"Time, the subtle thief of youth … "
John Milton. Sonnet 7: How soon hath Time, the subtle thief of youth
There's a subtle, but significant, problem with the work that we do. It's largely invisible to our families. Visiting us at work and watching our labor is seldom possible and violates patient privacy. "Nobody knows the trouble I see."
It is hard for them to understand what it is like, why we are tired, or the stress involved. Many stressors are mental or emotional, not just tasks, but intellectual turmoil in sorting patients, being inclusive and accurate when making lists of differential diagnoses, the self-questioning and self-doubt of 'what am I missing here?" or "why didn't I see that earlier?" Wondering if one is seeing the patient's inner needs or hidden agenda. Reacting to outbursts or abusive behavior. "Is this case one where I am going to see a lawyer's letter or law suit?"
Having a "Take Your Daughter To Work Day" conveys little, and necessarily is as sanitized beyond recognition as the silly 'medical' and 'emergency' dramas on television. Other occupations, such as military, police, and fire, have come to grips with the reality of Post-Traumatic Stress Disorder in their field, but I think that Emergency Nursing doesn't yet accept the cumulative nature of the stresses in our field.
My own career includes both prehospital and in-hospital care. Stressors occur in both, but in different ways. The 'shop culture' in each is to a greater or lesser degree, one of tough self-reliance, and 'these things don't bother me." Available support is probably greater within a hospital than outside, where the environment is more isolating and 'John Wayne' cultural issues are prevalent. And there are cases that we will never mention; sparing them, but taking the weight of our experiences totally upon ourselves. If this seems unreal, recall those nurses you've known who decided emergency nursing 'wasn't for them' and wanted to move to 'something else' or even leave nursing. Were we always clear upon what really bothered them?
Some cases never involve the hospital and are selected out as only living persons or those with potential viability are ever transported, thus there is no exposure for hospital staff to the greatest carnage. Decapitations, incinerations, the decomposed, —the person struck by a locomotive who is now only a three-foot square pile of rags, do not need a hospital for care. The slashed throat, whose spilled warm blood gives rise to visible vapors in the cool night air of a two A.M. bar-closing; if 'medical care would be unavailing' the body is left for the homicide investigation.
A woman, now suddenly a widow, watched her husband fall in the bathroom, proving the statistic that one-third of first heart attacks is a sudden cardiac death; his head having gone through the shower door glass lies in the same position with jagged shards surrounding his head and neck, must now have to learn that his body shall remain that way until the police and coroner's deputies arrive for the investigation. How great must be her shock.
I recall a shift in emotional content for myself while attempting resuscitation of a one-month old infant (who appeared more dead than stated); the care-giver thinking that it "had only been 10 minutes." Pulmonary compliance was so poor that I gave up the BVM to instead give oxygen -enriched mouth-to-mouth resuscitation. Tears welled up while doing so as I thought of my own toddlers. The infant's Mom and Dad weren't present as they had gone away for the weekend to a gambling resort. Was there already some post-partum depression at work in that family? How would things be to find they no longer had a child?
The public think that our stress would be due to such lurid cases as these, and that "Man, you must see some really weird S**t." Certainly, such things happen less often than is imagined by them. More often, I think, greater psychic wear and tear occurs from repetitive lower stress matters analogous to the growth of a cave or the Grand Canyon by continuous flow of water. Almost a 'Death by a Thousand Cuts.' One fellow left our department to work in Post Anesthesia Care because, "I just want to be able to sit down." Hearing an endless litany of patients' woes takes a toll.
Some have called this "Compassion Fatigue." I don't think that there's a fatigue in giving compassion; I think that it is endlessly drawing from a well of one's own reserves to the point of exhaustion, and the sore muscles, bad feet, bad back, and bad bladder sacrificed in endless giving to those in need. Need always exceeds resources, doesn't it?
I do belief that staff should be able to negotiate for the sort of shifts that they wish. However, it seems to me that the prevalent twelve-hour shift pattern has seduced many into long term problems for short term gain. It is an enticing thought to work 'fewer' days; but the semblance of more time for oneself can turn into extra shifts for a new house. Remember, too, that the institution saves considerable money with fewer shifts to staff, despite awkward shift plans to avoid penalties in overtime compensation and taxation that incur when staff work more than forty hours weekly. It is not necessarily to our advantage to accept such terms.
Especially in urban areas, economics mean multiple incomes for housing, longer commutes to affordable homes, yet staff are not consistently relieved for breaks, stay late to finish charting or work, and are cautioned to avoid dangerous 'micro-sleeps' while commuting when fatigued. Staff meetings are seldom scheduled for night shift but where managers can fit them in to their daily round of meetings during what would otherwise be a sleeping period for the night worker.
Long hours and working extra are part of the 'American Way.' Yet, there is increased physical wear and tear, and increased psychic wear and tear may well occur with extended hours, increased fatigue, and decreased rest or decompression. Our resilience is worn down.
I know too, that having to work 'eight days a week' kept me from spending the time that I would have liked to have with my children, and sharing tasks and responsibilities with my wife. That time spent at home was out-of-sync with normal hours of the real world, and often taken up with essential sleep before the next shift.
As time passed, jobs and wages changed, and things improved, but were never normal. Especially, when social, civic, and child-rearing responsibilities, due to odd hours and mandatory every other weekend shifts and holiday requests, required a fixed date for planning three months in advance; a form of 'unobtanium.' How can one's work (and its meaning) be seen in context by family? If an older child should be able to visit and observe during one's night shift, that child will likely fall asleep. They don't see it.
Now that our children are grown and have Life and families apart, I feel a great regret that I missed their childhoods. Yes, I made time for Scouts and other activities. But always with a necessary eye on the clock and calendar for return to work; indeed, once, nearly two months went by, without a single night at home or day off. That was too much.
The American people have forgotten the struggle of Labor to achieve "Eight hours for Work, Eight hours for rest, Eight hours for what we will." Spending six days a week or more in mines or fields to pay off the Company Store, seems incomprehensible toil, yet it is a forgotten tale. Now, we are drawn into stolen hours by longer commutes and traffic delays, more than one income necessary to have a decent place to live, and the hours of overscheduling children and ourselves: stolen from the eight hours for rest and eight hours for what we will.
It's been said that 'Nursing works on Guilt"; perhaps due to its background in orders of nunnery. Scheduling and vacation or holiday requests are countered with tinges of guilt and compulsion to 'make it fair.' It certainly is insufficiently flexible and the burden is on oneself to 'find your own replacement.' Also, "I requested it off and couldn't get a replacement, now I can't call in sick even though I am sick.'
How then do we recover our equanimity? How do we reduce stress? I'm not sure. There are many conventional and familiar suggestions, each with some potential merit, but any list is surely incomplete nor particularized to an individual's own needs. I am increasingly sure, however, that many would find better balance in "Eight hours for Work, Eight hours for rest, Eight hours for what we will."
Tom Trimble, RN
All opinions are solely those of the author.
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