An enterprise piece on the dangers of exhaustion amongst nurses.
The hospital smells exactly how you’d expect it to. A mixture of bleach, hand sanitizer and stale meatloaf. You can hear Golden Girls playing in the waiting room, the squeaking of non-slip tennis shoes and the low buzz of machines hard at work. The rhythmic pulsing of oxygen machines and beeping of heart monitors are the only sounds of life. That is, of course, if you can ignore the murmuring chatter of nurses.
It is 7 p.m. on Monday, March 12. Most people are preparing supper or getting their kids cleaned up for bed. The nurses at Mercy, however, are preparing for a shift change.
It is hard to identify who is leaving for the day and who is just clocking in as both groups look exhausted.
Erin Geller rubs her eyes and yawns. “I forgot to wash my scrubs last night,” she says. “So, this is last night’s blood.” Her black scrubs have the faintest trace of a stain near her shoe which is also coated with hospital sludge. She quickly wipes her shoe with an antibacterial wipe.
She tells me that she fell asleep immediately after she got home from work. Instead of waking up early to wash her scrubs, she woke up only half an hour before her next shift.
“This is from last week’s anal fistula,” she said, pointing to her heel. I ask her what that is. She laughs. “You don’t want to know.”
Erin Geller, 23, “charting” for her hospital floor. This involves writing reports and details of the evening’s activities.
Mercy Hospital Northwest Arkansas is a Catholic-based, not-for-profit hospital in Rogers, Arkansas. Geller is one of many nurses that works full-time, 12-hour shifts. The taxing hours and responsibilities can negatively affect the mental health of the nurses, and nights when they are short staffed are even worse.
Nurses at Mercy manage a 10+ patient workload, meaning they are in charge of distributing medication, running tests and checking on over ten patients at least once every two hours. A particularly tricky patient can consume their energy throughout their shift. Mercy is an independent hospital, fortunate enough to afford supportive staff like aides and technicians to work alongside nurses at night.
Rural hospitals around the nation, however, are not afforded the same luxuries. On April 24, 2019, after 10 years of revisions and amendments, a Washington bill was passed to support nurses in these facilities (called Critical Access Hospitals). The bill requires that nurses have lunch and rest breaks throughout their shifts, and ensures they are not significantly understaffed due to financial constraints. The government’s financial support is essential for these small hospitals, and the nurses are especially at risk for being overworked and exhausted.
Washington state was not the first to pass a bill that protects nurses. In 2016, New Hampshire officials introduced a law to ensure rural hospitals like these received the necessary funding and staffing to serve their population.
In March 2019, Illinois nurses rallied together to introduce the Safe Patient Limits Act (House Bill 2604), to mandate acceptable limits on how many patients each nurse can treat in a shift. California is the only state that has passed a bill regulating the ratio of patients per nurse, and studies support this practice, discovering that New Jersey and Pennsylvania would have had significantly fewer deaths if they followed this practice as well (14 and 10 percent fewer deaths, respectively).
It is particularly dangerous for nurses to work overtime, as studies prove that working more than 10 hours a day results in lower quality of care and increased errors. Sleep deprivation impairs memory, decision making and cognitive functions, resulting in an increase in the occurrence of error, infection and death.
Long shifts not only pose a danger to patients, but to nurses as well. Nurses are twice as likely as the general public to experience depression, with the symptoms exacerbated by fatigue and anxiety, especially when nurses are under significant pressure at work.
Nursing regulations are state-specific, but the American Nurses Foundation and the National Council of State Boards of Nursing, Inc. are national committees that ensure each state is getting equal representation on a national scale. If the Washington bill works, many states are expected to follow suit, protecting their nurses and patients with similar laws.
The laws for Critical Access Hospitals will not cover nurses like Geller, but they’re hopeful these regulations will eventually make it to privately owned hospitals like Mercy. Because most large hospitals are owned by conglomerates like Mercy, Mayo, etc., it is difficult to create a uniformed front and create change.
Geller works 40 hours a week, regularly working up to four days in a row. With this schedule, she says it is nearly impossible to catch up on sleep. Sleep deprived night nurses have a higher number of medical errors compared to non-sleep deprived night nurses, according to a study performed by the Current Health Sciences Journal.
Working at night makes you more likely to experience long-term sleep deprivation as the light exposure suppresses melatonin that is normally secreted at night, when other people are asleep. Additionally, people who work at night have unusual circadian rhythms, contributing to depression and “sleep debt,” over time.
To combat this issue, hospitals like Mercy employ support staff to help the nurses. This allows the nurses to focus on each patient and spend more time performing medical tasks instead of showering patients or cleaning rooms.
“Noah’s my aid tonight,” Geller tells me. “Love the kid, but he’s like a bad luck charm. Whenever I work with him there’s always some lady on laxatives that doesn’t want to be cleaned up by a guy.” I ask her how often she runs into that problem. “Nightly,” she laughs.
Geller and joins Noah Hinchcliffe to make their rounds, introducing themselves to their patients and running vital signs.
Noah Hinchcliffe, demonstrating how he uses a thermometer to take temperatures. At only 19, Noah is a nurse’s aid, taking classes to become a registered nurse.
I can’t participate in this, so I hover by the nurse’s station as the day nurses finish up. All the nurses here are women, with smeared makeup and disheveled ponytails. They’re in a hurry to return to their lives, hopefully getting the kids to bed at a decent hour to catch enough shut eye for their next shift. I direct my attention to Andi Cullwell, a blonde nurse adding cream to a giant cup of coffee.
“This is my fourth night in a row,” she tells me with an eye roll. “I think I’m still asleep.” Cullwell just turned 30 and she’s been a nurse for two years. She has two kids at home, ages five and three.
Her kids are involved in extracurricular activities like sports and performances with their school. Cullwell attended her oldest son’s baseball game on a weekend off and said she spent the majority of the time disciplining her youngest and trying to stay awake.
“They’re more exhausting than work,” she laughed. “Crazy bastards.”
After finishing their rounds, Geller and Hinchcliffe come back to the nursing station to fill in Cullwell on the weekend’s activities. The three of them have coordinated their schedules so they have the same weekends off, but Cullwell chose to spend time with her kids this weekend.
“They needed a break from Grandpa,” she says to me. Cullwell’s dad lives on social security and babysits for her while she sleeps during the day. “He’s much cheaper than daycare,” she tells me. She’s in a hurry to move out of his house and get back on her feet though, as she feels her dad isn’t involved enough to give accurate care to her kids.
“They know everything about Desperate Housewives, but not how to spell ‘orange,’” She said when I asked her how he is as a babysitter. “He’s just too old for all their energy.”
Cullwell is very candid about what it’s like to raise kids on a nursing schedule. “I feel bad because I’m always tired when they’re awake. It’s hard to tolerate all their questions and weird stories.”
She said that last week her oldest told her he believes more in aliens than in God. “That’s just not a conversation I have the energy for,” she laughs. “I’ll let my dad deal with that one.”
Cullwell has saved enough money to afford daycare for her youngest, and her oldest will be attending kindergarten in the fall. She’s excited for the transition and hopes to spend significantly more time with them.
The night-shift nursing staff on the sixth floor of Mercy Hospital Northwest Arkansas (Hinchcliffe and Cullwell are in the back row on the far left). Not everyone is pictured.
Hinchcliffe has more energy than both the girls combined. He’s 19-years-old and taking nurses classes at NWACC to be an RN (registered nurse). He said that taking classes and working full time is hard, but he is passionate about nursing and pursuing this degree.
Right now he’s a nurse’s aide, which mean he does all the nurse’s dirty work, changing bed pans and bathing patients. “It’s fun because I work with Erin and Andi,” he gushes. “Last week Erin brought me Chick Fil A.”
Hinchcliffe says that he likes working nights because it’s easier. “The patients are asleep so they can’t complain as much,” he said. “And there aren’t any families or doctors, so it’s calmer than days.”
The calm atmosphere of night shifts can contribute lackadaisical or improper nursing practices. Ann E. Rogers, an associate professor of Pennsylvania School of Nursing and the Center for Sleep and Respiratory Neurobiology, said that nurses who have not obtained adequate amounts of sleep put their patients in significant danger.
She reports that accidents at the hospital are more likely to occur on a night shift, and the risk goes up significantly if the nurse is working consecutive nights. According to her study, by the fourth night shift, an average nurse is 36 percent more likely to make a mistake.
I asked Geller if she’s ever taken one of the counseling sessions offered by Mercy. Mental health days, when combined with counseling, can be essential to improving work conditions and sleep patterns. She says she has not utilized either of the services.
“I’m just busy,” she shrugged.
I told the trio about Shift Work Disorder, the mood disorder associated with working at night. Long-term sleep deprivation and abnormal circadian rhythms can contribute to depression and anxiety, worsening any pre-existing health issues.
“Well that’s great,” Geller laughs. “No wonder I’m so depressed.”
When I first read about Shift Work Disorder, Geller immediately came into my mind. I met Geller in my college dorm, she lived on my floor and regularly joined us for study sessions. She was fairly relaxed during our first semester of college, but as she transitioned to nursing school she was usually too busy studying to enjoy herself in college.
“My last boyfriend begged me to see a therapist,” she said. “My test anxiety was so bad I wouldn’t be able to sleep for days. I went to a counselor a few times, but my schedule was too complicated to keep seeing her [counselor].”
Geller suffered with severe anxiety during nursing school and was prone to seasonal depression, even when she was getting regular sleep. I wanted to see how her hospital schedule contributed to her already existing mental health conditions.
Many people who work at night complain that they miss out on spending time with their families and friends outside of work. Geller agrees with this. “It’s hard because all I want to do during the day is sleep. And when I’m at work, I just want to go home and sleep.”
When I asked if she ever experienced depression from her schedule, she replied, “This was my first winter working night shifts. I’m not doing that shit again. Ever.”
This Christmas, Geller didn’t have time to go home and see her family in Dallas. “I know I don’t want to do Christmas alone again,” Geller said.”
Because she just started at Mercy, she works the shifts no one else wants. That means working on Thanksgiving, Christmas and New Year’s Eve. She laughs, “I even worked on St. Patrick’s Day.”
Shift Work Disorder affects nurses nationally, and many nurses have proposed solutions to this problem. The Washington bill is one of many necessary laws to protect nurses. Because nursing laws are determined on a state-by-state basis, it is a difficult process to put these in motion. Lawmakers do not have a clear grasp on the needs of nurses, evident by the viral video posted on April 16, 2019. The video features Washington State Senator Maureen Walsh demeaning nursing by saying, “ I understand…making sure that we have ‘rest breaks’ and things like that. But I also understand that we need to care for patients first and foremost…I would submit to you that those [critical access hospital] nurses probably do get breaks! They probably play cards for a considerable amount of the day!”
Matthew Keller, WSNA Director of Nursing Practice and Health Policy responded to the video saying, “No, Senator, nurses are not sitting around playing cards. They are taking care of your neighbors, your family, your community.”
It was evident Senator Walsh had not informed herself on the proposed policies, as she tried to argue that reducing the amount of overtime would reduce the level of care for patients. In fact, this bill looks to help increase the level of care for patients by ensuring safe practices and nurses that are not suffering from sleep deprivation or severe cases of Shift Work Disorder.
Keller further argues with the senator saying, “[Nurses] do read the research: mandatory overtime is bad for patient care and it’s bad for your rural hospitals. With all due respect, Sen. Walsh: perhaps it’s time for you to put down the cards and pick up the literature.”
By the end of our interview, Geller said she is “totally over,” the night shift. “You get paid more to work at night, but I don’t care about that anymore. My mental health is worth so much more.”
Geller’s friend, Nicole Melson, transferred to a Mercy clinic last week because she didn’t like the hospital’s grueling schedule. I asked Geller if she’d consider doing the same. “I mean, I like working at the hospital,” she said. “It’s fast and I learn a lot. But it is hard. It’s really hard.”
I reached out to Melson and asked why she transferred to the clinic. “I just thought you had to work at a hospital right out of school. I hated it. I didn’t know any of the doctors and I never got any weekends off,” she said.
I asked if she liked her new schedule. “I thought I’d hate working a nine to five, but I love it. I’m just getting my sleeping schedule back.”
Her new schedule lets her interact with doctors and patients on a day-to-day basis. “I actually get to know the doctors so I learn a lot from working with them directly.” She said the change has significantly improved her social and romantic life too, as she is on the same schedule as other professionals.
I didn’t interview Melson long enough to adequately judge her mental health or determine exactly how she’s benefited from the schedule change. I can, however, attest that Melson smiled the most out of the other nurses I interviewed and perhaps that is significant enough.