To Whom It May Concern:
I am writing to you in light of a series of events that have led me to the understanding that inaction is, indeed, a conscious decision. My name is Sonja M. Schwartzbach, and I am a registered nurse in the cardiothoracic intensive care unit at a level-one trauma center in the tri-state area. I am writing to you because I fear that others will not. I am writing to you because I believe that the collective voice of the nursing community is not heard. I am writing to you out of a desperate attempt to continue to work in the profession that I love, one that I hope will end with safety and security for all and not as some cautionary tale.
Before entering the nursing profession in 2012, I worked in the corporate setting. Upon graduation from Rutgers University in 2008, I was on track to work for a large media company with plans to attend law school. Through a series of unfortunate events, which in hindsight, seem to be a blessing in disguise, I discovered that nursing was, in fact, my calling. I was able to work as a nursing assistant while waiting tables at a local dive bar during nursing school, and this exposure to an acute care setting helped set me on the path toward starting my nursing career.
Today, as a nurse for over four years, I love my chosen path and the life and lessons it has provided me. In addition to feeling the support of my colleagues – from the critical care technicians to the Chief of Cardiothoracic surgery – I very often get the sense that my patients and their family members feel deep gratitude for the level of care they receive, even during their most difficult moments. However, my greatest struggle since starting in an intensive care environment has been synthesizing some of the more stressful and emotionally challenging events in a manner that is conducive to patient care but also protects me: the caregiver. And while I genuinely enjoy caring for patients and their families – many of which are some of the most critically ill individuals in the state – I believe that the greatest roadblock toward my capacity to provide the highest standard of professional care is this: nursing is often seen as an afterthought, even by the most pro-nursing institutions.
Nurses are expensive. We are the largest professional work force in healthcare, and with over 3.1 million professional nurses in the country, it appears that we are large in number but small as a priority. Nurses are overworked. Underpaid. Stretched too thin and sliced too lean and made to feel disposable when we are, indeed, indispensible. Perhaps my greatest concern regarding the ever-evolving healthcare platform is this: as the system becomes more focused on metrics and quantifiable figures, nursing feels the brunt of the blow. No longer can we connect with our patients and their families with adequate time to assess, evaluate, and provide physical and emotional support. Instead, we must quickly and efficiently bag the body of the deceased and usher family members away so that we can admit the next person into the empty ICU bed. Ease the bottlenecks. Decrease lengths of stay. Focus on hardwood floors and culinary delights instead of compassionate care and critical thinking. These are just a few of the countless examples of how the profession is forced to battle not only death and disease, but also red tape and bureaucracy.
As a nurse, I believe that each and every member of the profession requires a healthy outlet to decompress and allow our minds to recharge. For me, that outlet has always been writing. However, as far as nurses go, we often allow everyone and everything else to trump our own needs, and we are often left sacrificing our own peace of mind for the sake of the team or our patients or our children or our parents, etc. We are notoriously good at caring for others but – at times, seem to overlook ourselves. I have noticed this trend not only in my own unit but also in speaking to numerous nurses who I have come to meet and network with over the years. It is no secret that recent studies have attributed the micro- and macro- traumas that nurses experience to PTSD symptoms on par with that of Iraq war veterans. In fact, a recent study conducted by Dr. Marc Moss and Meredith Mealer, RN, PhD from the University of Colorado Hospital concluded the PTSD rates among ICU nurses to be around twenty percent.
So herein lies the dilemma of the new-age nurse: often staffed with far too many patients and too few resources; fighting to save life after life, put out fire after fire while institutional roadblocks only fan the flames. Our mental and physical well-being are up in smoke; we choke back budget cuts and salary freezes and decreased resources with expectations of performing better, faster, and stronger. We are plagued by the physical impacts of caring for one or two or ten patients at a time. We are bound by the constraints of time and space: we can only do so much during our long and busy day, and most days that never feels like enough. We are burdened by the struggle and strife of the human condition, yet have minimal respite to unload the stress, guilt, sorrow, or pain that might impact us. And still, we press forth. We carry on. We do as we have always done, and give our all for our patients: that is, of course, until we have nothing left of ourselves. How is it possible, plausible, or reasonable to push a group of professionals to their collective breaking point, and not provide adequate resources to protect their physical and emotional well-being? Is it simply that, while we are many, we are far from mighty? Somehow, I cannot believe this to be true.
In addition to my work as a nurse, I am also a writer for the profession. Last August, the Huffington Post asked me to become a nurse-blogger for the media giant, and since that point in time I’ve written my first manuscript on nursing and launched my own website. I come to you not as an angry and bitter pill who is frustrated and lashing out through pettiness and contempt: I write as someone who is passionate about the nursing community, and the mountains my fellow colleagues must move to work through a fractured system every single day. Through inadequate staffing and support resources for the nursing domain, we are forced not to flex, but to stretch and bend. Eventually, we will break. The days of life-long bedside nurses are gone, as my colleagues are searching for a way out of the acute care setting in droves, and with an impending shortage on the way, these issues will only get worse before they get better. We are physically drained; emotionally taxed; mentally exhausted; and as we give every last part of ourselves, I sit and wonder: when will the well run dry? When will enough be enough? What will it take for our final straw to break? When will we stop speaking, and finally start acting?
Below is a piece that I recently wrote and was hesitant to publish: it’s raw. It’s emotional. And I assure you: I am not alone in my struggle. Please take a few moments to read my most personal thoughts, bearing in mind that staffing issues and demands further complicate the moral and ethical battleground in which we as nurses work. This piece is not easy to read. It’s painful. It’s sobering. And it should be: unless you’ve lived it, it’s nearly impossible for you to understand the extent of how much we at the bedside do, and why we so desperately need the resources to do it. Nonetheless, I urge you to take a few moments and try.
I hope it makes you uncomfortable. I pray it makes you concerned. And I expect it leads to a loud and public understanding of what has for decades remained quiet issue.
It’s time to stop taking orders, and start taking action.
Sonja M. Schwartzbach, BSN, RN, CCRN
I want to preface this piece by making one thing perfectly clear: I’m not crazy. We’ve all got quirks and issues and idiosyncrasies that make us unique, and I don’t think of this as flawed: I believe it’s what makes us human. However, I do believe in the necessity of balance. We must exist in an environment where Yin meets Yang; where the tumultuous ocean of our inner being is calmed by the ebb and flow of our emotional state. There are times, however, where the waves that come crashing down upon our psyche are simply too large a burden to bear, and we kick and scream and sputter in an effort to keep from being washed away.
Early yesterday morning, I woke not with birds chirping at my window or to the sound of an alarm clock, but to a guttural and blood-curdling scream. It took me a moment, in my state of panic, to connect the fact that the shrieking cry, which resonated throughout the four walls of my far-too-warm bedroom, was emanating from my own vocal cords. The room seemed to shrink around me as I struggled to catch my breath. I was drowning within the sea of my untapped emotions, and the tears that poured down my hot, red face were proof that high tide was in full effect. What was a night terror progressed to what might only be described as a panic attack – and while I’ve never experienced anything quite like this before, it surely felt in line with what the textbooks had taught me.
I am a nurse. It is my job, every single shift, to lay it all on the line for the sake of my patients. Everything – and I mean everything – is expected to be done with the safety and security of my patients and their families in mind. In the intensive care setting which I call my hospital home, this expectation feels amplified: we fight tooth and nail, head versus heart, to keep those charged with our care alive. Yet while the healthcare system is ever evolving, it remains an antiquated one. There is an expectation that either you suck it up, buttercup because that’s simply how it is and how things have always been done, or profess yourself a martyr to the profession a la Nightingale. I often find my own health and wellness at the very bottom of my weighty to-do list, resigned to the idea that I might grab a bite to eat or sip on stale coffee or take a moment to pee after marking just one more item off of my very literal checklist. But as that list grows and my patient becomes more critical, I often find myself decompensating as well: mentally exhausted, physically depleted, and emotionally drained.
I know I’m not alone. It’s not okay to say that what seemingly separates the good nurses from the great ones is the level of self-sacrifice that is poured into a shift while on the clock…and how this bleeds into our personal lives thereafter. It’s not okay that we are told by awe-struck friends and family members that they could never give as much as we do to total strangers, and yet the stark reality is that they don’t even know the half of it. It’s not okay that this is not the exception in nursing, but seems to be the rule. It’s more than the drugs that we push. It’s more than fibrillating hearts that feel shock. And ribs aren’t the only things that crack. The only thing that hurts more than the ache of a long day or a critical patient or a grieving family is the idea that we are expected to remain beacons of strength and virtue when all a rational human would want is to break down and cry.
Am I the crazy one? Woken from my slumber in a state of confusion and turmoil, haunted by the ghosts of patients past within my mind? Am I the weak one? Flooded with emotions that I thought I’d adequately vetted through outlets ranging from drunk and disorderly to written and benign? Am I the incapable one? Blaming myself in the midst of my psyche for circumstances beyond my control – for feeling compelled that, while one foot may have been in my patient’s grave, it was I who somehow slammed the casket closed? At what point does crazy become comfortable? How long before emotions become emptiness? How long before another patient dies, and a part of me is pronounced along with her?
Early yesterday morning, I did something that I rarely do: I didn’t just have a dream; I lived it. I breathed it. I felt immersed in the sights and sounds and smells that permeated the depths of my mind. And while I rarely ever remember a dream, this time it was different: it felt so tremendously real – it was stunning HD quality, fantasy meets reality, blurring the edges between awake and asleep. In my dream, I sat in a spacious home office overlooking a sunny mountain terrain – I found myself in an oversized leather chair with my laptop in hand, admiring the blue skies and the sunshine and the trees that swayed in the breeze. I could feel just how happy I felt in my dream world: I was content. I was comfortable. I sat writing who-knows-what about Lord-knows-who with a mug of coffee and an oversized t-shirt and sense of undeniable happiness. This: this dream world was my sanctuary.
Early yesterday morning, my safe space was quickly ripped away. I stood in my dream world and walked toward the bathroom of my imaginary home on this imaginary day, unaware of the tidal wave that would consume me. I opened the door and found my sanctuary was a murder scene – the crisp white subway tile of my perfect little home splattered with dark red blood like some twisted Pollock painting. I wanted to stop…I wanted so desperately to turn away; to wake up; to tear myself out of the scene that would greet me, but I could only move forward. I could feel the horror in my dream; I can still hear the echoing sound of my screams; when I was greeted by a body – cold and pale and dead – lying in a pool of blood in the bathtub. And the very worst part – the detail of this nightmare that will forever remain ingrained in my brain – is the blood that poured from the woman’s sternotomy. Her incision oozing slowly, steadily…a painful reminder that perhaps her death was expedited through artificial means. And while I didn’t recognize her face: I knew who she was. I knew her story. I flashed through her circumstances and family and friends. I thought about her condition, decline, and demise. I had visions of her bandaged and bloated and mottled, her big blue eyes forever staring into my own. Did I help her, or did I hurt her? Was she surviving on borrowed time, or did I help to seal her fate? Did she come to me in a dream…or did I bring her forth in this terror? Sweating. Screaming. Shaking. Pain.
Am I the crazy one? Or was this only a matter of time? Is this the definition of sacrifice? Is this simply part of the job? How can I ride this wave, when my eyes are red and my lungs are full and the sea has a life of its own? Because in this moment, while I reflect with hopes of healing, I feel desperate for a plan. The terror lies in uncertainty, and despite my best attempt at understanding, I shake and shriek at the unknown: I’ll never know whether it was her blood seeping under the cracks of my locked doors, or if it was my own.
Who saves the nurse, when she’s the one who’s drowning?