Should gallows and derogatory humor have a place in the hospital setting? “How does it feel to be a patient in a room who just got diagnosed with recurrent ovarian cancer and to hear laughter down the hallway?” Massachusetts General Hospital oncologist Richard Penson wondered in a journal article. Referring to patients who overheard a staff member using derogatory humor that they angrily assumed was about them, a psychiatrist described “the stray bullet effect—it’s not directed at them but they perceive it [to be].” Other doctors worry that derogatory humor, like the Oscar for dramatic patients, can cause staff members to develop preconceived, negative notions about a patient or type of patient.
But the benefits to staff and ultimately to patients may outweigh occasional wounded feelings. One would hope that doctors and nurses would be permitted to take whatever nondestructive steps they need to be able to provide the best possible care. Bioethicist Katie Watson observed, “Critics of backstage gallows humor who are admirably concerned with empathy for patients sometimes seem curiously devoid of empathy for physicians. Medicine is an odd profession, in which we ask ordinary people to act as if feces and vomit do not smell, unusual bodies are not at all remarkable, and death is not frightening.”
Researchers have said that when medical students use derogatory slang about patients, they are deflecting their feelings of anger or disgust away from the patients who frustrate them because they don’t take care of themselves and, therefore, waste the hospital’s resources. It is, California researchers concluded, “a safety valve for ‘letting off steam.’ ”
Many nurses described these types of humor as defense mechanisms, as an innate reflex. “It’s depressing when you’re dealing with people hurting mentally, so much that a lot of them want to die. The only way to deal with this is to make extremely inappropriate jokes,” an Indiana psychiatric nurse said. “An example would be joking about ridiculously poor suicide attempts, which sounds terribly insensitive. The other day we got a patient who ‘attempted suicide’ by taking a few of this med, a few of that, a couple sprays of Raid, and a shot of bleach. Like, really? Is that the best you can do? Of course, we already know the answer (a cry for help), but sometimes it’s the inappropriate jokes that make the job a little easier to handle.”
The public would find nurses’ frequent use of gallows humor “scandalous,” said a Texas travel nurse. “Laypeople would think I’m the most awful human being in the world if they could hear my mouth during a Code Blue or Priority 1 trauma. It’s a by-product of being placed in situations where death is common and unimaginable horrors are just another day at work. Gallows humor helps to deal with some of the horrible things we see in a way that bonds us together as a team against the bad stuff. We have to take care of these dying, abused, neglected, sick patients and then turn right around and take care of the minor things without missing a beat,” she said. “Bad things happen, and I can’t stop it. All I can do is try to support my patients to the best of my ability. Keeping that in mind helps me sleep at night. In the midst of those traumas and tragedies, I compartmentalize: I allow a part of myself to mourn and feel sad, while the majority of my attention is focused on the task at hand. I’m trying to save a life and that is my primary goal, but sometimes the stress of doing that task builds and needs a release. We use gallows humor to relieve that stress.”
Joking, even during codes, can empower healthcare workers, provide a fresh perspective, create a sense of control, and locate joy or playfulness in a devastating moment. This is important because nurses must get through the traumas intact so they can be fresh and focused for the next patient and the next. They have to concentrate intensely in critical situations one minute, and then let go so they can immediately move on. Gallows humor helps to ease that transition and to leave work thoughts in the workplace. “Nurses need to blow off the adrenaline pent up after patient care. It’s better to dress up those feelings behind laughter than carry that burden home with you,” said a Washington State hospice nurse.
A Canadian study found that nursing school educators who used humor experienced less emotional exhaustion and higher levels of personal accomplishment than other educators. In fact, experts specifically recommend that healthcare professionals utilize gallows humor as a survival tactic and to combat burnout. Nurse and humorist Karyn Buxman encourages nurses to find humor in their work: “Start a collection of humorous comments, events, or charting notes, keeping in mind that patient confidentiality is paramount.”
Gallows humor in hospitals has not been heavily researched, but the existing literature mostly supports using it. “When is behind-the-scenes gallows humor okay, and when should it cause concern?” Katie Watson, the bioethicist, asked. “To answer, I would first want to think about who is harmed by the joking.” Ultimately, in cases such as the pizza-tipping joke, she concluded, “To me, the butt of the doctors’ tip joke is not the patient. It’s death. The residents fought death with all they had, and death won.” And that’s why the joke is okay.
Humor is a way for nurses to find dawn in the darkness, to self-empower, and to unite with each other, determined and defiant. Above all, humor is a way to locate hope amid hardship, which is exactly what patients need nurses to do.
Chapter 6
The Stepford Nurse:
How Hospitals Game the System for Patient “Satisfaction”
“The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”
—Code of Ethics for Nurses, Provision 3
“Hospitals tend to focus on what they get sued for. Hospitals used to have COWs: computers on wheels. A while ago, a nurse said, ‘What’s up with the COW in Two?’ Well, the patient in Room Two knew she was in Room Two and filed a lawsuit and won. So now hospitals call them WOWs: workstations on wheels.”
—a Washington, DC, ER nurse
LARA SOUTH GENERAL HOSPITAL, February
The first few weeks of Lara’s separation from her husband were terrifying, while she tried to figure out whether she could support herself and two small children on her own. She couldn’t afford the mortgage on the house, which broke her heart because she and John had built their home, and her brother lived next door. She let John stay in the house because she didn’t want their children to have to adjust to two new homes. He was sure his gambling could cover the costs.
At first, Lara waited for John to apologize and agree to get treatment. Even as she moved her things out of the house, she thought he would realize that he needed her and he needed help. He watched the children while she worked and attended NA meetings, but when they exchanged them, he showed no signs of wanting to reconcile. In response to people who asked him why Lara left, John said, “She’s jealous about something I wrote on Twitter,” trivializing his years of issues down to one tweet.
As much as it hurt, John’s delight at being single helped Lara move past her initial doubt about her decision to leave him. It was more difficult for her to get over being sad, lonely, and scared. How would she pay the bills by herself and have enough time for her children? How would she resist the temptation to turn to narcotics?
Eventually, Lara’s realtor found a small rental house within her budget and near the kids’ school. Several NA friends helped her move, and a girlfriend gave her two U-Hauls worth of free furniture. The men she knew in NA offered her handyman assistance. Many of the women called to say they had gone through something similar, offering consolation and strength.
Still, Lara was unsettled most of the time. She tried to stay busy, because when she wasn’t, she either dwelled on her anger or cried. She was able to pull herself together only when she was at work or with Sebastian and Lindsey. It helped to focus on getting them through their homework or finding activities to do together on weekends.
Lara had seen a lawyer to begin divorce proceedings, but she didn’t like when the lawyer said, “We’re going to get him.” Instead, she went to a media
tor, who worked things out amicably.
Now Lara’s main worry was how to afford her rent. Luckily, South General had been accommodating. The first time she called to ask whether there were any openings on the schedule to increase her hours and her paycheck, the ER director said there were not. “Do you need to just come in to work, though?” the director asked, and created a spot for Lara anyway. She allowed Lara a nontraditional schedule: two twelve-hour shifts plus her children’s school hours. Lara dropped the kids off at school, arrived at the hospital by 11:00 a.m., worked for four hours, and left to make the forty-five-minute drive to pick them up.
Lara pulled this shift every weekday in addition to the twelve-hour night shifts. John was happy to watch the kids because he believed the babysitting got him out of paying child support. Lara knew her children were fine with John; for all of his shortcomings, he was a decent father. But it killed her to spend so much time away from them. Every NA meeting she attended was another hour that she could have spent with Sebastian and Lindsey.
At South General, Rose, the ER’s kindest nurse, connected Lara with Holly, a skilled, businesslike African American nurse whom Lara liked but had not gotten to know well. Holly, it turned out, had just divorced a cheating husband whose behavior was eerily similar to John’s; the women joked that but for the racial difference, their husbands could have been the same man. Every shift they shared, Lara and Holly made a point of checking in on each other, exchanging quick hugs and comparing stories. It was a relief for Lara to hang out with someone who understood her situation.
Several other nurses were so supportive that Lara felt as if she had a sisterhood looking out for her at work. To her knowledge, no one had complained that the nurse manager let her come to work whenever she wanted. Once, Lara was crying in a bathroom stall when she overheard the charge nurse say, “Lara’s here but don’t give her anything stressful. Just keep her busy.” Lara smiled, warmed because, despite some poor choices she’d made in life, she had chosen a career that was flexible enough to accommodate a single mom and that attracted the kind of women who protected each other.
One day Fatima approached her at shift change. “I heard you were having a hard time with your separation,” Fatima said. “I hope it goes better than mine did.” She told Lara about the fighting and drama that had plagued her own marriage and subsequent divorce. She mentioned that her ex-husband had been an alcoholic, a fact Lara filed away for future reference. Sometime when they were alone, she could talk to Fatima about her own family’s battles with alcoholism to segue into a discussion about addiction.
Lara was glad that Fatima felt comfortable enough to approach her. She couldn’t mention the drugs because they were in the middle of the ER, but she wanted to. She wanted to say that she knew why Fatima always wore long sleeves in the heated ER (track marks), and that she knew why Fatima’s hands were red and puffy (frequently shooting into a vein impeded blood flow). Perhaps after a few more conversations they would be friendly enough that Lara could raise the issue.
She sensed that time was running out.
JULIETTE PINES MEMORIAL, February
On a relatively slow afternoon, Juliette was documenting at the nurses station. While she relished the adrenaline rush of busy workdays in the ER, she also treasured the occasional quiet spell that allowed her to chat with her coworkers or in the back office with Clark Preston.
Molly had been trying to convince Juliette to leave Pines because the clique bothered her so much. “Why don’t you work agency? There’s no reason not to,” Molly had told her. “You can work anywhere you want, you don’t have to do holidays or weekends, and the pay is higher.”
Juliette had resisted because the devil she knew was better than the devil she didn’t. She had anxiety about putting herself in new work situations. And while the clique overshadowed her job, she was still able to find positive connections with patients and some of her coworkers.
Ruby, the recently divorced nurse, stopped by the nurses station to say hello. “So what’s the deal with him?” she asked, pointing to a good-looking murse who was an incorrigible flirt. “I know he’s young for me, but what’s the deal?”
“If my daughter were in her twenties, I would not let her date him,” Juliette replied. “He cheats on his girlfriend every six months.”
“I gotta get laid. My little toy isn’t doing it for me anymore,” Ruby said.
Juliette was both surprised and pleased by the confession. She liked Ruby and respected her as a nurse, but they had not spent time together outside of work. How refreshing it was to gab with a coworker about something personal. “I know someone who’s more than willing,” she said. On a scrap of paper, she scribbled the name of the womanizer whose dalliances with several nurses had caused his secretary girlfriend to have a panic attack. She handed it to Ruby.
“Hmm, Dr. Fontaine. Isn’t he a little short? Cute, though,” Ruby said.
“He’s always down here. But apparently he’s been around the block a number of times.”
“Well, I’d just have to wrap his thing up twice then,” Ruby said, pondering the piece of paper.
Juliette cracked up. “Are you going to triage? I’ll walk you there.”
The women walked past the waiting area and stopped abruptly. Erin, a likeable young nurse, was heading toward the back wall with a large pair of forceps. “Uh, what are you doing, Erin?” Juliette asked.
“I have to get some candy out of the vending machine,” Erin said.
“Why, does a diabetic patient need some sugar?” Juliette joked, and followed her.
Two techs were kneeling in front of the machine. A dozen snacks were caught between the glass and the shelves. In front of an audience of patients and families in the waiting room, Erin tried using the forceps to reach the bags. No dice.
A few minutes later, Gabriel, the secretary, came over, rolling up his sleeves to reach inside the machine. “I can do it!” he announced. He couldn’t do it.
A murse brought a splint instrument that he had manipulated into the shape of a hook. The techs tried to grab the candy with the hook. “What if I get a lacerated finger?” one of them asked.
“That’s workman’s comp!” Juliette answered. The group laughed.
Soon, Dr. Preston came by. “Come on, Dr. Preston, you can do it!” someone shouted.
Ruby elbowed Juliette. “I bet those fingers can do anything.”
The staff and the patients watched as Dr. Preston reached his exceptionally long arm far into the machine and jarred loose a bag of Doritos. Finally, the chips and sweets tumbled from the machine. A cheer went up from the waiting room. Dr. Preston bowed and left.
Back at the nurses station, Juliette saw Dr. Fontaine flirting with a nurse. Ruby sidled by and bent toward Juliette’s ear. “Really?” Ruby whispered. Juliette grinned, raised her eyebrows, and nodded.
When Juliette got home that evening, she was still on a high from a fun day at work. As usual, she stripped off her dirty scrubs in her garage so as not to bring the germs into her house, painstakingly washed her hands and arms up to her shoulders, and pecked Tim on the cheek. She found 7-year-old Michelle on the couch.
She hugged her daughter tightly in greeting, but Michelle didn’t smile.
“Mommy, do you work tomorrow?” she asked.
“Yes, honey. It’s Tuesday.”
Michelle’s shoulders slumped. “It seems like you never have a day off. I want you home in the mornings to help me get ready. I wish you could work just in the afternoons.”
Juliette’s cheerfulness dissipated beneath her guilt. If she took shorter shifts, she’d lose not only wages but also opportunities to bond with her coworkers, as she had today. She decided then and there to apply for a clinical ladder promotion.
In the past, nurses who wanted to advance their career could study for extra degrees or apply for jobs in management. Juliette had no in
terest in applying for Erica’s vacant senior charge nurse position, or for any other administrative role, because she preferred to care directly for patients rather than supervise her peers.
Juliette loved bedside nursing because she cherished the direct interactions with patients. “I love being around them, being able to make all types of patients feel better,” she explained. “I love the moments of connection with the patient and with the family.”
Clinical ladders offered nurses like Juliette opportunities for a raise and recognition without having to leave the bedside. While the stages could vary by the hospital, Pines’ ladder offered four rungs of recognition: clinician level 1 (entry level), clinician level 2 (proficient), clinician level 3 (advanced), and clinical level 4 (expert). Each level required research, initiative, and a demonstrated level of clinical knowledge and advanced practice work. Juliette had reached advanced clinician level 3 a while ago. She didn’t have too much left to do to finish her application for clinical 4. She resolved to complete the requisite research project (which she had started and set aside last year) to reach the top level as a validation of her skills and a rationalization for keeping a demanding job that took time away from her daughter.
To achieve a clinical ladder promotion, nurses had to be in good standing at the hospital. Pines had a policy prohibiting nurses who made one patient identification error from applying for any type of promotion that year. Two mistakes in a twelve-month period and the nurse would be fired. Juliette knew she hadn’t made any notable mistakes, but she wanted to make sure she qualified before she put in the work.
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 24