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

by Alexandra Robbins

  Much like sorority members, the nurses I interviewed were split on whether nurse hazing is ultimately beneficial or detrimental to the profession. At first, Emma, a Mid-Atlantic surgical nurse, was furious when an older nurse hazed her at the Pyxis by “making me feel stupid, when my main goal was to get my patients their medications as efficiently as possible. [I felt] this sort of hazing was totally unnecessary and counterproductive,” Emma said.

  Now that she has been on the job for a few years, however, Emma finds herself defending the practice. “Older nurses feel a need to set a high standard and not baby new nurses. Sometimes this comes off as very harsh and unnecessary, but in retrospect, I really appreciate being challenged to be diligent early on, even if it meant being called out on my failings in front of others. This sort of corrective hazing that a few older nurses are known for might not be the most delicate way to help someone see their errors, but it certainly is effective. I was fortunate that the nurses on our unit generally don’t ‘eat their young’ just for the sake of it, but rather to guide and provide the opportunity for new nurses to prove themselves.”

  In recent years, as workplace bullying generally has become an increasing part of the national dialogue, some nurses worry that supervisors are abandoning a no-nonsense teaching style because new graduates might consider it bullying. “We’ve coddled these new young nurses. There is way too much hand-holding,” said a Virginia Neonatal Intensive Care Unit (NICU) nurse. “If a new nurse screws up or doesn’t have her stuff together, she needs to know. We have to hold ourselves and each other accountable for our patients’ care. Nurses should eat their young to get rid of the weak. If you can’t deal with an older nurse correcting you and watching out for your practice, how are you going to handle resuscitating a dead patient solo, or dealing with an alcoholic sex offender who is making disgusting comments to you?”

  Even some younger nurses are willing to let the practice continue if it prepares new graduates by whipping them into shape, like a nursing boot camp. “Nurses take an immense amount of pride in what they know, what they’ve seen, what they’ve experienced. And unless you know what they know, seen what they’ve seen, or experienced what they have (and you won’t, especially when you’re a new grad and new to a unit), you don’t know jack until you prove yourself otherwise. So suck it up, earn your place,” said a New York pediatric ICU nurse who graduated two years ago.

  A nurse in Lebanon argued that bullying among nurses is “good because it is part of the learning process. It helps you sharpen your communication skills. We learn how to face our bully, act with knowledge, and continue doing what we do best for the sake of the patients.” Similarly, the New Zealand study found that a small number of nurse bullying victims viewed the situation positively because it enabled them to stand up for themselves and to “feel stronger.” A Washington, DC, pediatric oncology nurse remembered when older nurses drilled her relentlessly about various patients and diseases. “One nurse was so intimidating that I was crying as I tried to give report to the next nurse. But you do certainly learn things quickly that way.”

  Another similarity to sorority hazing: Nurses eating their young continues because nurses often don’t report it. Researchers say that nurses tend to keep quiet because they are afraid of retaliation, they don’t think reporting the behavior will penalize the bully or result in change, or the perpetrator is a manager. Like patient assault, lateral aggression has become so ingrained in the culture of the profession that many nurses don’t report the behavior because they—both victims and perpetrators—don’t realize that it is unacceptable. In one study, when nurses confronted their aggressors, three-quarters were “shocked that the victims felt that way.”

  Some older nurses said that they don’t mean to treat new nurses harshly; their language or tone can reflect the tension of an urgent moment. An Arizona pediatric oncology research nurse tries to give students as many appropriate nursing tasks as possible. One day, however, this nurse’s young patient was declining and she needed help from seasoned nurses, residents, and respiratory therapists. As the nurse was attempting to contact the child’s parents, a student approached her to ask, “What should I do?” The nurse recalled, “It seems like an innocent enough question, but I had fifteen people I was listening to and giving information to. The last thing I needed was some clingy, high-strung student asking what she should do. I said, ‘Stand in the corner. Watch, and don’t say a word!’ I knew the minute it came out of my mouth that I had just eaten my young. I simply was not nice. But if a student doesn’t have the wherewithal to know she’s in the midst of a tremendous learning situation just by observing, I certainly don’t have the time to explain it to her at that moment.”

  In Washington State, a day surgery nurse explained that although she enjoys precepting on occasion, “It all depends on where my head is on any given day. I’m very Type A and if I’m in a ‘gotta get it done’ mode, then mentoring can drive me nuts, because obviously a new employee (especially new grads) takes lots of time getting stuff done that I know I could be doing so much faster. And sometimes I feel I must jump in and do part of the job. That is not good mentoring,” she said.

  Because so many departments are short-staffed and turnover is frequent, some inexperienced nurses are automatically expected to take on massive responsibility and pressured to work on critical patients whether or not they are ready. A nurse in Singapore said that nurses eat their young because they expect new nurses “to be as skillful as if you were already thirty years into the job. And if you are not up to their standards, you may be given a tongue-lashing, taken off the learning curve, or banished indefinitely to the Siberia of nursing chores to clear bedpans and clean backsides,” a repercussion reminiscent of the 1909 New York Times article.

  When these new nurses get overwhelmed, complain that they have too many assignments, or don’t have the experience to handle their tasks properly, older nurses can get frustrated; they might have little sympathy because they are or were in the same boat. “We work hard, come to work on time, prepared, focused, and ready to jump into the trenches,” said a twenty-year veteran of a Midwestern NICU. “We have had years of terrible hours, schedules, and holidays—obviously tons of shitty, unfair assignments—and we just did it, trusting that the seasoned nurses had a plan with the assignment choices.”

  At the same time, if inexperienced nurses are too casual, older nurses might think they don’t take their work seriously. The generational divide is severe. In the United States, the average nurse is 47, and many nurses are delaying retirement through their late sixties, according to a 2014 Health Affairs study. “The younger nurses have good skills and, with our guidance, demonstrate excellent skills over time. The issue is that they lack respect and can be rude and arrogant. You lose patience with nurses who can’t wait their turn, won’t shut up and listen, can’t stay off their phones, argue with policy, or show their butt-cracks. They whine about their assignments, take chances when asking for help would be safer, take long lunches, interrupt, and bad-mouth other nurses within earshot. They come to work rushed and on the phone, eating, and often not in scrubs; ignore parents of sick children while they are charting; and often surf the Internet,” the Midwestern nurse said. “There is a pecking order and a prejudice against the younger nurses because they are hard to work with. When my generation of nurses started, we were so intimidated as new nurses that we came in early, took notes, and focused on the task at hand. We have years of experience and skills that can’t be matched.”

  While “kids-these-days” gripes are predictable and inescapable in any profession, they are louder in nursing because the workforce skews older. Widening the generational divide, nursing degree programs have changed since older nurses began working. Until the late 1970s, nurses attended school in the hospital setting, where they learned both in classes and in the wards, explained Canadian nurse and author Donna Yates-Adelman. “Today, baccalaureate degree nurses graduate with ve
ry little hands-on clinical experience and are left to catch up after they graduate,” she said. “This has created a rift between the new graduates and the working nurses (many who are hospital-trained), who see it as having to help finish the new nurses’ education.”

  Indeed, a Florida Atlantic University study revealed that the young nurses most affected by nurses eating their young “were those with university education; they felt they were resented for learning too much theory and not enough practical training.” Canadian researchers found that “older, diploma-prepared nurses expressed resentment for new baccalaureate degree graduate nurses. These older nurses would relax at the desk and watch their new colleagues flounder. Young baccalaureate nurses . . . concealed their educational background to prevent ridicule and resistance.”

  The quandary leaves new nurses feeling stuck. To earn respect from their coworkers, they need the experience gained from what amounts to on-the-job training. But some coworkers aren’t necessarily willing to give them that training because they don’t respect the new nurses. When a Kansas nurse’s colleague grumbled, “I hate nursing students,” the nurse said, “I told her, ‘This from someone who was once a nursing student.’ How quickly we forget where we came from.”

  Younger nurses say they feel like they can’t win: If they are too timid, coworkers push them to toughen them up; if they are too confident, coworkers try to take them down a notch. “In my ER, new nurses are lumped into the same boat: know-it-alls who know nothing who are trying to steal the thunder of the older nurses around them. Which is hysterical,” said a Texas nurse who has been at her job for less than a year. “These experienced nurses have years of wisdom they could share to help a younger nurse. But when they do, it’s to assert dominance. They hold it over your head: ‘Remember that time I saved your ass?’ And they use it and use it and use it against you.”

  No matter the cause, lateral aggression, like doctor–nurse bullying, is a problem that goes beyond hurt feelings. It can be just as psychologically damaging as physical abuse, and the effects can last for years. Nurse victims can suffer from symptoms of depression, anxiety, fear, shame, self-blame, guilt, post-traumatic stress disorder, and eroded self-esteem.

  Furthermore, multiple studies have found that bullying can have substantial economic consequences for healthcare institutions. Researchers found that higher rates of workplace bullying are associated with higher rates of nurses quitting or intending to quit. This turnover can cost workplaces between $40,000 and $100,000 per nurse, and the sick days nurses take to cope with or avoid incidents can cost additional hundreds of thousands of dollars.

  Nurse bullying also has been proven to increase medical errors and accidents and decrease productivity. Besides the distraction of dealing with the behavior and the effects of the emotional fallout, Griffin observed that “lateral violence stops newly licensed nurses from asking questions, seeking validation of known knowledge, and feeling like they fit in, and stops them from acquiring the tacit knowledge-build necessary in clinical practice.” When nurses are afraid to ask questions, they are less likely to be able to provide safe care.

  From sorority to sisterhood

  Nurses are a sisterhood, a sisterhood that can be empowering, invigorating, edifying, spirit-raising, the stuff of the “secret club” about which a nurse rhapsodized in the introduction to this book. But this sisterhood (males included) could be so much stronger if nurses weren’t divided by perceived hostilities, misdirected anger, and vast generational rifts.

  Beginning in nursing school, nurses learn to be advocates for patients, but not necessarily to be advocates for each other. As new graduates during a time of vulnerability, some nurses are trampled by the same coworkers they need to support them through their transition to practice. Strong mentors can dramatically help both to change this atmosphere and to help new nurses thrive despite it. A New Jersey nurse practitioner who said it’s her “goal to change the attitude of ‘nurses eat their young’ ” advised mentors to “engage in teachable moments, put your ego away, learn something from the mentored, and take pride in the work you do. If you love your work, you will impart that passion to others.”

  That impression during a nurse’s formative years can last for an entire career. Several nurses told me that they chose their specialty because of a particularly impassioned instructor or that they have returned to a cherished mentor for guidance repeatedly throughout their careers. More than a decade after working with her, an Arkansas CRNA is still in contact with a mentor who was “like a big sister to me. She taught me to be a patient advocate, to stand up to doctors, and voice my opinion if I felt like something would affect the patient negatively or if I had an idea that might benefit the patient. She also taught me to say no if asked to do something I wasn’t comfortable with. She gave me a confidence in my professional abilities that has allowed me to achieve my ultimate career goal.”

  The mentor/mentored relationship can benefit both parties. A Washington State PACU nurse precepted two new graduate nurses who remained at her hospital and now work as her peers. “I love the feeling of supporting them and knowing that I provide a safe space for asking questions and sharing stories. And I got a couple of great friends out of it!” the nurse said.

  Nurses representing all generations want to strengthen the sisterhood. “We may be fat, old, and wrinkled, but we pitch in and help each other even when it is not our patient. If the youngsters would just lay low and learn instead of being competitive, then they would flourish,” said an Ohio NICU nurse. “When something cool is going on, I try and snatch a new nurse to share with her. We have had the occasional nurse who is excited about learning but also cautious. She is easy to tuck under your wing and share everything you know with her, [while] often learning from her newer views at the same time.”

  Young nurses said they want the same thing. Experienced nurses “are the foundation of hospital care, and their strength and giving nature inspires me to want to learn more and succeed as a nursing student,” said a Massachusetts first-year student. “One nurse I work with has a great skill of being able to explain complex body functions in ways students are able to understand. After becoming a nurse, I hope I can be as influential to students as the nurses are to me.”

  When a nursing team is able to build an ideal sisterhood, the result is glorious. A Florida high-risk OB nurse said that the camaraderie among her nursing team is “unparalleled.” At and outside of work, these nurses grew to know and to respect each other. “When we finish our individual nursing assignments, we check on one another to see that everyone has completed their nursing responsibilities and assist them if they haven’t. Working holidays is part of the deal, so we plan dinners to celebrate at work since we can’t celebrate with our families. Our job creates a place of comfort, happiness, support, and sisterly love. I know I could depend on these nurse sisters for anything I may need. It’s just the way it is with nurses.”

  It is the way it could be.

  Chapter 5

  Burnt to a Crisp:

  How Nurses Cope–and Why Some Crack

  “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.”

  —Code of Ethics for Nurses, Provision 5

  “Compassion fatigue made it so much harder to take care of patients. Here I was, using all of my might to drag myself out of bed and march on, and I’m seeing these people whining over hangnails and really minor problems while I’m holding back tears and contemplating killing myself.”

  —A North Carolina ER nurse

  “I love the free entertainment that patients provide. People say and do the most ridiculous things, and I’ve got a front row seat to the absurdity.”

  —A Colorado travel nurse

  SAM   CITYCENTER MEDICAL, December

  On weekend nights, Citycenter’s ER r
egularly saw hordes of boisterous drunken patients brought in by police, EMS, or, occasionally, friends. Many times, the patients demanded to leave, but hospitals were supposed to keep intoxicated patients because they could be a harm to themselves or to others; and many of them were injured but too drunk to know it. The staff was allowed to discharge these patients when they were clinically sober—able to follow commands, walk with a steady gait, and tolerate oral fluids—even if they were not legally sober.

  One chilly evening, EMS brought in a patient who was particularly riled up.

  “I’m leaving this fucking place!” said the patient, a large man in his twenties.

  “No, sir, you can’t leave. You’re drunk,” Sam replied. She stepped to his bed and stood in his way, as nurses were supposed to, to prevent him from walking out.

  “I’m not drunk!” He started to sit up.

  “Yes, you are drunk. As soon as you sober up, we’ll let you leave,” Sam said.

  “I am sober.” He swung his legs over the side of the bed.

  Sam, composed, stood her ground next to the bed. “Lay back, take a nap. We’ll get you some juice if you want.”

  “I don’t want any fucking juice!” the man yelled.

  Sam looked him hard in the eyes. “I’m really sorry but you’re not leaving. That’s the way it’s going to go. You can sit down or we can have security help you sit down.”