The Dark Night

Ever since I was a patient care technician prior to starting nursing school, I knew night shift was a different beast than day shift. People who have experienced being a patient or working in an in-patient setting understand that the day shift is all hustle and bustle.

- My commuting has some nice views, but the darkness and loneliness of working while society sleeps seems to offset the positives.

What goes on during the day?

Diagnostic appointments are carried out, consultations take place, case managers are present, patients are working with physical and occupational therapists (PT/OT), and all/most of the providers are around placing new and amending standing orders. Each patient is assigned a provider and those individual providers are in charge or a plethora of caseloads; the assigned provider has to be contacted directly regarding any question about their specific patient. This may sound chaotic, but the fact that there are so many medical professionals present and that (for the most part) the providers know their patients, allows for the nursing staff to be surrounded by so much support.

When you sit down and write out the differences between day and night shift, it is shocking. The set-up of the night shift only causes more pain and suffering for all involved. Patients are at risk with fewer healthcare professionals monitoring them. Nurses are overworked and spread thin, unable to adequately assess all of their patients. What is the one commonality between the two lists below? The number of patients. That stays constant no matter the time of day, so why does the staffing shift so drastically after dark?

Day Shift Numbers

• 28 patients

• 6+ floor nurses

• Nursing Manager

• Clinical Resource Leader (Assistant Manager)

• 4+ Patient Care Technicians

• 3+ Physical/Occupational Therapists

• 2 Case Managers

• Access to Nursing Administration

• 1 overall Nursing Supervisor

• Transport staff

• 2+ IV therapists (for the whole hospital)

• Individual Providers

• Speech/Language Pathologists

• Psychological providers

• Palliative Care

• Wound Care

• Respiratory Therapists

• 1-to-1 observers for a patient who is psychologically unstable

Night Shift Numbers

• 28 patients

• 4 floor nurses

• <1 IV therapist on call for the entire hospital

• Respiratory Therapy

• 2-3 Patient Care Technicians

• 2 Providers for the overall patient population

• 1, usually a temporary traveler, overall nursing supervisor

For some reason, my current hospital has two providers who also have the role of being Primary Care Physicians. This title is an unofficial rule where the other hospitalists are not allowed to care for or update orders for patients under the care of these two specific physicians. These two individuals also only work day-time hours and do not work on weekends; this means that if a patient were to be admitted with chest pain or some cardiac issue on a Friday night, they would not be provided with adequate care until the weekend was over. Can someone tell me how this is okay?

Patient safety should always come first.

Why does this matter?

The ultimate point I am getting at is that hospital administration does not prioritize the safety of their staff or admitted patients; for them, it is a numbers game of keeping salaries low and patient intake high. Knowing this, I honestly would not want to be a patient in any capacity.

One of the reasons why there is so much staff turnover and burnout is because the hospital is running the operation like a business. Can the night shift nurses take care of the same amount of patients that are cared for during the day? The short answer is ‘yes’, but what quality of care is being provided? How can you provide effective care to 7 patients if 3 of them are detoxing from alcohol, 2 are “sundowning” from dementia, 1 is experiencing septic shock, and 1 is having a heart attack?

The answer to that is, “you cannot”.

- The above memes are not exaggerations

There is a reason why the majority of Rapid Response/Emergency calls are paged overhead during the night-to-day shift transition; so many variables are missed at night due to the high acuity of the patients and the sheer patient load.

Messing up or missing a key variable that identifies or provides a solution for an acute change in patient status not only affects the patient but it also can cause the nurse to lose their license. Hospital administrators are putting their staff and patients in harm's way; they are willing to do this so that they can keep making an unrealistic amount of money for themselves and because we are all expendable staff.

A Snapshot of How Nightshift has Impacted My Routine:

My residency program had me spend about 12 weeks working on dayshift with anywhere between a 3-5 patient assignment. I was able to experience the described chaos of the operations in the hospital when the sun is up and everyone is there.

It felt like hitting a wall when reality set in after the transition to night shift was complete. I was faced with 7 patient assignments, inadequate staffing across the board, and almost no support (other than from the other 3 struggling nurses on my shift).

I went from looking forward to going to work and caring for my patients to having intense anxiety attacks in my car on the commute to work, counting down the 13 hours from the time I parked, and hoping that I was able to keep all my patients alive until 7:30 in the morning (and this, unfortunately, does not always happen). Besides the high amount of experienced anxiety, slight depression and PTSD from dealing with constant death and COVID, there is the disruption of the natural circadian rhythm and the malnutrition.

- The burnout is real, and I am feeling it

Since starting my job back in October of 2020, I have probably: taken about seven or eight 30-minute unpaid breaks, gone to the bathroom about 15 times, and had a sip of water about 20ish times. I have lost 20 or so pounds since I started work due to the lack of nourishment; there just is not enough time to step away from the floor due to the lack of staffing and the lack of stability of patients.

I am tired all the time.

I sleep from 9:30am to about 3:30-4pm prior to a 7pm-7:30am shift. I need to get to work at least 30-45 minutes early to look up all my patients and mentally prepare for the shift; then I clock in at 6:53pm and do not clock out until at least 8:30-9am the following day; then I repeat this for the following shift later that night. The issue with the sleep-wake cycle is compounded when I sleep following my two-three shifts in a row; I sleep until about 4pm and need to eat just to get ready to go back to bed. I somehow am always tired on my days off and cannot seem to catch up on sleep. The lack of sleep regularity, malnutrition, disruption of the natural bathroom schedule, and the introduction to dealing with mental health is attacking the body from all angles; I am unsure who would voluntarily put themselves through this torture.

- Never feels like I am ever caught up on sleep; it's embarrassing to fall asleep when getting together with friends or family

The thing is, we did not necessarily sign up for these particular working conditions. Did I know this job was going to be tough? Yes. Did I know that there was going to be a pandemic? Not really, but that is neither here nor there. Did I expect employers to take care of their staff, provide staffing and resources necessary for safe working conditions? Yes; but this is definitely the new reality of healthcare. Whether it is working during the day or the night, there is a constant hustle to provide care for your patients all while caring for yourself, which is why nursing is my cardio.