There and back again

April 24, 2007 -- Today The Wall Street Journal published a mostly excellent piece by editor John Blanton, who resigned from the paper and became a nurse in a post-9/11 search for meaning. The well-written piece focuses on the crushing workload and fear of error Blanton faced as a new burn unit nurse. It has extensive, specific descriptions of the complexity and importance of nursing care. And it ably describes Blanton's transition from novice toward higher competence. Sadly, Blanton quits nursing after a couple years because, as a person in his forties, he feels he cannot afford to work as a junior nurse. The piece arguably gives too much weight to the daunting challenges the new nurse confronts, though this may simply be an honest account of the first two years at the bedside. And there is no discussion of whether the fear or financial pressures Blanton faced call for reform in the way nursing is practiced or financed. The assumption seems to be that what he experienced is his problem, but in the midst of the worst nursing shortage in U.S. history, we're not so sure. Even so, this is one of the best newspaper accounts of what nurses do that we have read, and we commend Blanton and the Journal.

Blanton's piece is headlined "Care and Chaos on the Night Nursing Shift: In a Search for Purpose, an Editor Changes Careers; 'He's Asking for You Again.'" For roughly the first two thirds of the long piece, the recurring themes are Blanton's "war with the clock" and his desperate wish not to "hurt anyone tonight." He explains that in 2002, at age 40, he left his job as a "page-one editor" at the Journal after 9/11 caused him to question his purpose:  

Jolted from the complacency of a comfortable career, I became convinced that I could achieve selfish fulfillment through devotion to service -- to the individual, to the community, to the vulnerable.

This reference to "selfish fulfillment" is a rare acknowledgement of the self-interest at the heart of service professions like nursing--one that is generally lost in the familiar "angel" blather--and Blanton simply tosses it off, almost casually. He says he considered other professions, but kept thinking of those who nursed his mother in the ICU before her death:

I marveled at the way they melded an aloof, precise professionalism with a mysterious human (and humane) instinct. They seemed to operate in a purer space, beyond worldly distractions.

Later passages make clear that Blanton is not suggesting that what nurses do is not "worldly" in the sense that is not real, difficult, or messy, but that it seems to present the world in a very defined package--these patients, these health problems, this 12-hour shift--with little need to worry about the surrounding avalanche of social problems and media noise. Of course, nursing in a larger sense could not be more concerned with the world's most difficult health and social issues, and those issues regularly intrude on its seemingly well-defined clinical shifts. Because many if not most readers do not know that nurses work at the cutting edge of public health, there is some risk that such "beyond worldly distractions" language will mislead.

Blanton says he earned his BSN in an accelerated program "after a year that remains largely a blur." He passed the state licensing exam and began working nights "in the 20-bed burn ICU of a giant hospital in New York City." He notes that after "several months of hospital classes and floor training," he was, "for less than half the pay I earned at the Journal ...doing my part to help ease the nation's nursing shortage."

Blanton offers unusually compelling and specific descriptions of the nursing care he provided. He chats with a young patient while frantically trying to compensate for the fact that the unit is out of the proper dressings for the patient's extensive burns. After 90 minutes of this, Blanton is desperately behind on his other patient, who lies nearby on a ventilator.

I spent the rest of the night ping-ponging between the two, catching up with one while falling behind with the other, documenting my shortcomings through it all in my patients' charts.

Blanton explains that in his first months, any deviation from "the template of nursing duties [he] had been taught to perform like clockwork" could throw him off. Since such deviations were more the rule than the exception, he "operated in a state of continuous low-grade panic, punctuated by spikes of abject terror."

My skills were those of any new nurse. With easily shattered confidence, I could start an IV, administer medications, bathe a bed-bound patient and change linens, change dressings, insert all sorts of catheters and tubes, read lab results and electrocardiograms. I knew to be vigilant against infection, pneumonia, pressure ulcers, medication errors and the many other lurking threats to hospital patients. On the burn unit, pain control loomed large. I also knew, as both executor of treatment plans and patient advocate, to keep a close eye on what doctors ordered. They make mistakes, too.

Blanton says that while he felt "stupid," "slow," and "dangerous," the veterans "floated around the unit, maintaining a cool composure no matter what crisis erupted." He mentions the "nurses eat their young" trope, and notes that his colleagues "weren't always nice," but he makes clear that they were "essential backup," answering his questions and offering help, making him a better nurse by being tough on him.

He talks about working the 12-hour night shift, something that has profound effects on the nurses who must endure it but that receives little public attention.

The 12-hour frenzies, worry about my patients and paltry sleep bred chronic fatigue. I was often in a fog: At home, I spooned coffee into my cat's food bowl, and mistook toothpaste for shampoo. ... I fell asleep in chairs, on subway trains, in taxis, at movies, at supper tables.

Blanton explains the complexity and physical difficulty of patient care on the unit in detail. We hear about the constant walking to and from different rooms ("Already thin, I lost weight as a nurse."). He refers to assessments, monitoring, medication administration, hygiene issues, time-consuming infection control procedures, charting, tests, fixing problems left over from the last shift such as a clogged feeding tube, coping with equipment shortages and unexpected crises, and always, "the clocks mocking me from the walls." He makes clear what was at stake:

There could be no skimping, no coasting through a shift because of a headache or trouble at home. For 12 hours, I belonged to people whose survival was at stake. A sloppy physical assessment could later explode in disaster if a potential problem -- a bum IV, an incipient pressure ulcer, abnormal lung sounds -- went unnoticed. Rooms required meticulous inspection, too, to ensure that vital equipment was present and functioning: A missing bag mask ... could cause lethal delays.

He devotes a paragraph to burn care,

a big, messy, smelly job that demanded painstaking attention to detail. ... We had to work fast because burns impair the body's ability to regulate temperature; exposure can cause life-threatening hypothermia. And simply moving and turning a patient can cause blood pressure to soar or the heart to jump into a dangerous rhythm.

Blanton says he tried to be alert to the smallest changes in his patients' condition, and he managed to talk to patients to assess their conditions, to teach them, to get a larger sense of their lives in order to help them recover. But he "felt hurried, with little time for the reassuring smile and comforting touch one sees on TV commercials that laud nursing as the caring profession." This is a wry comment on the Johnson & Johnson "Campaign for Nursing's Future" commercials, which have tended to reinforce emotional angel imagery but communicate virtually nothing of the mentally and physically challenging work Blanton describes.

While Blanton's lengthy descriptions of his first months as a nurse might be enough to terrify potential nurses among his readers, he does eventually make clear what it was all for.

But though my new career terrified me, tired me and was impoverishing me, it yielded that satisfying sense of purpose that had motivated me at the start. ... I could see that even my frantic novice's efforts contributed to a cumulatively positive effect... In time, the great majority of patients improved. Their grossly swollen bodies returned to supple form. Their wounds closed or were successfully grafted. They relearned to breathe. They talked -- laughed, even -- walked, healed and were discharged. Sometimes, they returned for a visit, shockingly normal in their workaday appearance, neatly dressed and coifed.

And eventually he realizes that he too has gotten better. A young patient, badly burned in a house fire, actually asks for him to be his nurse: "That I might be the kind of nurse whose arrival cheers a patient -- now there was a thought." Blanton says that he was making "the transition from novice nurse, focused almost exclusively on the completion of discrete tasks, to a higher level of competence, able to meld immediate duties with a comprehensive view of patients' needs." Blanton finds that he can perform most of his tasks in about half the time it took when he started. He is no longer intimidated by emergencies ("That's what nurses do. They deal with the unexpected and set priorities.") He gets more rest and gains confidence, even finding time to wash some patients' hair, recalling the "blissful expression" on his mother's face when a nurse's aide had done it for her in the ICU.

My patients lay clean, well-bandaged and stable, tucked under smooth white sheets amid the rhythmic click, beep and whoosh of ICU equipment. When morning shift change came around, I felt that I should take a bow. I had made peace with the clock, and I was proud to be a nurse.

But as Blanton makes professional progress, his financial situation deteriorates. His pay is "that of a 22-year-old college graduate"--not enough even to meet his immediate needs, much less provide for the future of someone in his early 40's. He notes that many nurses his age "enjoyed dual-income lives" and had decades of "seniority pay." In fact, experienced nurses should make substantially more than new ones, because veteran nurses, like veterans in any professional field, are far more skilled. We doubt anyone would characterize a physician with 20 years of experience as receiving "seniority pay." The use of this term by nurses themselves seems like a sad example of nurses internalizing what society has always told them--they do relatively straightforward shift work. (A nurse is a nurse is a nurse.)

In any case, Blanton cannot pay his bills, which include student loans. He begins to accrue credit card debt and dip into his retirement savings. He bounces checks.

I was frustrated by circumstances and shamed by my inability to overcome them -- and by what that implied. Sooner or later, I would have to quit. When the time came, guilt was the overarching feeling: The hospital had devoted precious resources to training me, and now I was leaving. But the nurse managers took my departure with equanimity. "Why the hell did you ever decide to go into nursing anyway?" one of my veteran colleagues said.

Blanton returns to the Journal. But he says his "three-year foray into nursing" was not "an expensive midlife misstep."

Too frequently, perhaps, I crave a shift -- a one-off 12-hour respite back on the burn unit, a reprieve from the news cycle, the BlackBerry, the office patter about war and Anna Nicole Smith. Despite the stress and complexity of nursing, the framework is simple: nurse, patient, clock. The craving often hits me on the subway in the early morning or the early evening, when it's hard to miss the one or two passengers wearing scrubs, making their way to and from shift change. ... I imagine following one of them off the train, down the street to the hospital, putting on my scrubs and moving into that purer space, beyond worldly distractions.

Here again, we hope readers don't get the impression that nursing is really just "nurse, patient, clock." We understand Blanton's point, but nurses have always been deeply engaged with important health and policy issues, and their innovations--from Florence Nightingale forwards--have changed how health care works. Nurses work on the cutting edge of health research and policy. And of course, nurses in many clinical settings (such as the ED or public health positions) would be unlikely to say their work was "beyond worldly distractions." It might have been good for Blanton to make clearer that his observations about nursing were to a significant extent a function of the specific type of work he did and his approach to it. We doubt all burn unit nurses conceive of their work as being confined to the needs of 2-3 patients on a given shift; surely some are active in relevant research or public health initiatives, such as fire safety programs.

Blanton closes the piece by stating, perhaps a bit coyly, that he has just renewed his New York state nursing license. He can't afford to be a nurse, but it seems that he can't quite give up the idea of it either--it's in his blood.

Blanton's piece does many important things well. It makes the "stress and complexity" of nursing clear and vivid for the Journal 's elite readership, or at least those who make it to page D7, where the story ran. In a media environment dominated by easy stereotypes, this is absolutely critical. Blanton tells us exactly what he did for patients and why it mattered. It's true that he hits the daunting stress and workload of his early months so hard that some readers may end up terrified beyond the ability of the latter part of the piece to remedy. But when Blanton gets to some of the satisfaction of being a good nurse--the boy's request for his care, the sense that by the end of a shift Blanton ought to take a bow--it means immeasurably more because we know that he is not an unskilled handholder. He has made a significant difference in the outcomes of his patients.

Another notable aspect of Blanton's account is how peripheral physicians seem to be to his work. He does mention that they may complicate his shift with "orders" for lab work or tube feedings. But he mentions no significant interaction with them, and the picture he paints of hospital care--nurse, patient, clock--suggests that physicians are only marginally involved. Of course, this will not shock nurses, but the average reader, after a lifetime of social and media messages presenting physicians as the providers of all important hospital care, may be surprised.

In a couple respects, the piece might have given more context. Blanton suggests that staffing on his unit was adequate for him once he became more experienced. But it sounds like staffing was not sufficient when he started, because a new nurse cannot be expected to operate with the same efficiency and accuracy as an experienced one. Blanton seems to accept his dangerous first months as just part of the process. However, it's not clear that his level of desperation was necessary or safe, and the piece might have benefited from consideration of whether this was short-staffing given the skill mix involved. Blanton may have been fortunate not to hurt anyone, but that doesn't mean the system he describes was adequate to protect patients. Some hospitals have begun to implement measures, such as mentorship programs for new nurses, that may address some of these safety concerns and help improve nursing retention as well.

The piece does not explore whether the situation that caused Blanton's departure after just two years is simply an inevitable result of a late career entry by someone without adequate financial backup, or something that calls for policy reform. His account suggests that he was a bright, very conscientious nurse, and well on his way to being a very good one. Should society simply accept Blanton's departure with the same "equanimity" that his managers apparently did, in the face of the worst nursing shortage in U.S. history, for which second career entrants may be an important part of the solution? Are new nurses underpaid as a general matter? Should we expand scholarship or loan forgiveness programs for nurses like Blanton?

Of course, we realize that the piece is a first-person account, and that the focus is on what Blanton experienced, rather than larger policy issues. As such an account, the piece is unusually strong and very helpful. We commend Blanton for writing it and the Wall Street Journal for publishing it.

Please send letters of thanks to author John Blanton, RN at John.Blanton@wsj.com and please copy us at letters@truthaboutnursing.org. Thank you!