Nursing: A day in the life

6:15 a.m. — Katy Prochaska’s shift is scheduled to begin at 6:30 a.m.; but she is already here, dressed in scrubs and going over the patient status report with Melissa Altamirano, a night nurse planning to leave soon. Never mind that Altamirano worked an 8-hour shift the day before and then returned, having been called back at 3 a.m. Never mind that Prochaska worked the day before and will work the next day. What matters is the moment, and how the 37 patients on Community Hospital’s Main Pavilion floor are doing.

As charge nurse for the shift, Prochaska’s job is to watch the entire floor, both patients and nurses, to make sure the flow of activity is efficient and effective, that every patient is assigned to someone’s care, and that every nurse is clear about his or her responsibilities. But first, she has to be clear.

“We’ve got a stab wound,” Altamirano says. “This patient’s cardiac heavy. This one has metastatic cancer of the liver. This one has a pacemaker. This is a very talkative patient, a sweetheart. This one’s grumpy and responds better to male nurses. This one is a lucky lady; it’s not cancer.”

A “heavy” patient is one who is very sick. Prochaska has five heavy cases under her charge this morning.

6:30 a.m. — “Melissa is giving me a report of all the critical information about every patient,” Prochaska says. “Each patient is assigned to a team of registered nurses (R.N.s), licensed vocational nurses (L.V.N.s), and nursing assistants, with four to five patients per team. Today, it’s five patients since we’re in overflow. There’s not a lot of room for admissions today; we’ll have to see what happens.”

6:45 a.m. — The lights are turned on at the nurses’ station and the activity is noticeable. Nurses and technicians are moving like bees, in and out of the station, their conversations creating a low and steady hum.

7:10 a.m. — Altamirano completes her report, and Prochaska turns to give a similar report to Christine Hooks, a unit receptionist and monitor technician who will station herself at the nurses’ station to answer the telephone and keep her eyes on the row of monitors reporting the status of each patient.

“This is the only telemetry floor in the hospital,” says Prochaska, “which means there is a cardiac monitor in every patient’s room that is being monitored at the nurses’ station.
Every nurse who works this floor is telemetry-certified and can read and interpret the monitors. Christine is our hub, directing a lot of what we do, depending on phone calls and monitor information. Any nurse who feels overwhelmed should spend a day in her shoes.”

7:25 a.m. — Prochaska grabs the binder that contains the diagnoses, orders, medications, and plans for each patient for the day and meets with the R.N.s and nursing assistants to create teams and assign patients to them.

7:45 a.m. — Prochaska stops to check on two patients whose stability concerns her. She is stopped in the hallway by two other nurses; she confers with them, discussing their patients’ circumstances. She gives the nurses direction and proceeds down the hallway until she is stopped by still more nurses with questions.

8 a.m. — The nurses’ station is suddenly quiet. The change of shift is complete, the night shift giving way to the day shift. The nurses have their assignments and they’ve all departed to the patient rooms. Prochaska stops in the overflow unit; the place she calls a “mini-ER” is divided by curtained cubicles that shelter patients who need monitoring while awaiting their own rooms.

She returns to the hallway to begin patient rounds but stops, alerted by Hooks that a phone call awaits; spinning on her sneakers, she ducks into her office to take the call.

Victoria Balestreri, R.N., glances up from her desk, where she is working on performance analysis and review of the nursing staff, not for disciplinary purposes but to serve as a learning tool. Balestreri welcomes the change from her frequent role as charge nurse or her floor-time duties.

“Since they come out of ICU and ER, we get very sick patients on this floor,” Balestreri says. “It creates a very active, demanding job for our nurses. Turnover is high because the potential for burnout is high. A nurse could springboard off this floor and work just about anywhere.

Most nurses on this floor are control freaks; we have to be. What makes the day a success are the monitors and the people watching them. I could not sit at that desk all day, watch monitors, and take calls. I’d rather run around and take care of patients.”

8:30 a.m. — An alarm sounds, dispatching a nurse from the station and down the hall to a patient’s room. “That means a patient is attempting to get out of bed,” says Balestreri. “Patients who are disoriented or dizzy have a monitor clipped to their shoulder to alert us when they leave the bed without assistance and risk falling. Apparently someone has left their bed.”

Prochaska checks to make sure someone has updated the “crash cart,” confirming that the oxygen tank and other equipment are in place. “The last thing we want is to hear a code that requires the cart and find it ill-equipped.” She then lets herself into the supply room by punching in a code at the door and confirms that the trays are filled with supplies.

She stops in the hallway to discuss the plan for a patient with two nurses. The conversation is hushed and highly technical, characterized by a lot of updating, explaining, and active listening. The nurses’ commitment and respect is carried in their tone, their language, and their attention to one another.

Prochaska’s beeper sounds and she returns to her office to take a phone call. Her conversation with a doctor involves changing a patient’s code status to DNR — do not resuscitate. She asks Balestreri to take the phone and serve as a witness to the change of orders.

“Can somebody help with a patient turn in 32, please?”

Prochaska pokes her head out of her office and finds that another nurse has already responded.

8:45 a.m. — Prochaska begins her patient rounds 45 minutes later than she had intended. She introduces herself to a patient, who complains of no sleep during the past two nights. She speaks to his concerns, checks his monitor, and lets him know his nurse will be in soon.

“Being in the hospital is rough on people,” she says. “Someone is checking their vital signs every four hours through the night; it’s hard to get any sleep. I really can’t think of any place less restful. When I find a patient who is sleeping, I try to keep people out. Naps are critical around here.”

Prochaska’s beeper sounds and she turns down the hall to take a phone call. A patient has called from his room, wanting to talk to the charge nurse. She steps into his room just as his doctor arrives.

The patient is confused, disoriented, and unsure of what’s happening. He wants to know when he’s leaving and he can’t remember his protocol for medication.

“We strive for that delicate balance between giving a patient credibility and validity,” Prochaska says, “and not reacting to freak them out. I’ve learned that the charge nurse sets the tone for the nursing staff and the patients. I never want to dismiss feelings; I need to remain calm and give people the sense that there is support for them.”

9 a.m. — Altamirano is still on duty, filling out a report at the nurses’ station. She promises to leave by 10.

Prochaska is still making her rounds. She checks in with a patient who can’t find her glasses. Prochaska looks for them until they surface, then checks the patient’s monitor and leaves. “I’m a jack-of-all-trades,” she says. “I’m a big advocate of doing what it takes to empower people. If that means finding a person’s glasses so they can read, well, it’s all good medicine.”

In the next room, Prochaska meets a patient who is visiting the Peninsula on vacation. Having sensed “funny feelings” in his chest, he was admitted to the hospital; now, pending test results, he is looking forward to being released so he can resume his vacation.

“So you decided to take the scenic route and visit our delightful hospital,” she says. He laughs. “We get a surprising number of people from out of town. But then, we are a tourist community. You get somebody out on the golf course who feels a twinge in his chest, and in he comes.”

9:30 a.m. — “I’m going on a break,” says Patricia Owen, L.V.N., to another nurse. “I have no problems to report.” Owen, who has been a “floater” at Community Hospital for 35 years, works her shift on whatever floor she is assigned.

“My job is pretty standard throughout the hospital,” she says. “Except for this floor, where we get a lot of cardiac patients because of the telemetry.”

9:50 a.m. — Prochaska approaches an “isolation” patient room where a sign is posted that reads, “Contact Precaution. Wear gloves and gown. Discard gloves and gown. Exit room. Wash with soap and water.”

“Since I am healthy,” she says, “any bacteria I encounter in this room won’t affect me. But I don’t want to carry it into another patient room, where someone’s resistance is down. The procedure is very clear.”

In the patient’s absence, she steps in to read the monitor and then departs to the sink built into the nurses’ station and washes her hands, part of a steady stream of nurses, technicians, and doctors who have been visiting that sink all morning.

10 a.m. — Altamirano gives Prochaska a final patient status report before heading home. They stop, mid-sentence, to respond to a patient request for a basin and then continue. Prochaska will forward the information in Altamirano’s report to the charge nurse on the next shift.

10:10 a.m. — Prochaska stops her rounds to check the heart rate of a patient down the hall. En route, she stops to cover a call for a nurse, already engaged in another patient room. She returns to her mission to check the heart rate and enters a room where the wall is plastered with “Get Well Grandma” pictures.

Meanwhile, a woman alternates between wandering the hall during procedures, a cup of coffee clutched to her chest, and returning to her mother’s bedside. She offers a winsome smile to nurses bustling past her.

10:30 a.m. — Prochaska completes her rounds. She is halfway through her shift. She begins going over patient reports with her other nurses as she did with Altamirano.

11:15 a.m. — Prochaska takes a 30-minute lunch break.

11:45 a.m. — Prochaska returns from lunch and begins requesting updates regarding patient status from all nurses.

12:30 p.m. — Prochaska starts to assess staffing needs for the evening. She makes assignments, which she will give to the incoming charge nurse.

2:30 p.m. — The next charge nurse comes on duty and, like Altamirano before her, Prochaska begins her report.

“Nursing becomes difficult,” she says, “when performing any one role for too long. Floor nursing can be grounding, but it’s exhausting. As the charge nurse, I see the floor from a different perspective. On the floor, we’re in the trenches. As charge nurse, the scope is broader. Neither is easier nor harder, just different. For me, the combination is best. I didn’t understand the concept of burnout when I started. I was just too excited. Now, I understand the importance of variety.”

3 p.m. — If all goes according to plan, Prochaska will clock out and go home.