What Nursing Is Actually Like

When does your day actually start?

I work nights. So, 7 PM to 7 AM, three twelves a week. But my day starts around 4:30 in the afternoon because I need to flip my sleep. I wake up, eat something that's technically dinner but feels like breakfast, shower, pack my bag. I have a whole system with the bag. Two meals, three snacks, a 32-ounce water bottle, my stethoscope, an extra pair of compression socks because my feet swell after hour eight and I learned the hard way that starting with fresh socks at midnight makes the last four hours survivable.

I get to the unit at 6:40. Report starts at 7. But I like to pull up the census in Epic before I sit down for report, just to see what I'm walking into. How many patients on the floor. Who's been here for six days and who came up from the ER at 5 PM with a brand new admit workup that nobody's finished. How many are on telemetry. Whether anyone is flagged for fall risk, because if they are, I need to check that the bed alarm is actually turned on, because about 40% of the time it's not. Someone turned it off during a bed change or a transport and forgot to reset it.

You're charge nurse three nights a week. What does that mean in practice?

It means I have my own patient assignment, usually four patients, and I also manage the floor. Staffing, bed assignments, admissions, transfers, escalations. If a nurse has a question about a medication, they come to me. If a patient's family is upset, they come to me. If the ER calls and says they have a patient ready to come up and we don't have a clean bed, I figure that out. I'm a nurse and a manager at the same time, and neither role gets my full attention because they're always competing.

On a good night, charge is mostly logistics. I'm assigning the new admit to whoever has the lightest load, I'm making sure the CNA isn't drowning, I'm checking on the nurse who's been here two months and still takes 20 minutes to hang a piggyback because she triple-checks everything. On a bad night, charge means I'm the one who starts chest compressions at 3 AM while someone else calls the code.

Tell me about a specific shift. Something recent.

Last Wednesday. I had four patients. Room 12A was a 74-year-old woman, post-op hip replacement, day two, doing fine, mostly needed pain management and help getting to the bathroom. Room 12B was a 58-year-old man admitted for cellulitis, IV antibiotics every six hours, diabetic, needed blood sugar checks and sliding scale insulin. Room 14A was a 43-year-old woman with pancreatitis who hadn't eaten in four days and was miserable and kept calling about nausea even though she'd already gotten her Zofran. Room 14B was an 81-year-old man named Mr. Trevino who was there for a COPD exacerbation and had been in and out of our unit three times in the last four months. He knew the floor better than some of the nurses.

Mr. Trevino is the kind of patient I think about. He's pleasant. He never pushes the call light unless he actually needs something. He knows his own oxygen settings. He'll tell you "I'm usually on two liters at home but they bumped me to four when I came in." And every time he's discharged, I know he'll be back. His home situation, he lives alone, his wife passed two years ago, his daughter drives up from Cincinnati on weekends but he's managing his own meds and his own nebulizer and his own oxygen concentrator for five days a week by himself. The system discharges him when his O2 sats are stable. The system doesn't ask whether he can actually manage at home. That's not a nursing problem, technically. But it feels like one every time I see his name on the census again.

What happened later that night?

Around 2:30 AM I was charting at the nurses' station. Tanya, she's my CNA, the best one on our floor, she'd just finished rounding. Vitals on everyone, repositioning the patients who needed it. She came back and said "14B looks a little gray." That's not clinical language. She didn't say his oxygen was low or his blood pressure was off. She said he looked gray. And Tanya has been doing this for eleven years and when she says something like that, I move.

I went into Mr. Trevino's room. He was sitting up in bed. His oxygen was reading 88 on the monitor, which for a COPD patient isn't great but isn't immediately alarming. But Tanya was right. He looked gray. Not blue. Not cyanotic. Just, the color had left his face. I asked him how he felt and he said "tired." Which could mean anything or could mean his body was working too hard.

I bumped his oxygen to six liters. Listened to his lungs. Diminished on the right side, which was new from my last assessment. I paged the hospitalist, Dr. Khatri. She's one of the ones who actually answers pages at 2 AM without making you feel like you ruined her night. She ordered a portable chest X-ray and labs. By 3:15, the X-ray showed a new pleural effusion on the right. He needed a thoracentesis but that wasn't happening until morning, so the plan was to keep him upright, increase the O2, monitor closely.

He was fine. Or, he was stable. He didn't code, nothing dramatic happened. But that whole sequence, from Tanya saying "he looks gray" to me at the bedside to the page to the X-ray, that's about an hour of my night. And during that hour, 12A buzzed twice because she needed help getting to the bathroom, 14A called for nausea medication, and a new admit arrived from the ER that I had to assign to another nurse because I was dealing with Mr. Trevino. That's what a night shift actually looks like. You're always in the middle of three things, and the one that matters most is the one you're scared about.

You said Dr. Khatri is one of the ones who answers pages. What about the ones who don't?

Some hospitalists take 15 to 20 minutes to call back. Some call back and sound annoyed. Like you've interrupted something. And you probably have. They're covering 15 to 20 patients across the hospital, they're exhausted too. I get it. But when I'm standing in a room with a patient whose oxygen is dropping and I need an order, and I'm waiting for a callback, those minutes feel very different on my end than they do on theirs.

There's a hospitalist I won't name who once told me, when I paged about a patient whose blood pressure had dropped to 82 systolic, "just give a bolus and I'll see them on rounds." At 3 AM. Systolic of 82. I gave the bolus, obviously, but I also wanted to say, I'm not calling you because I don't know what to do. I'm calling you because I need the order to do it. Nurses can't prescribe. We can assess, we can anticipate, we can know exactly what the patient needs, but we can't write the order. So we page. And sometimes the person on the other end treats the page like an inconvenience rather than, you know. A nurse telling you something is wrong.

How much of your shift is documentation?

I'd guess 30 to 40 percent. On a night shift with no codes and no new admits, maybe more like 25. But charting in Epic is, it's a whole thing. Every assessment has to be documented. Head to toe, every four hours. That means I'm clicking through drop-down menus for neuro, cardiac, respiratory, GI, skin, musculoskeletal, psychosocial, for each of my four patients, and each assessment takes about eight minutes if nothing's abnormal. If something IS abnormal, you're typing narrative notes explaining what you found and what you did about it. Medication administration gets scanned and documented. I&Os, intake and output, that's charted. Fall risk scores, Braden scores for skin breakdown, pain reassessments 30 minutes after every pain med. The chart is a legal document. If it's not charted, it didn't happen. So you chart everything, and the charting takes you away from the bedside, and then someone asks why you're not at the bedside.

What's yours?

How fast you learn to metabolize death. I don't mean you stop caring. I mean you develop this, I don't know, this processing speed. My first year, I had a patient die on my shift. A woman in her sixties, cardiac arrest, we coded her for 30 minutes and she didn't come back. I sat in the break room afterward and I couldn't eat my sandwich. I just sat there. My preceptor, a nurse named Gloria who'd been doing this for 22 years, she came in and sat next to me and said "you still have three patients." Not cold. Just true. The other three patients didn't stop needing care because someone in room 8 died.

Ten years later, I've been present for, I think, around 30 deaths. Some expected. Comfort care patients, hospice transitions, families gathered around. Some not. And what's changed isn't that I feel less. It's that I feel it faster. The grief compresses. It goes from days to hours to, now, this tight knot in my chest that I carry through the rest of the shift and then release in my car on the drive home. I cry in my car maybe once a month. Not sobbing. Just, the knot loosening. And then I drive home and Marcus, my husband, asks how my night was and I say "fine." Because how do you explain to someone who works in IT that a man died at 4 AM and you cleaned his body and called his daughter and then you went and gave your other patient her 6 AM metoprolol like nothing happened? You don't explain it. You just say fine.

The thing nobody tells you is that the speed isn't a flaw. It's a skill. And it's also a loss. You lose something every time you get faster at it.

How did you end up in neuro ICU?

I was pre-med at Georgia State. Biology major, all the prerequisites, MCAT study plan taped to my dorm wall. And then my dad got laid off, and my mom, she's a nurse practitioner in Atlanta, she sat me down and said, look, medical school is $250,000 and you'd be 30 before you start earning. She wasn't telling me not to do it. She was telling me to look at the math. And the math was, I had $34,000 in undergrad loans already and no savings and no family money.

So I did an accelerated BSN program. Fifteen months. It was brutal, honestly, because I kept comparing it to the path I didn't take. Every time I learned pharmacology I'd think, med students learn this deeper. Every time I did clinical rotations I'd think, residents get to make the actual decisions. That comparison, it took me about two years to let go of. I'm still not totally sure I have.

I requested neuro ICU because the pathophysiology is the most complex nursing specialty I could find. Traumatic brain injuries, strokes, post-surgical craniotomies, status epilepticus. The assessments are constant. You're doing neuro checks every hour, sometimes every 30 minutes. Pupil reactivity, Glasgow Coma Scale, level of consciousness, motor responses. One pupil that's a millimeter bigger than it was an hour ago can mean rising intracranial pressure, and if you catch it at "a millimeter bigger" instead of "fixed and dilated," that's the difference between the neurosurgeon drilling a burr hole and, well, the alternative.

Walk me through a day that sticks with you.

I had a patient, a 19-year-old. Motorcycle accident. TBI, traumatic brain injury. He'd been in our unit for six days. I'd had him for three of those shifts. His name was on the assignment board and every time I saw it I felt something tighten in my chest because 19 is, that's not someone who's supposed to be in a neuro ICU. He was intubated, sedated, on an ICP monitor. His intracranial pressure had been running high, 22, 24, for two days. Normal is under 20. Dr. Osei, the neurosurgeon, had done an EVD, an external ventricular drain, to try to relieve the pressure. It helped some. Brought him down to 18, 19.

His parents were there every day. His mom brought a blanket from home, this blue fleece thing, and draped it over the hospital blanket. His dad stood by the window. He didn't sit. The whole time I knew that family, six shifts, I never saw his dad sit down. I think standing was how he stayed ready. Like if he sat down he'd have to accept that waiting was all he could do.

On this particular day, a Tuesday, Dr. Osei came in at about 10 AM and told me he wanted to do an apnea test. He said it quietly, at the nurses' station, not in front of the family. An apnea test is one of the components of a brain death exam. You turn off the ventilator and watch whether the patient makes any spontaneous respiratory effort. If they don't breathe on their own for a set period, that's one piece of the determination.

What was going through your head at that point?

I'd been watching this kid's neuro exams trend downward for three days. No cough reflex. No gag reflex. Pupils fixed at 6 millimeters. I knew where this was going. But knowing it clinically and knowing it in your body are two different things. Clinically, I was already thinking about the sequence: the apnea test, the second physician exam, the time of death documentation, organ procurement if the family consents. I'd been through this before. I knew the steps.

In my body, I was thinking about the blue fleece blanket. I was thinking about how his mom had asked me that morning if I thought he could hear her. And I said what I always say, which is "there's evidence that hearing is one of the last senses, and I'd encourage you to keep talking to him." That's a true statement. It's also the statement you give when you don't want to say what you actually think. And what I actually thought was, no. I don't think he can hear you. I think what's keeping his body going is the ventilator and the norepinephrine drip and the ICP monitoring that I check every 30 minutes. I think the person you knew left days ago. But you don't say that. You give the true statement and let them hold onto it.

How did the rest of that day go?

Dr. Osei spoke to the family. I was in the room for that conversation. The mom asked, "does this mean he's gone?" and Dr. Osei said, "we need to do a series of tests to determine brain function," which is medically precise and also not what she was asking. She was asking if her son was dead. And the answer was probably yes, but the protocol requires tests and documentation and a second physician, and all of that takes hours. So for those hours, the family exists in this space where their son is legally alive but functionally, probably, not. And I'm in the room managing his drips, checking his lines, suctioning his ET tube, performing all the tasks of keeping a body alive while everyone in the room is beginning to understand that the person is gone.

Dave, the respiratory therapist, he ran the apnea test with me. We've done this together four times now. Dave is the kind of person who doesn't talk during the test. He watches the monitor. I watch the patient. Eight minutes of watching a chest not rise. It's the longest eight minutes in medicine. You're watching for any breath. Any twitch of respiratory effort. And you're simultaneously hoping for it and knowing that if it comes, if there's one weak breath, it complicates everything. Because then it's not brain death. Then it's a patient who might have minimal brainstem function, and the family gets hope, and the hope leads to weeks or months of a body in a bed that will never wake up. I've seen that too. I don't know which one is worse.

You mentioned you were pre-med. Does that change how you experience the ICU?

It makes me notice things I probably wouldn't otherwise. I read the imaging reports. I understand the pharmacokinetics of the drips I'm titrating. When Dr. Osei adjusts a treatment plan, I follow the reasoning. Most nurses do some of that, but I do it compulsively. Priya, my girlfriend, she's an internal medicine resident at Memorial Hermann, different hospital, and sometimes we'll be eating dinner and she'll describe a case and I'll respond with a differential and she'll pause and say "you would've been a good doctor." And I don't know how to hear that. Because it's a compliment and it's also a reminder of the path I didn't take.

The difference between me and Priya isn't knowledge. Not really. It's authority. She writes the orders. I carry them out. She decides the plan. I execute it. And that distinction, which sounds clean on paper, it gets messy at 3 AM when I can see that a patient needs something and I have to wait for a callback to make it happen. I don't think that's a flaw in the system exactly. Scope of practice exists for a reason. But it's a strange thing to spend 12 hours at a bedside making constant clinical assessments and then have to ask permission to act on them.

What's yours?

How good you get at reading families. Not the patient. The family. You learn to scan a room when you walk in and know within about ten seconds what kind of shift it's going to be. Are they hovering over the monitor? They're anxious, they need education, they need someone to translate the numbers into something human. Are they on their phones, calm, talking to each other? They've accepted the situation, they trust the team, they'll let you work. Is one family member standing with their arms crossed asking questions with a tone that says "I Googled this"? That person needs time. They need you to sit down, not stand, make eye contact, answer everything without being defensive. If you get that person wrong, they go to your charge nurse, then your manager, then patient relations, and suddenly you're writing an incident statement about a conversation that went sideways because you were efficient when they needed you to be slow.

The part nobody talks about is that managing families is a clinical skill. It's not soft skills. It's not "being nice." It's assessment. You're assessing their coping, their comprehension, their grief stage, their capacity to make decisions, and you're doing it while simultaneously managing a ventilator and four IV drips and a neuro assessment that's due in 12 minutes. And nobody teaches it. There's no module in nursing school called "How to Tell a Mother Her Son's Pupils Are Fixed." You learn it the first time you're in the room when it happens, and you either figure it out or you don't.

You became a nurse at 41. What were you doing before that?

Medical assistant. Fifteen years at a family practice in Pikeville. Dr. Colvin's office. Three exam rooms, one other MA, a front desk person named Brenda who'd been there since the Reagan administration, and me. I did vitals, drew blood, did EKGs, prepped patients, stocked supplies, called in prescriptions once the doctor signed off on them. I liked it. I was good at it. But after about year eight or nine, I started running into this wall where I knew what was wrong with a patient and I couldn't do anything about it.

Like, a woman would come in with a blood sugar of 340 and I'd take her vitals and I'd know, from fifteen years of seeing diabetic patients, that she needed her Metformin adjusted and probably a referral to an endocrinologist and definitely a conversation about her diet that was longer than four minutes. And I'd write down the vitals and walk them back to the doctor and he'd spend six minutes with her because the schedule had 28 patients that day and there was nothing I could do except hand him the chart. I couldn't assess. I couldn't plan. I couldn't recommend. The scope of an MA is: follow instructions. And after fifteen years of following instructions while having opinions I wasn't allowed to voice, I went back to school.

What was nursing school like at 41?

Humbling. I was in an ADN program at Big Sandy Community and Technical College. Two years. My classmates were 19, 20, 21. I had a daughter, Kayla, who was 16 at the time. I'd go home after clinicals and she'd be doing her homework and I'd be doing mine at the same table. She thought it was hilarious. I thought it was terrifying because the content is, it's a lot. A&P was fine, I'd been around medicine long enough that the anatomy wasn't foreign. But pharmacology? Calculating drip rates? Pathophysiology of renal failure? That's different from knowing that a patient's blood pressure is high. That's knowing WHY it's high and what the body is doing wrong and what each medication does at the cellular level to fix it. I studied more in those two years than in the rest of my life combined.

Passed the NCLEX on the first try. Cried in the Panera parking lot when I got the result. Not because it was hard, I mean it was hard, but because I was 41 and I'd finally crossed over to the side of the room where I was allowed to think out loud.

How did you end up in home health?

I did two years on a med-surg floor at Pikeville Medical Center. Learned a ton. But I hated the hospital. And I mean hated. The politics, the staffing ratios, the charting. I had six patients most shifts and I felt like I was giving each of them 15% of what they needed. One night I drove home after a shift and told my husband Mike, I said, I didn't become a nurse to spend 40% of my time clicking boxes in a computer. I became a nurse so I could sit with people and figure out what's actually going on with them.

Home health gave me that. The trade-off is everything else. But the core of it, being alone in a room with one patient, assessing them, making a plan, using your own clinical judgment, that's what I wanted. I work for a home health agency. Crystal, my supervisor, she gives me my schedule and I drive. I see five to seven patients a day. They're scattered across three counties. I drive, I don't know, 80, 90 miles on a typical day. Some days more if I've got someone out in Martin County, which is, we're talking hollers where your cell service cuts out and your GPS stops working and you're following handwritten directions on a sticky note.

Describe a recent visit that shows what this work is really like.

I have a patient named Dale. Diabetic foot wound. I've been seeing him twice a week for four months. He lives in a single-wide off Route 292. No air conditioning. Has a box fan in the window. He's 62, lives alone, his wife left about five years ago, his son is somewhere in Ohio but they don't talk much. Dale is on disability. His wound is on the plantar surface of his left foot, which means the bottom, and it's a Wagner grade 2, so it's through the skin into the tendon but hasn't hit bone yet. In theory, this wound should have closed by now. Four months is a long time for a grade 2.

The problem is compliance, which is a word I've come to hate because it puts all the blame on the patient. Dale is "noncompliant" with offloading, which means he's supposed to stay off that foot as much as possible. But he lives alone. Nobody brings him groceries. He walks to the kitchen, he walks to the bathroom, he walks to the mailbox. Every step is pressure on the wound. I've ordered a wheelchair through his insurance. It took six weeks to get approved and it doesn't fit through his bathroom door. So he walks.

Last Thursday I pulled up to his trailer and the front door was open, which is unusual. I knocked, said his name. He said "in here." He was on the floor of the living room. Not fallen. Sitting. He'd lowered himself onto the floor because, he said, his back hurt too much to sit in the chair and the floor felt better. He'd been there about an hour. His wound was open, no dressing on it, because he'd taken the dressing off to shower that morning and couldn't reach his own foot to put a new one on.

So I knelt down on the floor of this trailer in July, the box fan doing absolutely nothing, flies coming in through the open door, and I cleaned and dressed a wound on a man's foot while he sat on the carpet and apologized for the mess. That's home health nursing. Nobody in a hospital ever apologizes for the mess.

What did you do about the bigger picture for Dale?

I called Dr. Pham, the wound care specialist. She's at a clinic about 45 minutes from Dale's place. I asked about a wound vac, which would put negative pressure on the wound and speed healing. She agreed it was appropriate. Getting it authorized through Dale's insurance took three phone calls over two weeks. When it finally arrived, I drove out and set it up. Taught Dale how to charge the battery, what the alarms mean, when to call me. He looked at this machine strapped to his foot and said "is all this for me?" Like he couldn't believe that much equipment was being deployed for one person's foot.

That interaction is maybe 90 seconds of his day. But it stuck with me because, where Dale lives, in this part of Kentucky, a lot of people don't expect much from the healthcare system. They've been told no so many times, by insurance, by pharmacies, by clinics that are an hour away and don't take their plan, that when someone shows up at their door with actual medical equipment and says "this is going to help," their first reaction is surprise. Not gratitude, exactly. Surprise. Like the system accidentally noticed them.

What's the hardest part of working alone?

The clinical decisions. In a hospital, if you're not sure about something, there's another nurse ten feet away. There's a charge nurse. There's a rapid response team. In a trailer in Martin County, it's me and the patient and whatever's in my nursing bag. I carry a stethoscope, a blood pressure cuff, wound care supplies, a pulse ox, a glucometer, a thermometer. That's my entire hospital.

I had a patient, Mrs. Halsey, 91, lives alone, I see her once a week for congestive heart failure management. I weigh her, check her vitals, listen to her lungs, assess her edema. One visit, about two months ago, her weight was up four pounds from the previous week and her ankles were swollen and her lungs had crackles at the bases. All signs that she was retaining fluid. Her Lasix dose probably needed to be bumped. But I can't change the dose. I can call her cardiologist, who's in Lexington, two hours away, and leave a message with his nurse, who might call me back in four hours or might call me back tomorrow. In the meantime, Mrs. Halsey is sitting in her kitchen with fluid building up around her heart and I'm standing there with a stethoscope and a phone and no authority to fix the immediate problem.

I waited in her driveway for the callback. Ate my string cheese and drank my Diet Coke and waited. He called back in 90 minutes, which is actually fast. Increased the Lasix from 40 to 60. I drove to the pharmacy in Prestonsburg, picked up the new prescription, drove back to Mrs. Halsey's house, and gave her the first dose. Three hours round trip for a 20-milligram adjustment. In a hospital, that would've been a five-minute conversation and a new order in Epic.

What's yours?

The poverty. I don't mean I'm surprised by it. I grew up here. I know what eastern Kentucky looks like. But there's a difference between knowing it and being the person whose job it is to provide medical care inside of it. I walk into homes where the medication bottles are lined up on the kitchen counter and half of them are expired because the patient couldn't afford the refills. I see patients who are choosing between insulin and electricity. I dress wounds in rooms where the water doesn't run hot. And I chart all of this, "patient lives alone, limited support, financial barriers to medication adherence," and the chart goes into the system and the system says "continue plan of care" and I come back next week and nothing has changed except the wound is a little bigger or the blood sugar is a little higher.

I'm not a social worker. I'm not a case manager. But in home health, especially out here, you become both because nobody else is coming. I've driven patients to the pharmacy. I've called churches to ask about food pantries. I've sat on the phone with insurance companies for 45 minutes arguing about a wound vac authorization while my next patient waited. None of that is in my job description. All of it is in my job.

My daughter Kayla started nursing school this year. She wants to do labor and delivery. Something happy, she says. I didn't tell her that every specialty has its version of this. The thing that follows you home. The patient you think about when you're making dinner. Whatever unit she ends up on, there'll be a Dale. She'll find out.