

It is tempting to attribute nurses’ hostility to their high-stakes work environment. But studies show that more nurses experience bullying from peers than do doctors or other healthcare staff. And nurses are verbally abused more frequently by each other than by patients, patients’ families, and physicians.

As distressing as it is for a nurse to be bullied by a physician, disruptive-behavior expert Alan Rosenstein reported that nurses are more upset by nurse-on-nurse “backbiting and unnecessary scrutiny.” As one nurse wrote him, “I expect that behavior from the surgeons, not the nurses, because I rely on them as my peers.”

In 1986, nursing professor Judith Meissner coined the phrase “nurses eat their young” as a call to action for nurses to stop ripping apart inexperienced coworkers. Nearly thirty years later, the practice festers, and while younger nurses may more often be targeted, no nurse is immune. As a Washington State Post-Anesthesia Care Unit nurse said, “There is a culture of treating other nurses like dirt.” The mystery is why this behavior continues.

Bullying among nurses goes by several names, including nurse-on-nurse hostility and lateral aggression. Rosenstein noted that nurse bullying is usually less direct than doctor bullying; it is more frequently behind-the-back “undermining, clique formation, and other types of passive-aggressive behaviors.” Indeed, a Research in Nursing & Health survey found that the most common bullying methods are, as Juliette experienced, “being given an unmanageable workload (71 percent) and being ignored or excluded (58 percent).” Nurse bullies have admitted to other researchers that their most frequent weapon was “to stop talking when others entered the room.”

According to Griffin, the five most frequent forms of lateral aggression among nurses, in order of frequency, are: “Nonverbal innuendo (raising of eyebrows, face-making), verbal affront (covert or overt, snide remarks, lack of openness, abrupt responses), undermining activities (turning away, not available), withholding information . . . , [and] sabotage (deliberately setting up a negative situation).”

Several other behaviors fall under the bullying umbrella, including when nurses gossip; ignore; condescend; belittle; humiliate; in-fight; unjustly criticize; fail to support a coworker because of dislike; give the silent treatment; make slurs or jokes about race, religion, appearance, demeanor, gender, or sexual orientation; or exclude a nurse from socializing. Bullying includes giving hints that a coworker should quit his or her job and excessively monitoring a peer’s work. Pennsylvania State professor Cheryl Dellasega has written that other common relationally aggressive behaviors include “manipulating or intimidating another nurse into doing something . . ., teasing another nurse about lack of skill or knowledge, running a smear campaign, or otherwise trying to get others to turn against a nurse.”

Verbal sexual harassment, unwanted touching, and physical intimidation also feature in the nurse bullying landscape, though less prominently. Canadian researcher Brian McKenna learned about incidents among nurses such as “sexual harassment with the promise of employment for compliance” and “colleagues ‘setting up’ a nurse to be exposed to sexually inappropriate behavior from patients.”

The Workplace Bullying Institute reported that nurses regularly call its help line. Founder Gary Namie has said, “The same people tasked with saving lives of strangers turn on their own if they don’t like someone’s makeup or the car she drives.” Nurses told me of coworkers they call “the Troll” or “Bitch on wheels.”

Studies support Molly’s observation that nurses “eat their fat;” Finnish researchers found that bullying victims have a higher body mass index than other nurses. But nurses of all shapes and ages shared stories about other nurses making fun of their clothes, gossiping, berating peers until they quit, and purposely withholding information to embarrass them in front of doctors and other nurses. A Virginia ER nurse said that when she was a new graduate, older nurses tried to humiliate her in front of the attending, took credit for her work, told physicians that she didn’t know what she was doing, and changed her charting to sabotage her career. A Michigan nurse manager’s director forced her to retire because she refused to bully staff like her predecessor did. Bullying behavior happens, the nurse said, “because when there is little support for nurses, they make themselves feel better by making someone else look worse.”

“Structural bullying,” or unfair or punitive actions by supervisors, is a major problem in the field. A New Zealand study found that more than one-third of nurse respondents believed they were neglected, had learning opportunities blocked, and were given responsibilities for which they were not equipped. Nurses report that charge nurses, nurse managers, and other supervisors can penalize nurses they don’t like by giving them undesirable schedules or patient assignments, piling on the workload, or pressuring them not to use their vacation or sick days. A nurse told University of Massachusetts professor Shellie Simons, “During my first pregnancy, because the charge nurse did not like me, I was assigned the most infectious patients: HIV, tuberculosis, and hepatitis.”

Some administrators use vague standard descriptors like “core values” to arbitrarily punish nurses. In the Northeast, a nurse was sent home without pay for wearing her hood up during the walk from the parking garage to the hospital, because the dress code for nurses on hospital property (even when they are not on the clock) prohibited hoods, jeans, and flip-flops. “Our hospital uses the term ‘professional behavior and attire’ to discipline at will, and all it takes is one complaint,” said a nurse at that hospital. The hospital’s managers demanded that nurses cover tattoos and piercings, “even though they were hired with them. They requested a nurse to alter her hair color because it was dyed an unnatural shade of red.” The administrators did not enforce these dress code policies on physicians.

Misunderstanding among specialties

Prejudices and perceived tiers among nurse specialties and degrees contribute to the animosity. A Hospital Access Management article reported that “nurses create a kind of hierarchy within their own ranks in which trauma and cardiac critical care nurses, for example, consider themselves the ‘cream of the crop.’ ” Some nurses joke that RN stands for “Real Nurse,” which denigrates Licensed Practical Nurses. (LPNs have taken approximately one year’s worth of courses; RNs have at least a two-year degree, a three-year diploma, or a four-year bachelor’s degree.) Nurses told me about rivalries among specialties, between hospital and rehabilitation nurses, and between hospital nurses and nurses at doctors’ offices. A cardiovascular ICU nurse said that because her specialty is often considered the top in the field, when she floats to other units, they give her the worst assignments. A nurse practitioner said that she and her colleagues call ER nurses “trauma jockeys” because they enjoy “blood and gore” and “gossip about the people who come through and the gore they see.”

Several nurses said that other units mistakenly believe their specialty is easy. “They think we don’t work very hard and that we’re not as tough as med/surg or ER nurses,” a Maryland postpartum nurse said. In nursing school, one of her clinical instructors, a medical/surgical nurse, told the class that if she were in postpartum, “I would get so bored. I like working hard.”

A school nurse in Louisiana told me, “People think I put Band-Aids on all day, but it’s not that simple.” School nursing is far more complex than the stereotype implies. “I think the public generally believes that school nurses want to take it easy and just do some first aid,” said Carolyn Duff, president of the National Association of School Nurses, which estimates that there are approximately 70,000 school nurses in the United States. “What’s really true is that nurses who work in schools are highly skilled and highly educated generalists who are responsible for both the children and the adults in their building.”

In fact, school nurses may have a larger potential patient load than other nurses. School nursing requires the technical skills to treat chronic disease conditions, as well as the intellectual skills necessary for disaster planning, Duff said. “For students who may not see the school nurse often, planning occurs for them whether their parents know it or not. Take something as simple as immunization compliance: School nurses are accountable for making sure their populations are immunized according to state regulations. They know which students are not immunized and make sure when there are outbreaks, those students are excluded from school for their own protection. They have a constant awareness of each student’s particular needs.”

A South Carolina trauma nurse confessed that she looks down on floor nurses and nursing home nurses. “I will absolutely admit that I am biased. To me, everything less than critical care is somehow below nursing. I work at the highest level of my degree and scope of practice. Why should someone operating at the bottom also be called a nurse? It’s like that sad-but-true joke: ‘What do you call the person who graduates from medical school at the bottom of their class?’ ‘Doctor,’ ” she said. “Sometimes I almost wish that my RN came with a gold star next to it, because I crave some extra recognition for how hard I work. I am an RN, BSN, CEN, and almost a SANE [Registered Nurse, Bachelor’s of Science in Nursing, Certified Emergency Nurse, Sexual Assault Nurse Examiner]. Yet to the doctors and the patients I’m ‘just a nurse.’ ”

Part of the problem may be a lack of understanding among the specialties. For example, when I interviewed floor nurses across the country, I raised Molly’s complaint that floor nurses made excuses to avoid taking new patients at shift change. They told me that the reason they prefer not to take new patients then is because the chaotic timing could jeopardize patient safety. When ERs transfer a new patient at shift’s end, some floor nurses call it a “dump and run.” An Indiana psychiatric nurse said, “We don’t like taking patients at shift change because that’s the time when everything and everyone are the most disorganized, so the patient won’t get the attention he or she deserves. It’s not fair to the patient and it’s stressful for the staff.”

For approximately half an hour, the outgoing floor nurse is so busy giving report that she cannot give a new patient the necessary one-to-one time, which can involve a more complete medical assessment, settling in the patient and family, activating orders, writing admissions paperwork, starting labs, collecting specimens, documenting, setting up the room, making sure the patient is stable, etc. “We don’t just take vitals and tuck them in,” said an Arizona pediatric oncology nurse. The floor nurse needs to be with the new patients so she can pick up on a potentially life– threatening situation. As a Washington, DC, acute care nurse practitioner said, “It’s not safe to leave a patient who was just sitting in the ER alone in a room for that long while I’m speaking with someone else.”

Prejudice against minorities

Lateral aggression may be directed toward nurses who look, sound, or act different from the majority of the staff. Researchers have found that nurses have been targets because of their accents or ethnicity, because they are a float or per diem nurse, or because they received a promotion or honor that coworkers think is undeserved.

Gender falls into this category as well. Male nurses said that while their gender helps them with patients and administrators, it puts them at a disadvantage among fellow nurses. A study of Minnesota OR nurses found that male doctors treat male nurses better than female nurses and that they have better camaraderie. “I think I have better relationships with physicians than many female nurses because they know me better. And I stick out. You’re not going to remember every interaction you have with a tiny twenty-three-year-old blonde girl named Laura, because there are a dozen of those on my unit. You’re going to remember interacting with the random scruffy-faced dude who successfully helped a mother breastfeed for the first time,” said an East Coast nurse who is the only murse in a building of hundreds. “This also means that my mistakes are held against me longer and harder. But overall, I think my opinions are trusted more, and I’m viewed as more authoritative, even when I’m not. For the record, I don’t think it’s fair. I’ve been given opportunities that much more deserving nurses have been passed over for.”

In nursing school, the same murse said that his conspicuousness led instructors to have higher expectations of him than his female classmates. “My successes were highlighted in front of everyone, as were my failures. It’s like when the instructors were looking for an example, they picked the person who stood out the most, because I’m a guy,” he said. Now, at work among his colleagues, other nurses are more likely to “think I have a stick up my ass when I question anything,” and socially, “I usually end up feeling like the little brother, big brother, or comic relief, not part of the actual clan.”

The workplace “can be challenging” socially for male nurses, a New York City murse admitted. “I’m not really involved in my colleagues’ social functions outside work. Baby showers, wine tastings, bachelorette parties . . . Sounds fun, and while I do consider many coworkers my friends, a lone married man in his early thirties with a bunch of young women at these events would just be awkward.” Even when nurses like him don’t rely on their coworkers for socializing, nursing is such a team-oriented profession that bonding outside of the hospital can easily affect the working relationships within it.

Cliques

It would be shortsighted to dismiss Juliette’s complaints about her coworkers’ social exclusivity as trivial or irrelevant. Much of any workplace bullying comes from cliques, which both galvanize and hide the perpetrators. In material about workplace bullying, the American Nurses Association specifically stated, “Misuse of power can also occur when a nurse who, acting as charge nurse, shows favoritism toward friends or those in a personal clique while treating others poorly by assigning them more difficult assignments or by not offering to help. This misuse of power is done without regard for the nurse and the patient, and it exposes the vulnerability of both.” It is this sort of treatment that distressed Juliette.

Nurses spend long hours together and are dependent on coworkers both professionally and personally. Many studies have found that nurses have higher job satisfaction when they have positive relationships with colleagues. Of course, benign work relationships can form that leave some nurses feeling devalued or left out. A Louisiana pediatric nurse explained, “Some places have set weekends, so when you work full-time you always work with the same crew. Sometimes if you get switched or request the opposite weekend, it’s like you’re not a part of the team because you never worked with them, so they don’t help you like they help the others.”

More trouble comes when a nurse’s standing devolves from not quite fitting in to being alienated. A Michigan ICU nurse was tormented by a nurse practitioner who tried to rally other coworkers to “take her down.” The nurses tried to sabotage the ICU nurse, refusing to answer her questions and to teach her the electronic health record system. The nurse left the hospital because of this treatment.

A 21-year-old Southern ER nurse described a clique of supervisors as “something straight out of Mean Girls. They make each other stronger, like female bullies in high school.” Without the pack, these nurses seem socially needy and insecure, but “when they’re together, they go around wreaking havoc. While you’re running around frantically trying to take care of five patients, they’re sitting at the desk reading People, and looking at you, laughing, ‘Looks like you’re having fun over there.’”

Mean girls. Humiliation. Sabotage. Why is there such a strong bullying culture in a profession known for its empathy and compassion, and a profession in which even bullying victims enthusiastically gush about how much they love their job?

Oppression causes in-fighting

In 1909, Dr. Leon Harris told The New York Times that nurses were “subjected to a despotic set of rules and regulations which in their stringency and utter lack of justice compare favorably with Siberian prison rules.” The head nurses, whom Harris called “tyrants,” regularly fired young, pretty nurses in favor of less attractive women, and “abuse their position of power. Like many of their sex, their inclination to be petty and mean and small in their dealings with other women comes out strong.”

Harris went on to inform the Times that “the abominable outrages practiced on our young women at these institutions in the name of ‘hospital discipline’ ” included hazing young nurses, disgracing them for trivial reasons, micromanaging their lives outside of the hospital, forcing them to work when they were sick, ordering them to do kitchen work or scrub floors if the head nurse didn’t like them, and stripping nurses of the two hours of “off time” they were supposed to have during their twelve-hour shifts (a break that will have disappeared a century later). Certainly, nursing has changed since then, but Harris’s description illuminates the roots from which nursing grew.

Many people insultingly believe, like Harris, that nurses catfight because it’s women’s nature to, and the vast majority of nurses are female. Australian researcher Elaine Duffy has observed that people dismiss bullying “with statements like, ‘This is typical of bitchy females working together,’ implying that such behaviors are typically female.” That rationale is far too simplistic, but is related to a more plausible explanation.

In 1970, Brazilian philosopher Paulo Freire theorized that when a dominant group forces its own values and norms upon a less influential group, the oppressed group develops low self-esteem and becomes angry and aggressive as it tries to internalize those standards. As group members are made to feel inferior, they begin to disdain their own culture. Because the oppressed group won’t engage in violence against the more powerful dominators, its members turn on each other, dividing and infighting, sabotaging each other. Freire called this conduct “oppressed group behavior.”

Some nurse scholars contend that nurses are an oppressed population because of a history of submissiveness to mostly male physicians and administrators. In the early 1900s, doctors controlled nursing school curricula, steering programs to instruct nurses primarily on how to support physicians. Without autonomy or control over their occupation and treated by medical professionals as subordinates, nurses took on the characteristics of an oppressed group. As the Center for American Nurses reported, “The culture of the healthcare setting has been historically populated by images of the nurse as a ‘handmaiden’ in a patriarchal environment. The balance of power has not been in the nurse’s favor. . . . Too often, nurses have acquiesced to a victim mentality that only facilitates a sense of powerlessness.”

Browbeaten by doctors, administrators, patients, and patients’ families, nurses also came to accept bullying as an inevitable part of the job. “Unfortunately, many nurses have been taught to simply ‘grin and bear it,’ and as a result of prolonged abuse, nurses have become an oppressed group with nowhere to channel anger but at other nurses,” according to St. Joseph’s University researchers.

Venting to doctors or administrators could jeopardize nurses’ jobs, so they redirect their rage, frustration, or fear against each other, for which there are few repercussions. Interestingly, studies have found that when nurses are empowered at work, bullying occurs less frequently. This correlation supports the idea that when oppressed group members gain influence, they are less likely to lash out at each other.

Stress and burnout lead to bullying

When a healthcare organization does not empower employees—or when it restructures, downsizes, or keeps nurses short-staffed—nurse bullying increases. Studies have found that environments with volatile workloads, degenerating patient health, and increasingly confrontational patients and visitors create “a perfect storm for workplace bullying.”

This could tell us that when nurses are overly stressed and under excessive pressure, they become hostile toward the people they most frequently encounter during the workday: other nurses. Indeed, experts say that nurses who are burned out at work “are more likely to vent their frustration by abusing other nurses.” What other outlet do they have? In departments where nurses are rarely afforded the time to eat or go to the bathroom, they certainly wouldn’t be able to go for a walk or step outside to compose themselves. Stuck in their unit for hours on end, they can be so physically and emotionally worn out that they have little left for themselves, let alone each other. Nurses who are too drained or busy to take the time for self-care are more likely to engage in lateral aggression.