The Anonymous, Irreplaceable Nurse

I have written five books about the medical world over the past two decades, and for each book, I have plunged myself into the medical center milieu, living the life about which I was writing—psychiatry, pediatrics, surgery, genetics—from varied points of view. And yet, as I sat down to write this introduction, it was difficult to remember many of the nurses in those stories. Doctors and patients—yes. But the nurses are somehow and for some reason not nearly as clear in my memory.

And another thing—over the past few months, I have been back in the hospital for personal reasons: my mother, ninety-three, was admitted because of suspected heart problems; my son, twenty-one, experienced severe intestinal problems and was admitted; my uncle, eighty-six, and one of my oldest friends, Frank, seventy-two, were dying. Sitting and visiting with these four people who had been in my life for nearly as long as I could remember, I saw very few doctors, but I remember quite vividly who they were and what we talked about. Doctors are deity. They’re the guys who count—so we have been led to believe.

Yet they could not function in most venues without nurses. And where in my recollections are the helpful and caring nurses who were constantly in and out of the rooms, changing bandages, arranging schedules for testing, giving and explaining medications, calming the anxieties of patient and family? I cannot tell you what any of these nurses looked like, what their names were, where they came from. All I remember, and all that mattered, is that my loved ones were tended to by these irreplaceable yet (at least to me) semi-invisible people. I felt comforted and secure because they were there, yet took them for granted.

That these professionals are so unnoticed is a significant aspect of nursing that both intrigues and troubles me. There are over 2.7 million working registered nurses (RNs) in the United States—not to mention our many licensed practical nurses (LPNs) and licensed vocational nurses (LVNs)—compared with about 690,000 physicians and surgeons. There are more nurses in the United States than engineers (over 2 million) or accountants and auditors (1.2 million). Think of it: More than half of 1 percent of the entire US population are nurses—and the number of nurses is expected to grow over the next half-dozen years to nearly 3.5 million, due in part to the more than 75 million baby boomers who increasingly require residential, home, hospital, or hospice care. Why do we take their work for granted? Surely everyone should realize that nurses are the indispensible and anchoring element in our health care system.

Of course, we all know nurses; I mean, we know them as people. They work out at the gyms we go to, live in the apartment across the hall or in the house around the corner, hang out at the local Starbucks, take courses at the nearby universities where they work on advanced degrees; they are everywhere, men and women of all ages, from twenty-one-year-old graduates to middle-aged folks returning to the work force or starting new professions because of our ailing economy. Nurses are ubiquitous in society. We know that they help us, and we know that they are often the key forces who keep our loved ones (and us!) alive. And yet, we know very little about them—professionally.

There are many reasons for this lack of awareness, foremost of which might be the fact that nurses no longer wear distinctive uniforms, so we don’t readily notice or remember them. No more white hats with the red crosses or white nursing oxfords. Running shoes, clogs, and blue scrubs, sometimes with lab coats, pretty much constitute the wardrobe of all medical personnel in the hospital, nurses included. And the larger the medical center, the more categorized and confined the nurses become. While doctors, administrators, social workers, genetic counselors, and others float through the hospital, nurses remain more or less in their assigned, self-contained units. And because the workload is often overwhelming, they rarely leave the floor—or the operating room. Scrub nurses remain in the OR throughout their entire shifts, wearing masks. At one point in time, hospital cafeterias were maintained to serve the medical staff, but now they mostly service the families of patients. Most nurses in medical center settings have little time to sit down and eat meals like “normal” people.

There are also nurses in street clothes—home care nurses, mostly, who tend to the chronically ill or the dying. Nurses often specialize, these days. There are transport nurses assigned to ambulances or helicopters, for example, and transplant or procurement coordinator nurses, not to mention nurse practitioners who fulfill roles once played by physicians. In this collection of essays, you will become intimately involved with many different kinds of nurses from diverse walks of life, nurses of various ages and differing attitudes about their profession. Most of these essays were submitted in response to a call for manuscripts over a period of a few months. We received about two hundred, and most of them were quite excellent. Few nurses receive training in creative writing, and yet the power of the narratives and the clarity of the prose were quite astounding. Perhaps it is because nurses have such compelling stories to tell—and also because the stories they are telling have brewed inside of them for many years (in some cases, decades)—that the stories burst forth with vividness and passion.

But allow me to revisit the idea of and the reasons for nurses' anonymity in some quarters. Nurses tend to keep their experiences to themselves, though they do trust, confide in, and confess to other nurses. I am not saying that there’s no friction or animosity between nurses in the workplace. To the contrary, nurses are more critical of one another than are members of any other group in the medical center, including physicians. Nurses have a lot to prove to themselves and others precisely because their work is often not spotlighted. But as hard as they can be on one another, nurses faithfully and forcefully support each other in times of stress, emotion, and need—most especially the veteran nurses who reach out on a regular basis to those who are just entering the profession. This mentoring aspect fades as the nurses mature and fashion their own distinct ways of dealing with difficulty, but there seems to be an affinity and connection between the veterans and the rookies—the head nurses and the newbies.

A head nurse must be the strongest person in the unit, for he or she serves as a role model; at the same time, this person must exhibit tenderness and be attentive to younger nurses, usually recent graduates, especially those who are experiencing a patient’s death for the first time. Losing a patient is an initiation, a passage through which all nurses who work in tense and highly demanding environments must travel—a sad and unavoidable voyage that remains forever in the nurse’s consciousness.

I observed this passage quite vividly, once, learning from the points of view of both the veteran and the new nurse at a children’s hospital I was writing about. A head nurse in the neonatal intensive care unit (NICU) told me this story: a baby died while a brand-new nurse, fresh out of school, twenty-one years old, was caring for him. “I went to be with her right away, even before the baby was dead but when it was clear that death was imminent,” the head nurse told me. “I knew that the baby was taken care of. We had other nurses covering that baby at that time, and the social worker was with the mom and dad. So I went to be with that young nurse, who probably needed me more than anybody else did. I asked her, ‘Do you want to continue taking care of this baby, or would you like to change assignments?’

“And she didn’t say anything, and then I said, ‘I really think it would be better for you if you took care of this baby.’ She needed to know in the days to come she could go through this whole process. And she did. She was in tears, but she returned to the bedside and picked up the baby and held him. And after the baby died, she picked him up again and held him close to her. She held the baby because Mom and Dad could not hold the baby. Mom wanted to remember the baby the way he was when he was not sick. So she helped the family by doing that. But she also helped herself, because she was able to go through the whole process with this little baby and family. And after the baby died, she carried him downstairs to the morgue, where he was going to have his autopsy.

“She went through all of the sequences. And I think that the right decision was made for her to continue with that baby, but for her also to take note—to know that she had someone to talk to. Because you need to know that you are not going through this alone. That’s too hard. You see, this has happened to me. I have been that nurse taking care of the baby, and the baby has died, and I learned that the best thing was to do all you could for the baby and for the family, extend yourself to the maximum—because in the end you have to live with yourself.”

Weeks later, I met the nurse whose story the head nurse had told. “It was the first time I had ever dealt with anybody professionally or personally who was dying,” she told me. “But that day they assigned me to take care of Adam. About two hours after I started, they did his EEG (electroencephalogram), and everything was flat and nonreactive, and the parents decided that they were going to withdraw support. Right then and there, I just got a knot in my stomach because I knew that this was my first time. Don’t cry, don’t do anything—it was like I was really trying to talk myself into holding back from feeling anything. And then the parents didn’t want to hold him, and as bad as I felt and as teary-eyed as I was, I decided I wanted to hold him; somebody had to hold him. I just felt it was unfair to allow him to die alone.

“Since then, I have gone through this experience two or three more times. And it gets easier—not so much easier emotionally, but you are in better control of it. You might cry only one or two tears instead of bawling your eyes out. It is not as gut wrenching as it is the first time. It never feels better—it is just easier to hold back until you are driving home by yourself and nobody can see you crying.”

As I thought back to that conversation with the young nurse, I realized that the nurses in this collection are telling very similar stories. They are stories about nursing, of course, but also stories about aloneness and strength. These essays are survivor stories, narratives about how to get through the trauma and drama and the awful sadness that come from the day-to-day work in their profession. And I should add that nurses usually don’t share their stories with the outside world because they want to spare friends and family the sadness and shock they are forced to endure as parts of their jobs. More than anything, they want to leave the pressure and the scars of their profession behind them when they leave work at the end of a shift.

As I have said, nurses have been anonymous to many people—and for understandable reasons. But in this collection of essays, they are sharing their secret up-and-down lives with the world. Each essay tells a different story, but all of the essays have a common theme: No matter how difficult nurses’ lives or how secret their suffering, becoming a nurse entails movement into another dimension of strength and character and persistence; it is a path of irreplaceable and often unacknowledged service to society and humanity.

All nurses will understand the message inherent in the title of this book. It is the theme of survival, the theme of maturity, the theme of selflessly treating and healing all patients in any way possible, whether the credit that is due is forthcoming or not. No matter what your age, race, or sexual orientation is, you become a different, stronger, and more capable and well-adjusted person than you ever imagined possible, once you become a nurse. You have reached a plateau of service and empathy heretofore unimaginable. As Tilda Shalof expresses in her essay, “I See You,” all nurses say with confidence and know for certain that this phrase and title are true: “I wasn’t strong like this when I started out.”