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: 22 (всего у книги 33 страниц)

Chapter 8

Don’t Get Sick in July

:

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

“Nurses are frequently put in situations of conflict arising from competing loyalties in the workplace, including situations of conflicting expectations from patients, families, physicians, colleagues, and in many cases, healthcare organizations and health plans.”

–Code of Ethics for Nurses, Provision 2.2

“Somewhere along the line, when we lost the long white skirts, pleated blouses, and nursing caps of yesteryear, we also seemed to have lost the public’s respect. I would gladly go back to the nursing days of Florence Nightingale and Clara Barton to have the respect they had from society. I wish I could start a revolution for ER nurses specifically; we are the rock stars of nursing, but are treated like the red-headed bastard stepchild.”

–a North Carolina ER nurse

“So many things are just simply bullshit. I don’t know why I was surprised. I guess I always thought that when it came down to people’s lives, things like making money no matter what wouldn’t be so important.”

–a Texas ER nurse

LARA

  SOUTH GENERAL HOSPITAL, June

A divorced South General nurse in her late forties was trying to get pregnant through IVF. Afraid to give herself the injections, she asked Lara if she could come to her house and inject the daily shots. Lara agreed without hesitation. The nurse repeatedly tried to pay her for her time. “I’m not taking your money,” Lara told her. “Just tell me, how did you talk to your first husband when you guys were separating? What did you tell him? What did you wish you didn’t say? Help me with advice.”

Friends called Lara all the time to ask medical questions or to have her look at their injuries. Before she had kids, Lara slept over at her friend’s father’s house for two weeks because the family couldn’t afford a twenty-four-hour nurse and the man had painful bone cancer. “I’d never accept money for stuff like that,” Lara explained. “I do that in a heartbeat.”

She loved that people felt they could ask her opinion and that she could almost always help them. Being a nurse was more than a job. “It’s kind of who I am,” she said. “Nurses can truly make a difference in someone’s life. In the ER, even if it’s not a true emergency, an accident is something a person will never forget. That ER visit for stitches could be one of the worst times for people, and a nurse can make it a little better for them, putting them at ease, alleviating some of their fear. Even a pillow or blanket for someone’s grandma can make a difference. It may sound silly, but that makes nursing special.”

Now that the bills had started to come in and she was paying them, Lara had begun to grasp how well she could manage life as a single mom. She could support her family. She couldn’t spend as much time at home with her children as she wanted to, but she was doing her best, and she knew that her kids were safe when she left them with John. She had started to emerge from her funk, though she was still disappointed that she wouldn’t be able to go to PA school. She put her bachelor’s degree classes on hold, unsure of when she’d be able to continue them.

At work, she was able to focus more on her patients. One morning, Lara was working trauma and precepting a nursing student when an ambulance brought in a heavyset woman in her forties. While driving, the woman had told her spouse she didn’t feel well, then pulled over and went into cardiac arrest. The medics had briefly brought her back to life twice by the time she arrived at South General with no pulse. She was blue from midchest up.

Dr. Alisa Hawkins, a well-respected ER doctor, ran the code. While the team performed CPR, she reviewed several possible algorithms that could have caused the heart attack. Dr. Hawkins stuck a needle in the patient’s chest in case fluid had pooled around the heart.

“It’s not fluid,” Dr. Hawkins said. “Did we cover our Hs and Ts?” (“Hs and Ts” was a mnemonic device to help medical professionals run through possible causes for a cardiac arrest.)

“We did,” Lara said.

“Could be a blood clot in the lung,” said the doctor. “Does anyone have any ideas?”

“What do you think about t-PA?” Lara asked. Tissue plasminogen activator could save a patient by dissolving a clot or it could cause a patient to bleed out and die. Typically, the procedure required the patient’s or family’s written permission. In this case, the patient was technically dead anyway.

“Yeah, let’s do it,” Dr. Hawkins agreed.

The other nurses backed away from the bedside, suddenly busying themselves with other things. Lara looked around. She hadn’t given t-PA in more than a year. “Wow, really, guys?” Lara said. “Okay, I’ll do it.”

As the others continued CPR, Lara explained to her student what she was doing. “Usually you give a bolus [a single dose] of t-PA first intravenously, and if the patient is still alive, you do the second half over thirty minutes. But we don’t have that kind of time, so we’re doing a straight push over three minutes,” she said. She encouraged her student to take a turn performing CPR, which she had never done before. “It can be creepy to do CPR because you often break ribs even when you’re doing it right, so I want you to know what that feels like,” Lara told the student. Lara stood by the intravenous drip, slowly depressing the plunger of the syringe of t-PA while instructing the student how to set up the remaining medication. Afterward, the student thanked her effusively.

The patient, as expected, didn’t make it, but Lara found that she had completely regained her medical confidence. “I felt like it came back and flowed,” Lara explained to a friend, relieved that she was back on her game. “I didn’t feel like I was struggling to think through anything. That was nice, because my fear at work was missing something on a patient. As a team, we didn’t miss anything. T-PA might have helped, so I was glad I thought of it. Even though the patient died—really, she came in already dead—I walked out of there knowing I did every single thing I could possibly do to try to save her.”

•   •   •

A week later, Lara was having a tough morning. If getting through a divorce was a process that took two steps forward and one step back, then today was definitely a step back. She dropped the kids off at school and cried on the way to work. This sucks, she thought. I’m an old single mom and now I’ll have to date again.

Now that she was single, she supposed she could do what many nurses she knew had done: They kept an eye on the firefighters and policemen who brought patients in to the ER. At her former hospital, at least half a dozen nurses had married men they had met that way.

Lara had always been drawn to men in these positions, both because their uniforms were a turn-on and because they understood what it was like to be a nurse. “They’re protectors and caregivers,” Lara said. “Maybe it’s the whole men-in-uniform thing. Firemen stay in shape, and they have that sensitivity about saving lives. You feel safe when there’s a fireman or policeman around. They know what it’s like to look into the eyes of a parent whose kid just died. They understand.”

Still, Lara was scared to return to the dating world. How would she find the time to get to know someone when her life revolved exclusively around her kids, job, meetings, and workouts? Puffy-eyed and sulking, Lara moped into work at 11:15 a.m. “Are you coming from the breakfast?” Holly, that day’s charge nurse, asked her.

“What breakfast?” Lara asked. “I’m just coming in to work a couple hours.”

“You were supposed to be at the breakfast for the finalists,” Holly said. Lara didn’t know what she was talking about. “You’re a finalist for Nurse of the Month!” Holly said.

Lara laughed uneasily, thinking this was like an “Oh, you’re mom of the year” joke.

“The ER director sent you something in the mail.” Holly was serious.

“I moved,” Lara said.

For the rest of the day, Lara bounced between excitement that her work had been recognized and guilt that other ER nurses’ work had not. Her nomination was the talk of the department. Someone had taped a copy of the letter listing the finalists to a medicine cabinet for everyone to read. The ER nurses hadn’t even known the honor existed, because in the history of the award, no ER nurse had been a finalist.

Lara sensed some resentment from her coworkers toward the ER management. “If our managers can nominate us, why haven’t any of us been nominated all this time?” they said. “I work my ass off!”

The other nurses mostly teased Lara. They kidded that she missed the finalists’ breakfast on purpose because they knew that socializing with “management types” made her uncomfortable. Lara joked back that administrators must have “just been feeling sorry for me because I’m such a pathetic loser in a pathetic place right now.”

Another nurse snorted. “If that was the case, I would have been nominated a long time ago.”

Lara poked her head into the ER director’s office to say thank you.

“Girl, you work hard. It doesn’t go unnoticed,” the director said.

The boost came at just the right time. Until the nomination, Lara hadn’t realized how badly she had needed some sort of validation that at least something was going right in her life.

Two weeks later, when Lara arrived at work, Holly said, “You’re the hallway nurse from eleven to twelve, but then you’re going to the luncheon.” Nurses nearby snickered.

“A luncheon? I’m not going, guys,” Lara said.

“You have no choice. You won the award!” Holly said. She purposely had not told Lara she won until the last minute, so Lara couldn’t duck out.

Lara was stunned. Word spread quickly, as usual in the ER. Within an hour, everyone was referring to Lara as Nurse of the Month. “Hey, Nurse of the Month, can you help me in Room Nine?” “Can you roll this patient off the backboard, Nurse of the Month?” Only one nurse sneered at her, nastily sniping things like, “I’m going to take my patient up, if that’s all right with you, Nurse of the Month.”

Lara laughed it off. As great as it felt to win, she was a little mortified that she had been chosen above equally deserving coworkers.

At noon, Holly and the education coordinator found Lara in the hall. “I’m going to watch your patients for you,” the education coordinator said, clapping Lara on the back.

In the elevator, Lara squirmed. She was no good at chatting up bigwigs. She envisioned sitting across from them, stumbling to make conversation.

When Lara poked her head into a fancy doctors’ conference room she had never seen before, the head of the hospital stood up and came over to her, his arm extended. “Hello!” he said, shaking her hand. A handful of department heads and three nurse finalists from other departments were seated at a table laden with catered food. Wow, I would’ve looked really jerky if I hadn’t shown up, Lara thought.

As the hour progressed, she relaxed. The hospital chief was laid back and friendly. Mostly the group talked about the hospital. The chief discussed upcoming events and how much he appreciated the employees. But he kept coming back to the ER, which he seemed particularly excited about. “The ER holds this hospital together,” he said.

Lara listened with pride. “That made me feel grateful I was a part of it,” she told a friend. “I could have lost my license for my ridiculous behavior in the past, so this was a nice reminder. It got me energized to keep doing what I’m doing.”

The chief presented her with a trophy engraved with her name. Because it was too large to fit in her locker, Lara left it at the nurses station. But her coworkers moved the trophy to wherever Lara was working. If she was in a patient room, when she left, the trophy would be waiting for her at the door. If she went to the meds room, the trophy would magically appear in the hallway outside of it.

Despite the Nurse of the Month teasing, most of Lara’s coworkers were gracious. “You really deserve that,” one told her.

“I can see why you got it,” said another.

After work, Lara reflected to her friend. “I love nursing. I think I have the coolest, best job in the world,” Lara said. “I probably feel more passionate about it now than I ever have, because it got taken away from me. I am so lucky I didn’t go to jail. I am so lucky to be here with my amazing kids. Most nurses who did what I did lose their licenses or don’t get to return to an area that would be a trigger, like the ER. I am never going to stop being grateful that God gave me another chance to be a nurse.”

When she took the trophy home and told her children about it, they were so proud of her that they carefully placed her award on the shelf that displayed their soccer trophies.

SAM

  CITYCENTER MEDICAL, July

Since the charge nurses had begun to assign Sam regularly to Zone 1, the area with the sickest, most interesting patients in the ER, she was happier at Citycenter. Zone 1 procedures ran relatively smoothly on the night shift that could have been disastrous during the day. One night, the ER had two coding traumas simultaneously in the trauma bay, a CPR in progress on a patient with no pulse, and an unresponsive trauma patient. All eight nurses on duty came to work on them. Half the nurses were back-to-back, facing the gurneys; their bottoms kept bumping into each other as they worked. They were able to save one of the patients. Had this situation occurred during the day, Sam believed they would have lost both because the situation would have been even more chaotic.

Doctors on either shift made mistakes, particularly the new ones, particularly in July. One day, Sam watched with horror as a surgical intern inserted a chest tube into one of her patients and dropped the needle—a tree trunk of a surgical needle—onto the floor. “I’ll pick it up later,” he said, at Sam’s look. After the procedure, the surgeon strode toward the door.

“The needle!” Sam reminded him.

He briefly glanced around, said he couldn’t find it, then left the ER. It was a generally understood courtesy that doctors, nurses, and techs took care of their own sharps. Too often, new doctors didn’t clean up after themselves, or wouldn’t handle patients’ urinals, “as if they were too cool for school,” in Sam’s words. She was tired of these doctors “acting helpless when they’re really just lazy.” She paged the surgeon. He called her back ten minutes later.

“You need to find that needle,” Sam told him.

“I’m busy on the floor,” he said.

“I don’t care. The patient has HIV and hep-C. None of the nurses or cleaning staff are going to accidentally get stuck by that needle and get hep-C because your dumb ass dropped it and you won’t come find it.”

“I might be an hour.”

“That’s fine, but you better come down and find it because I am not your handmaiden.”

Shortly thereafter, the surgical team’s four medical students were in the patient’s room on their hands and knees. Sam scoffed. Who did the surgeon think he was? It was hardly safe for people to crawl on the ER floor. They found the needle within five minutes. The surgeon did not return downstairs.

There were a few physicians Sam enjoyed working with, like Dr. Geiger, who now would come to Sam specifically for assistance. But too many young doctors were careless. Recently, while a new surgeon was working on a patient, the connector between the chest tube and the drainage chamber came apart and fell onto the floor. The surgeon picked it up and put it back into the sterile chest tube. Sam stared openmouthed.

“Do you want another one? How about we change that out?” Sam said.

“Oh, well, yeah. Of course,” the doctor said, as if she had planned to all along. Sam ran to get another drainage chamber.

On her night off, Sam called William. He had ramped up the teasing lately, for no discernible reason. She wondered whether CeeCee had blabbed again, in which case Sam wanted to clear the air with him.

“I didn’t pee for at least eight hours last night,” Sam said by way of introduction.

“Me neither,” William said.

Sam smiled. “The fact that this conversation seems perfectly normal to us is odd in itself.”

“Hey, to do this job well, you need to be dedicated.”

“Yeah, in between getting berated and fighting with the lab, actually getting to help people is kind of awesome.”

“You have to keep it all in perspective,” William said.

Sam took a breath. “So what’s the deal?” she asked. “You’re acting like you’re twelve. Get your head out of your ass.”

“I’m interested in you, Sam.”

Sam almost dropped the phone. “Um, I guess I hadn’t noticed that.” Her heart pounded. Her dream guy was interested in her? This was the stuff of movies, not the kind of situation that happened in Sam’s real life.

“Well, yeah.”

“You have a girlfriend and I’m not going to be your little side fling.”

William paused. “Actually, things weren’t going so well. We broke up a couple of months ago.”

“Oh.” Gears turned. “You’re single?”

“Yes, I am.”

Sam processed this information. “I wish you’d told me that sooner. This whole time I thought you still had a girlfriend.”

“I don’t talk about my personal life at work, so there’s no way you would have known. And I didn’t know if you felt the same.”

“Well . . . maybe we should hang out,” she said.

“How about now?”

Within half an hour, he was at her door. They stood there for a moment.

“Hi,” she said.

“Hi,” William answered. They grinned sheepishly at each other.

Ten minutes later, they were settled on Sam’s couch, watching a movie. When William slid his broad muscled arm around her shoulder and leaned toward her, Sam’s mind raced. Okay, sure, I guess that’s what we’ll do now. As she kissed him back, she realized it didn’t feel awkward at all.

Nurse Confessions: Behind-the-Scenes Secrets from the Front Lines of Healthcare

As a fly on the wall of a hospital, you can learn a wealth of healthcare secrets, some of which are entertaining and some of which could save your or a loved one’s life. In front of an undercover reporter conducting research for this book, an exasperated attending physician at Citycenter shook her head as she corrected a colleague’s error. “Just trying to get through July,” she muttered. Her reason for saying so exposes a major secret about hospital life. Here is that secret, and others that nurses want you to know.

Don’t get sick in July.

Every year in teaching hospitals at the start of July, medical students become interns, interns become first-year residents, and each successive class of residents moves up a level. These new doctors are immediately thrust into direct patient care. As the National Bureau of Economic Research reported, “On day one, new interns may have the same responsibilities that the now-second-year residents had at the end of June (after they had a full year of experience).”

This upheaval causes what healthcare workers call “The July Effect” in the United States and “August Killing Season” in the United Kingdom (where the shift happens in August). The changeover harms patient care, increasing medical errors, medication dosage mistakes, and length of hospital stays. Most strikingly, in July, U.S. death rates in these hospitals surge 8 to 34 percent, or between 1,500 and 2,750 deaths. University of California San Diego researchers found that fatal medication errors “spike by 10 percent in July and in no other month.” In the U.K., August mortality rates rise by 6 to 8 percent as new doctors are tasked with surgeries and procedures that Britons say are “beyond their capabilities.” Patients in English hospitals have a higher early death-rate when they are admitted on the first Wednesday in August than patients admitted on the previous Wednesday.

Nurses always make vital contributions, but it is during these months in these hospitals that their vigilance is particularly paramount. Experienced nurses have seen more than inexperienced doctors. They know more about the hospital’s equipment and pharmacy system than someone new to the unit. “Nurses are correcting every error and preventing major mistakes every day,” said a Maryland solid-organ transplant nurse.

The residents who know enough to know what they do not know, and, therefore, listen to and seek out nurses for advice, are not the problem here. But too many residents, enamored of their MD status, won’t ask for help. “I’ve had doctors give orders for meds to be given IV that should never be given IV. And residents have asked me what a med was,” said a Washington State ER nurse. “They need to be guided and given lots of hints: ‘Would you like me to call the doctor who specializes in that? Would you like me to order that test?’ I don’t think they realize everything the nurse does for them and the patient. We cover their asses.”

Some patients who must be hospitalized in July for particularly complex procedures might consider avoiding teaching hospitals. Approximately 25 percent of U.S. hospitals are teaching hospitals, which patients can identify by checking the “About Us” page on a hospital’s website.

There are dead people in there.

If you see a large gray box in the hospital hallway, that’s not meal services. It’s probably a container holding a deceased patient, a Pennsylvania nurse said. “The morgue is never labeled that, either. They’ll call it something like ‘Anatomical Pathology,’ so if someone passes by, they won’t think there are dead bodies inside.”

We know secrets about your doctors.

Nurses have much to say about the doctors with whom they work. Perhaps more than anyone else, they are certain which doctors they would trust with their lives and which ones to steer clear of. “If you want to know if a medical facility or a doctor is any good, ask a nurse [away from that facility],” said a Washington State nurse. “Unless she doesn’t like you, she will tell you the truth.”

Some of their observations include:

After the procedures, when witnesses dwindle, doctors aren’t necessarily on their best behavior. An Arkansas nurse watched a cardiovascular surgeon check whether his female patient was awake. The doctor pulled down the sheet and twisted the patient’s nipple. “My reflex was as if he had done this to me: As soon as he touched her, I smacked him on the arm. He gave me the dirtiest look,” the nurse said. “A lot of nurses would like to smack their doctors once in a while.”

“Sometimes residents practice procedures on a patient after a code [such as using a needle and catheter to remove fluid from the sac around the heart]. We put a stop to this in our hospital,” said a nurse in the South. This practice does not occur as often as it used to. Before simulators were sophisticated enough for doctor training, physicians would “spend up to eight hours practicing on the deceased, which prevented family from coming in, and they did not know why,” a North Dakota nurse said.

“The highest-rated heart surgeon at my hospital, according to U.S. News & World Report, is the one I would least want to have operating on my family member,” said a nurse in the Northeast. “It seems that more of his cases come out of the OR with bleeding complications. The consensus among the nursing staff is that this happens with him more frequently than our other surgeons.”

“Some physicians, especially psychiatrists, make rounds at night or very early in the morning so they don’t have to talk to the patients,” said a Texas nurse.

“Doctors don’t always tell the truth, they often blame others to protect themselves, and some doctors are lazy. They want nurse practitioners to do the work and they bill for it [in the hospital],” said a Michigan nurse. “I’ve seen a lot of mistakes: misplaced lines, nonsterile technique, lying to patients or withholding information, wrong medication dosage. There was an incident where equipment in the OR was not used correctly and it affected the patient. No one told the family, but staff knew.”

Some doctors and nurses are placing bets about you.

Several nurses confess that they have wagered on patients. Guess the Blood Alcohol is a common game, where actual money changes hands. Other staffs try to guess the injuries of a patient arriving via ambulance. And surgeons have been observed playing “games of chance” during operations, placing bets on outcomes of risky procedures.

Hospital codes can vary, but the meanings are fairly common.

Different “codes” mean different things at the hospitals that announce them over the loudspeaker, but here is a sampling of what they can stand for (some hospitals use different colors to refer to these scenarios):

Code Blue: patient in cardiac arrest

Code Pink: infant abduction (all exits are secured)

Code Red: fire

Code Orange: hazardous material spill

Code Silver: hostage or weapon situation

Code White: communications equipment or computer system failure

Code Green (or Condition Green): combative patient

Code Gray: tornado warning/severe weather; a combative or violent patient or visitor

Depending on the hospital, a bomb threat can be a Code Gold, Code White, Code Black, or Code Yellow (among others).

Sometimes hospitals don’t want patients to guess what a page means.

Some hospitals further disguise codes to announce bad news. A page for Dr. or Mr. Firestone can indicate a fire. Code Strong signals hospital security that a patient or visitor is becoming aggressive. “MSET” (Medical Surgical Emergency Team) alerts staff to an unresponsive patient. At some hospitals, Code Lavender means that a doctor or nurse is overtaxed; at Ohio’s Cleveland Clinic and Hawaii’s North Hawaii Community Hospital, a rapid response team including a chaplain and a holistic nurse offers the healthcare provider Reiki, light massage, healthy snacks, water, and a lavender bracelet so that he or she remembers to take it easy.

Actually, Code Lavender, which is called approximately once or twice a week, is meant to achieve what Lara had hoped for with the debriefing room. Originally, Cleveland Clinic’s healing services team was created in 2008 for patients. “Then we started getting called more and more often for staff. If you care for one nurse, you’ve cared for twenty patients,” said the Reverend Amy Greene, director of spiritual care. Healing services is most often summoned for staff after an unexpected death. The team arranges backup coverage and finds the nurse or doctor a quiet corner in a break room or broom closet where she can listen to meditative music, talk to a chaplain, or simply find a few moments of peace.

The break lasts approximately ten minutes, which is enough to recharge someone, Greene said. “Compassion is self-perpetuating and reinvigorating, and it doesn’t take that long. Symbolically, this says that what happened to you is important, you’re important, and the institution has your back. Caring for the caregivers is much more important than we thought in times past.”

We have our own secret codes, too.

The most universal code that nurses call among themselves is a Code Brown, an elegant designation for an inelegant situation: a defecation mess. If you hear nurses referring to “liver rounds,” they are probably talking about happy hour. Non-gastrointestinal doctors who say they are doing “G.I. rounds” are likely taking a break to eat.

Some people impersonate nurses, and you have no idea.

A medical/surgical nurse who has worked in a pediatrician’s office warned that when you call a doctor’s office to speak to a nurse, you might not actually reach one. “Parents call to ask the nurse a medical question about their child. The medical assistants, who are not nurses, pick up the phone, say, ‘Hello, this is the nurse,’ and then give advice,” she said. “This is illegal and dangerous. Parents have no idea this is going on. MAs have taken a one– or two-year certificate training program, may not have a college degree, and do not have a license. I’ve heard them give incorrect advice. We worked hard to get where we are and it makes me mad when people think they can easily do our job. We have a two– or four-year college degree and a Registered Nursing License. If you are calling in to a doctor’s office, make sure you know who you are speaking to.” Ask whether you are speaking to a licensed nurse or to a medical assistant.

Sometimes we goof around with the medical equipment.

When a department is slow (more likely on the night shift), hospital staff members have several props with which to entertain themselves. Nurses told me about wheelchair-racing down the hall, playing darts with needle syringes and rubber-glove balloons, having squirt gun fights with saline syringes, and bowling with (empty, clean) urinal jugs for pins. A Louisiana nurse and her coworkers do lunges down the hall at three in the morning to stay awake during the night shift. On slow nights in a Virginia ER, nurses used to pull clothes out of the donation box and have runway fashion shows. “The little things you do with coworkers can make your shift exponentially better,” said a Minnesota travel nurse. “We listen to music all night, do the wobble wit (a group dance like the electric slide) at the nurses station, or have catwalk competitions down hospital hallways.”

We gossip about our patients . . . when they deserve it.

Plenty of nurses confessed that they gossip about their patients, although they take care to respect the patients who respect them. “If there’s something really different, salacious, or disgusting, we love to tell our coworkers,” said a Washington State nurse. One story involved a mentally disturbed patient who went into the bathroom, cut off his penis, and threw it across the waiting room. Most patients don’t have to worry, though. A Maryland cardiovascular ICU nurse said, “The funniest stories involve the crazy patient who did something with poop.”

We might use a larger needle than necessary.

In a practice that is not often discussed in the medical profession, some nurses occasionally use larger needles than necessary to “punish” obnoxious patients, as Molly did with the drug seeker.

Sometimes we break the rules.

If breaking a rule will help a patient or protect a colleague, some nurses will break it. A Midwestern nurse at a hospital that refuses to give nurses overtime has clocked out before she was finished so she wouldn’t get written up for working overtime, and then risked being penalized anyway by returning to the unit to care for her patients for free. “That used to never happen, to work in a place where you’re afraid to make a mistake or you’ll be fired,” she said. “Overstaffing the next shift is a mistake, ordering too many or too little supplies is a mistake, not answering the phone within the first few rings is a mistake.”