The Night Shift

Specifically, the night shift from the perspective of a lady who isn’t a night owl. Chances are good that new nurses, especially those interested in acute care environments, will experience night-shift work. My nocturnal adventure lasted 8 months, 3 days a week, 7pm-7am. At first it seemed ok. I was on orientation for about a month, with a caring, compassionate preceptor who helped me to divide and conquer the workload of one nurse. A week into our relationship I was already assessing all 5 patients, charting, passing meds, clarifying orders, and performing hand-offs comfortably. I was the calling docs and settling new admits, while my benevolent guide made sure I didn’t screw up. This was the honeymoon of my whole nursing career, because my preceptor acted as my personal CNA. I’d already had a year of experience in the skilled rehab center, and that involved at least twice as much wound care and med passes than the hospital. I sound blasé in the recounting, but these were all points of immense pride. I was doing it! I was critical thinking all over the place, problem-solving and helping people in pain (and their families) to sleep easy. As for working the night shift for the first time, George R. R. Martin said it best:

“Night gathers, and now my watch begins. I am the sword in the darkness. I am the watcher on the walls. I am the fire that burns against the cold, the light that brings the dawn, the horn that wakes the sleepers, the shield that guards the realms of men. I pledge my life and honor to the Night’s Watch, for this night and all the nights to come.”

nights-watch

Thanks, George, for recognizing the value of our nocturnal work.

(photo cred: http://winteriscoming.net/2015/06/18/the-wic-scale-winners-and-losers-for-mothers-mercy/)

What I didn’t experience was the frustration of short staffing, because I had a built-in aide in my preceptor. She took the patient in 505 to the bathroom for the seventh time in 12 hours so I could focus on my charting. She fielded the diabetic in 510’s request for soda for the fiftieth time, because I’d already had that conversation with him and was seeing other patients. Essentially, she shielded me from mundane frustrations that would smack me upside the head later on. I can be patient and empathic, or I can get shit done. Doing both is difficult.

It didn’t take long after losing my preceptor to realize that nurse-to-patient ratios really are all about getting shit done. I also found out how much I hate waking sleeping patients. The hard-nose nurse says, “tough luck, you’re in the hospital, you’re my patient, and we do what we’ve got to do to get you out of here. You may always refuse my care, but I am responsible for offering it, even if it interrupts your sleep.” And yet, the body needs sleep to heal. If there’s one thing I hate, it’s waking patients up to give them a heparin injection (small, stingy things that prevent blood clots) because the order reads every 6 hours.

Just for fun, here’s an outline of a typical shift (ha! No such thing. Let’s play pretend that these things follow a schedule…)

1850 – Arrive at work. Drink caffeinated beverage. Clock in, find out assignment, get ready for report.

1905 – Report. Play snag-a-nurse with everybody else looking to give and get report. It’s like speed dating. Round with off-going nurse on each patient; get an overview of the day, the main problems and successes, and what needs to be accomplished prior to discharge. Review family dynamics and potential discharge plans and dates. Find out who needs pain meds and sleep aids. Tell patients and families you will be back later with nighttime meds.

1940 – Report over. Claim computer and skim scheduled meds plus as-needed pain med availabilities. Note who needs their blood sugar checked before bed, and who has wounds to carie for – ideally before 0200.

2000 – Start pulling and passing meds. Assess along the way, listening to hearts and lungs, and querying after appetite and bowel habits. Check drains and tubes coming out of various orfices for output and patency. Due to age, injury, confusion/disorientation, and tethers like IVs, Foley catheters, oxygen tubing, and nasogastric tubing, pretty much everyone is a fall risk, so it’s best to help folks get ready for bed while you’re already in the room. This means brushing teeth, washing faces, going to the bathroom, and changing clothes. Doing so requires capping IVs and NG tubes, switching over oxygen, and transferring patients to walkers, wheelchairs, and bedpans. On a good night the 2000 med pass is done by 2200 – on a bad one it’s nearly midnight. Your scheduled med pass is easily interrupted by an admission, intractable vomiting, seizure, alcohol withdrawal, abnormal blood sugars, unresponsiveness, strokes, Sun-downers, and patients demanding to leave AMA (against medical advice) because they are utterly sick of submitting to hospitalization. There are also the more mundane tasks, like setting up cots for families sleeping in, and explaining to patients that although this is Colorado, they still can’t use marijuana in the hospital. In nursing school they tell you to delegate the small stuff, but with only one aide and up to 25-30 patients on the floor, there isn’t always someone to delegate to. You just do your best to check on the sickest first, and accommodate everybody else’s requests as you can.

0000 – hopefully you’re sitting down and charting by now. Review patients’ recent lab work and plans of care (again. Do this as frequently as possible). There are always some antibiotics that need to be hung around now, and people ready for more pain meds. Your incontinent patients need to be checked for wet linens. Elevated blood pressures should be followed up on by now, as well as elevated temps and blood sugars. While you’re at it, round on everybody else to make sure IV’s are still patent, and to change out fluid bags. Make sure everyone’s tucked in bed and not down on the floor. See to it that the NG tubes are still safely secured, and not leaking bile about the room. If it’s a good night you have time to eat something, unless you’re one of those people who feels nauseous working nights.

0200 – more antibiotics to hang and pain meds to pass. Keep charting. Read the prior nurse’s notes to see what they forgot to tell you in report.

By 0300 your charting is hopefully done, with only nursing notes left to sum up the shift. This is usually when I would sneak away for a half hour nap. In the next 4 hours, you need stay on top of pain meds and antibiotic schedules – those are the meds most commonly given round the clock. Labs are drawn at 0500, meaning patients are woken and stuck with needles. There are also heparin and lovenox injections to give, which are standard prophylaxis against bloodclots. They, too, are round the clock, and a dose inevitably falls in the wee hours of the morning. Unfortunately, waking your patients means they will probably have to go to the bathroom again – unless they’ve already been awake all night peeing, puking, or suffering from endogenous insomnia or anxiety. My favorite was the lady who called me into her room throughout the night to demand that the talkative woman in the corner be made to leave. The woman was a visual/ auditory hallucination, and as the patient became increasingly agitated we got an order for Benadryl so she’d sleep.

Other things to be done before change-of-shift include rotating IV sites, and changing linens and diapers for incontinent patients. You need to wake, weigh, and get vitals on the cancer patients (their doc always rounds early). You need to tally up everybody’s intakes and outputs. You need to do assess pain again, so everyone is in good shape for the next shift – the worst thing you can do is hand over a patient in pain, because the first couple hours of day shift are hectic, and it’s as good as shooting both your patient and the next nurse in the foot. If you do this over-often, they will probably complain about you to management.

My memory of this part of the shift is pretty blurry. If you’re like me, this is when you really feel like crap. I’d get incredibly frustrated inside when patients started waking up, asking to go to the bathroom and take showers, simply because it was inopportune timing and my empathy was shot. I’d feel sick and hung-over, and obsessed with making it to 0700. That’s when the next shift shows up, and you play snag-a-nurse again. This time you’re deliriously tired, and they look at you like you’re crazy while you try to give a succinct picture of the state of affairs.

0740 – Clock out, feeling dizzy and bitter. Regret the things you forgot to do and had to pass on to the next shift. Dread dealing with the language barriers, manipulative behaviors, and micro-aggressions again tonight. Run a stop light on the way home because you’re too damn tired to drive.

Night shift nursing isn’t for everyone. I suspect that my unhappiness had a lot to do with the drunk delirium that started to kick in around 0300. I definitely blew more than one stoplight in my 8 months on nights – I’d be a safer driver drunk. That, and I am an introvert. Between 5-6 patients, family members, co-workers, and change-of-shift handoffs to negotiate, I always dragged myself home ready to wash my hands of humanity forever. I became more negative and sarcastic, and felt myself losing the empathy that drew me into nursing in the first place. That’s why I quit, and why I wound up pursuing a crash-course in OR nursing. Maybe one-on-one is where it’s at, I thought. At least the surgeons would be known quantities, even if some of them were dicks. At least I wouldn’t have to deal with incontinence and language barriers.

I’m not outright opposed to incontinence and language barriers. I am, after all, a nurse. But when I’m stressed, tired, and busy, my patience and empathy are the first to go. That’s a recipe for disaster, but I wouldn’t have known it without putting myself to the test. I recognized it and GTFO. I hope in this post to supply a candid picture of what didn’t work for me. Nightshift floor nursing can be a great fit for some people – I’m just not one of them.

Floor nursing in general did not work for me. It is staffed to maximize productivity, yet the care is advertised as a boutique patient-centered experience. Rather than support nurses with adequate assistance and guaranteed time for breaks and self-care, we are schooled on customer service. My former unit was perpetually promoting scripts and key words in an attempt to wring out higher satisfaction ratings from patients, without stretching the budget. I’m sorry, but I didn’t go to nursing school to parrot “Is there anything else I can do to make your stay exceptional?” I am not a stewardess. Now, if you give me 4 patients instead of 5, I’d probably have time to keep my incontinent patient clean and dry, bathe the bed-bound peeps, and do more than a cursory interview with my Russian-speaking-only patient.

I’m just sayin’…

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