I’m sitting here, almost at the completion of my third year of my AGAC-DNP/CNS degree and utterly exhausted – emotionally, physically, mentally, I’m tapped. I’ve hit a point where I don’t even think I’m acting like myself, and the same goes for some of my classmates. I am irritable and unable to expend any additional ounce of energy on anyone because I use it all up during clinical and work days. When I get home, I just want to sit in silence and write blog posts haha.

Anyway, with one year left, I am forced to think about my future as an acute care geriatric nurse practitioner. I went in knowing I wanted to work in an ICU post-graduation and I am still planning that course. However, I’d be lying if I didn’t admit, the thought of going back to night shift and being a newbie again scares the hell out of me. Also, there is a nostalgic part of me that cringes at the thought of leaving bedside nursing behind forever – have I given up on a career I love so deeply? When I work my PRN shifts in the general ICU they go one of two ways. They either remind me of why I love nursing so much, or remind me of why I went to NP school. There is no in-between.

Since the second I entered ICU clinicals during my BSN, I knew that was it. I started working cardiac medical ICU, then was a glutton for cardiac surgical ICU. Everyone working in healthcare is a tad crazy, but ICU nurses and even more so, cardiac surgical ICU nurses are a special kind. We are neurotic because we have to be. We crave the complexities of that hemorrhaging lung transplant patient or the adrenaline rush of cracking a chest to save a life. We double, triple, quadruple check every single medication because if we were to make one wrong move, the patient could die. We may transfuse 100 blood products in one day and you can damn well bet we will check every unit to make sure the patient doesn’t receive a mismatch and we’ll do it fast, really fast. Our patients will not only exist with transplanted organs, but machines running various other ones (kidneys, lungs, heart), and 10-20 intravenous infusions running the rest.

While maintaining complex physiological components of the patient we will also absorb the social, emotional, and mental complexities of the patients and family members as well. Throughout our days we may learn the dying, unresponsive, patient in our bed is the sole breadwinner for his family. His wife will tell us that they just moved to the area and she doesn’t have a job yet, he carries the health insurance for her and their three children. Oh and, her teenage son attempted suicide; they have no family in the area to help. An elephant will linger in the room as we listen to this. Our patient, the one the healthcare team is desperately trying to save for his family, will not live. His wife will ask us if we have ever seen a patient in his condition live and some of us will avoid the subject, because answering honestly wouldn’t be the nurse’s place. So, we carry the pain and the elephant from room to room and some of us carry it home.

There are happy times too. When a fresh heart transplant awakens for the first time with a smile on her face, the ET tube is removed, and the first words out of her mouth are, “Thank you God for one more day.” Or when you think you see a miracle, a literal miracle, and that one patient who shouldn’t have lived, lives. Maybe even the small things are the best. Being able to wash a patient’s hair or get them out of the hospital into the sunshine for the first time in two months is an extraordinary feat. There is nothing more real than the emotions in a hospital experienced by the bedside nurse.

This is why I love my job and this is why I had to go back to school. When you walk in to a university hospital ICU these days, you will likely find two cohorts of nurses – those who have worked two years or less (ask them if they plan to leave, 95% will say yes) and those who have worked more than ten years. Why? Well, there are a number of reasons. Most veterans started before hospital administration revoked many privileges and have been grandfathered in. For instance, university hospitals used to offer full tuition reimbursement for employees and their children, payment for certifications, and great health insurance, so veterans will not leave for obvious reasons. Also, their hourly wage is very high. I’m told, there was far less bullshit then, meaning fewer learning modules, committees, projects, “requirements.” However, because of the current state, many veteran nurses stay within the same company, but move away from the bedside, which is a shame. Without the veteran nurses, who will train the new ones? Oh that’s right, I did.

At one year of ICU nursing I was already training new nurses. Was I qualified? No. When I told management I didn’t feel qualified they said, “Well, there is no one else.” We get that a lot. “There is no one to clean the room” after we transfer our second ICU patient for the day, haven’t eaten lunch, and a new patient is on the way. So, what do we do? We clean the room. We manage the complex patients, the complex families, we call security when our safety is threatened by either of them, our heads ache from the constant dinging of the monitors, pagers, nurse trackers (oh yes, they track us, too), and phones. Pharmacy needs us, the patient needs us, physical therapy needs us, respiratory therapy needs us, occupational therapy needs us, dietary, the doctor, the secretary, there is a mandatory in-service in the “break” room, administration wants to talk about the computer system etc. They expect you to be nice, but not too nice, compassionate, technically intelligent, and emotionally intelligent. Don’t cry while you’re putting your 35-year-old patient in a body bag because you have another patient on the way up to fill the bed and that patient can’t see you cry. We must change face to fit every scenario. Oh, and this type of intelligence – emotional intelligence, isn’t valued, although it should be. Finally, god forbid we have an extra nurse on the unit or a “slow” day, that means it’s time to send people home because all it boils down to are FTE’s, not preserving the sanity of nurses.

But, even then, I still love/loved the job and it is an absolute privilege. The chaos of healthcare feels comfortable to me. Nurses are the people who manage and attempt to control the chaos, which is key. Over the years, chaos within the system has increased exponentially. I can’t tell you how many times I have heard a new nurse tell me, “this isn’t how I thought it would be” and it crushes my heart. Nurses deserve the world and that is why I write these posts. They should not be begging to leave the bedside after two years or less in practice. This brings me to why nurses are leaving before they even get started.

Like I’ve stated previously, my experiences come from university hospital ICU nursing. I have worked at smaller university hospitals all the way up to one of the best in the country. Although the higher ranked hospitals treated their nurses fairly well regarding staffing, they definitely had their own set of problems and the same issues with turnover. It is also important to note the natural characteristics of an ICU nurse play a roll in the turnover. We are neurotic, over-achievers, organized, and driven. Therefore, we are likely predisposed to wanting to go back to school. However, we are also predisposed to understanding human limits and how much we can tolerate. This generation of nurses is perhaps the smartest ever; their intelligence amazes me every day and supersedes my own. But, before they can gain any real-life experience (which is equally as important), they are gone because the job is so physically, mentally, and emotionally taxing. Let me sum this up: The nurses caring for the sickest, most complicated patients are quitting before they even know anything and are being trained by other nurses who barely know anything. Does this bother anyone? Doctors are burned out too, but doctors get the societal-induced respect, while nurses frequently work in the shadows and have to earn respect (another key difference). This generation is not accustomed to working in the shadows, nor should their talents have to be minimized. Therefore, eventually, I believe it will be one of the current generation to change the trends, but for now many go back to school or transfer to a less stressful environment.

Writing this post has been hard because in no way do I want to disgrace my profession. Although there are many reasons I went back to school, there is a part of me that actually feels guilty for going back three years into ICU nursing – like I’m a quitter and I gave up. I still work in an ICU part time, but by the time I graduate I will have been an ICU nurse for 7 years, I knew I wouldn’t be able to take more past that. I also wonder if it was just me sometimes, even though I don’t think I’m the only one. Another part of me misses it so badly; I miss the job and I miss my friends, but the reality is, most of my friends have left or are back in school anyway. Finally, the last part of me wonders if it will even be any better as a nurse practitioner in an ICU? How can any practitioner in a hospital provide the best care for patients, if no one takes care of the practitioners? I really don’t know the answer to that one. Of course, the only way to change these things is to start a productive conversation about them. What would make you stay working in a crazy university hospital ICU? Despite everything, I still have hope that this generation of nurses will work together to create a better, sustainable, working environment. If you have worked for years in ICU nursing, what are your secrets? As always, I am so thankful we get each other.