Fear, loathing, and the good nurse

June 2, 2006 -- Today The Philadelphia Inquirer ran a long piece by Dawn Fallik, "Hospital 'boot camp' is a challenge to a young man's maturity." The article describes student Ryan Sholinsky's arduous year in Thomas Jefferson University's accelerated nursing program. The piece includes a wealth of information about what it's like to begin pursuing a nursing career today. And it conveys some of the intellectual, physical, and emotional demands of nursing, things that may surprise many readers. However, the piece is surprisingly thin when it comes to showing the major positive differences nurses make in patient outcomes, such as saving lives, advocating for patients, and teaching them how to stay well. Instead, it associates being a "good nurse" more with emotional support and resilience. At the same time, the piece's portrayal of the stress and fear Ryan experiences is so strong and so melodramatic that it may be the main thing most readers take away. We get a great sense of what it's like to screw up and almost take a life, but what's it like to save one? Perhaps a piece on medical school could rely on the pre-existing public understanding that physicians save lives and that medicine is at the very top of the socioeconomic order to provide context for such persistent negativity. We cannot say the same about a piece on nursing. Even so, those responsible for the piece deserve credit for telling readers much about the serious nature of nursing education.

Our saga begins with Ryan standing over a sink "trying not to throw up." The story says that, five weeks into nursing school, he had "overdosed" a woman at a local hospital. Readers who read much further learn that the error apparently occurred because Ryan had given a post-surgical patient her meds without checking with the charge nurse, and the charge nurse had later given her the same meds without checking the computer in which Ryan had entered that information. However the responsibility for this divides, the piece dramatically places it all on Ryan: he knew that starting nursing school at age 25 would be difficult, but "he never thought he'd flame out so fast." We learn that in the four years Ryan's instructor, nurse practitiioner Sharon Burke, had worked at Jefferson, "no student had ever overdosed a patient. Not on her watch." The patient turns out to be OK. In fact, "[e]veryone was fine. Except for Ryan. He was not so fine." Despite all this drama, evidently no action is ultimately taken against Ryan.

The piece provides a lot of factual detail about the nursing program and Ryan's decision to enroll. Ryan is not "worried about doing women's work," suggesting that he is secure and that, in any case, 25% of his class is male. Thomas Jefferson has a one year accelerated nursing program for students who already have bachelor's degrees. Indeed, Ryan was "lured by the promise of a three-day workweek, steady employment, and a starting salary of $50,000, all after just a year's training." Yet several paragraphs later, the piece notes that Ryan spent two years "slogging through prerequisites in microbiology, statistics and chemistry," which suggests that, like many associate's degree programs in nursing that are not really "just two years," this one is not really "just a year." The tendency to pretend nursing programs are shorter than they really are is understandable in light of the nursing shortage, but it does not give an adequate account of the profession to the public.

Fortunately, readers of this piece should at least be impressed by the difficulty of Ryan's course work. Only a month in, he is "overwhelmed" by courses like pathophysiology, pharmacology, and epidemiology, plus clinical shifts in area hospitals. The piece says the instructors call the program "boot camp," and it describes it accordingly: "They stripped students of their former selves as bus drivers, flight attendants, or homemakers to build them into good nurses--people who could walk into a room, assess a situation in less than 10 seconds, and take action." We like that description of nursing practice, but we're not so sure of the characterization of who the students are. The piece just said the program is for those with bachelor's degrees, yet none of the three pursuits listed requires anything beyond a high school education. Many nursing students today have a great deal of formal education before they come to nursing. Oddly, the piece never specifies where Ryan got his former degree or where he studied, an omission that would be very unlikely in a long piece about a medical student.

Meanwhile, the piece continues to pile on the hardship. In Ryan's clinicals, "[t]he work was intense: standing on his feet for hours, someone standing over his shoulder at every move." Unlike most of his fellow students, who had gotten full scholarships from local hospitals in exchange for post-graduation work commitments, Ryan was doing it on his own, with a loan from his parents. He lived in a rented room in a house that "smelled keenly of dog urine." Ryan's family, it turns out, was not sure the formerly wild youth was mature enough. And the piece suggests that the overdose incident showed that Ryan's "father was right. He wasn't ready." Indeed, nursing school had been "full of unwelcome surprises." On Ryan's first day at the hospital, a physician "swooped in, brusquely asking questions and cutting off the answers," then lifting a patient's gown to check a catheter with no regard for the patient's privacy, given the open door. "Ryan was appalled." The "job wasn't cushy," with more and sicker patients to care for, and the work "took its toll, with hours of standing and reaching and turning increasingly heavier [sic] patients." The piece devotes a short section to dealing with bodily fluids, specifically the colostomy bag of a gastrointestinal patient. This is of course a real part of nursing, and to its credit the piece resists making it seem worse than it is. We hear more about the "constant demands of school and work," which Ryan's old drinking buddies don't seem to get: "What part of 'I'm in a really hard program' don't they understand?" Through all this, we get little sense that Ryan had made a single friend in the program, or indeed, that he had anyone at all to help him handle the stress. He appears to be facing a bleak landscape, essentially alone.

The piece tells how instructor Burke recently lost three ED patients in one shift, yet had the presence of mind to cover one man with blankets, so that his hands would not be cold when his daughter arrived--"[t]hat's what it meant to her to be a good nurse." Burke reportedly finds Ryan "smart" and "caring," but at first isn't sure he's capable of the warm blanket maneuver. We agree that that kind of action is very important, and can really help a family member grieve. But we can't agree that that action alone--which any considerate person might do, regardless of training--is "what it means to be a good nurse." It seems to us that many things make a good nurse, but if you have to pick just one, the piece was much closer in its short description of assessing a critical situation in seconds and taking quick action. If we had to choose, that's what we'd want from our nurse.

Later, the piece suggests that being a good nurse consists of being able to handle emotional stress. "Taking care of a patient's basic needs was one thing, but Ryan knew it took more to be a good nurse." Based on what follows, that "more" seems to be the ability to handle the fact that a heroin addict might give birth to a very sick baby, then breastfeed her even though the methadone in the mother's system could kill the infant. Of course that is emotionally difficult, but again, if we had to choose one thing, we might say being able to actually save that baby's life would be what we'd hope for most in a "good nurse." And indeed, the piece does describe nurses and physicians rushing into the child's room for the code and working furiously, while Ryan remains outside, feeling helpless. Finally, "the doctors brought [the baby] back," and later, "doctors were still trying to figure out what had happened." We guess the "good nurses" were just managing their own emotional conditions. However, nursing does not consist solely of meeting "basic needs" and handling the emotional strain of illness and death. It requires critical thinking, advanced interpersonal skills, and extensive technical knowledge, as the piece itself suggests in its early descriptions of Ryan's course work.

The article concludes with a description of Ryan's situation just before graduation. Rejecting the hospital with the "disrespectful physician," he had accepted at job on the cardiac stepdown unit at Cooper University Hospital. Cooper offered only half the other hospital's $15,000 sign-on bonus, but there "he'd watched as doctors talked easily to nurses, to patients." This note sends a good message about the importance of collegial relations to the practice environment of nurses. The piece shows us Ryan in a pre-graduation shift at Cooper, eager to get more responsibility, as he monitors and assesses a patient, noticing "a wince that hadn't been there before." The piece ends with Ryan asking the patient where it hurts. We could have used some indication of what Ryan might do with that information to help the patient. But his question alone brings out some of the importance of nurses' constant monitoring. And it suggests that Burke is correct that Ryan has evolved into "the kind of nurse she would want taking care of her own family." The final note informs us that Ryan graduated with a 3.86 grade point average, and that he was due to take his nursing board exams later in June--a good reminder that he had to complete a competitive academic program to become a nurse.

It's important to remember how unusual it is for a mainstream press piece to take a good look at nursing education and convey how academically and emotionally challenging it is. We just wish the piece had been more balanced in tone and content, and that it had looked more closely at nurses' advanced skills, the tangible positive differences they make in patient outcomes, and the professional satisfaction that can result.

We thank Dawn Fallik and the Inquirer for this serious, if somewhat forbidding, look at the rigors of nursing education today.

See Dawn Fallik's "Hospital 'boot camp' is a challenge to a young man's maturity" in the June 2, 2006 edition of The Philadelphia Inquirer.

Contact staff writer Dawn Fallik with comments at dfallik@phillynews.com