In every hospital, the nurses who work the night shift are a special breed. They must be masters of multitasking. They must make critical judgments as they decide whether to bring in on-call physicians. And most importantly, they must understand how to listen to the sleepless patient, to the lonely soul struggling to make it through another night of anxiety, which illness brings to everyone.
By Cindy Miller and Edward Miller | Photographs by John Glenn
No word pairing is more common in the English language than “night and day.” It is the very epitome of contrast.
Poets, of course, favor the darkness, where they sense quietude touched by a bit of mystery, a somewhat foreboding stillness to be endured before the welcome light of day. This rich perspective dates back to the creation story in Genesis, which opens with a formless, empty darkness over the earth, awaiting a divine imposition of light.
To Victoria Ekpo, a nurse in one of Piedmont Atlanta Hospital’s medical/surgical units, the night-and-day difference may not be theological, but it is no less real. In a busy hospital, the night shift is truly a different realm.
Victoria’s night shift is not what most people imagine. It’s not particularly quiet. Nor is the pace steady and predictable. Carefully prescribed procedures serve as the metronome of activity, until adrenaline-pumping interruptions break the routines. All night, the pressure to be perfect prevails.
“The pressure comes from having five or six lives in your hands every night,” Victoria says. “We have help, of course, but we all know we’re the patients’ first line of protection. That’s stressful and rewarding at the same time.”
Her night shift begins and ends the same way –– a changing of the guard in the form of a handoff. Nurses, one from the incoming shift and another from the outgoing, walk the halls in pairs, studying the “green sheets” — compact records that document treatment in the last 12 hours. They visit each patient and update each other on what’s been done and what still needs doing. It’s the night’s most important ritual, its alpha and omega.
As Victoria begins her night shift, with the handoff complete, she returns to the rooms to prepare patients for the evening. For all appearances, this could be the start of a day shift if it weren’t for the sunset coming through the windows. The scene will soon settle into a cadence set by routines focused on patient assessment (How are they doing?) and the delivery of medicines and tests (What do we need to do next?).
The choreography of the night for Victoria and her colleagues is punctuated by teamwork barely perceptible to laymen and by hours of tedious attention to details. Procedures are followed, checked and checked again. Medications arrive with punctuality.
For patients, sleep drifts in when it can. For nurses, the tension comes from knowing that the next ringing of a patient’s call button could be a life-or-death crisis. Or not.
Nursing is often a spiritual calling, not unlike that of a chaplain. Every night, when she gets out of her car, Victoria says a prayer: “I ask the Lord to be my hands and my brain, to guide me in everything I do to keep my patients safe.”
Sometimes, answering the prayer involves drudgery, but just as often, Victoria and her colleagues feel their higher calling as they sit with patients during the quiet moments of the night and help them understand and confront the anxiety of a diagnosis they didn’t want to hear.
Day shifts have a different feel. Patients are awake and need more attention. Families come and go. Doctors are in the units visiting patients, changing orders, consulting with colleagues. Testing, treatment and administrative tasks fill the hours.
At night, physicians and nurse practitioners are always available for consultation and intervention, but the nurses bear most of the front-line responsibilities as they manage patient care and their own fatigue on 12-hour shifts.
Interruptions punctuate the night. Blood must be drawn, EKGs taken, prescriptions changed and delivered, new patients received.
A call light blinks and a chime sounds when a patient needs help. The light at the nurses’ station doesn’t explain, “Here’s what happening in room 512.” It simply signals that routines must halt to accommodate the summons.
Occasionally, a “code” is called for a patient in cardiac distress. On television shows about hospitals, this is often the dramatic scene just before a commercial. On Piedmont’s fifth floor, it happens calmly as a Rapid Response Team arrives to assess and administer aid. It may seem paradoxical that the unexpected can be anticipated and handled routinely, but that’s the result of the practiced teamwork essential in any modern hospital.
“We’re a great team,” Victoria says. “Camaraderie is part of our culture at night.”
To her, camaraderie means more than amiable colleagues. Nurses place a high level of trust in each other, and trust is critical in the solitary moments of the night.
“When we face an unusually difficult situation, we need to trust others to help, if they can, or call for help, if we need them to,” Victoria says. “That’s how we learn to cover for each other to make sure the patients’ needs are covered.”
To do this, night nurses have to be on-the-job teachers as well as lifelong learners. For Victoria, the teaching role is a formal one. She coaches new nurses during their weeks-long orientation to the night shift. But for every nurse in the unit, learning is a nightly constant.
What does it take to work at night? Stamina, for one thing. Night shifts, which can stretch to 14 hours or more, fatigue the body.
The night shift is not for everyone — and it’s particularly tough on families. After a typical night, Victoria leaves the hospital between 7:30 and 8:30 a.m. — later if she’s held up in the handoff or a staff meeting.
“I have two children, ages 5 and 1,” she says. “I get home after my husband takes them to school and daycare in the morning.” At best, she’ll get to sleep by 9:30 a.m. or so. She calls it a power nap. “I get up about 1:40 so I can pick them up at 2:15.”
She tries to catch a short nap before she has to be back at the hospital by 6:30 p.m. Days off are for catching up.
It’s not an easy lifestyle on the job either, day or night. All nurses must be master multitaskers as they juggle patient-room visits, monitor medication schedules and keep up with the demands of documenting everything. Nurses depend on an efficiency born of experience to cope with the load.
Why do nurses choose this life? Victoria says her first interest in medicine and healing came from a toy doctor’s kit she had as a child.
“As an adult, I chose nursing because I wanted to be closer to patients. A doctor might see 50 or more in a day, but I want to spend more time with fewer people.” The night shift accommodates that goal.
In the diversity of a medical/surgical unit, even a few patients can be a challenge. Some nurses prefer working with more focused specialties, like cardiology or pediatrics. But on a medical/surgical floor at night, handling a wide range of patient needs is part of the job description.
During one shift, for example, Victoria might be dealing with an 80-year-old with pancreatitis, a 52-year-old in isolation after bladder surgery, a 67-year-old with a Lupus flare-up or a 32-year-old with nausea symptoms but no precise diagnosis. In the daytime, attending physicians tend to be close at hand. At night, they are available, but have to be called. That call-or-not-to-call decision gives night-shift nurses a special sense of responsibility. To some, it feels isolating, to others, empowering. A skilled nurse knows what must be done immediately, and what can wait.
Listening deeply to patients is another essential skill.
“People may not know a lot about medicine,” Victoria says, “but they do have a sense of what’s going on in their bodies. You have to listen as they explain and let them help you understand.”
Sometimes that understanding is painful for the nurses.
“Not long ago I had a patient whose cancer had returned,” Victoria says. “Her illness had been a long struggle, and she wanted to stop treatment. She asked that her code be changed to AND (Allow Natural Death).
“Her husband of 20 years wanted her to keep up the struggle, but she knew she was not going to recover. In a few days, she was no longer alert. She couldn’t speak. Her husband was in tears. He asked me ‘How long?’ but no one can answer that question. An hour or so later, she died.
“At that point my main concern was to comfort him. It’s seldom easy. That’s why this job can be emotionally draining. Your compassion has to be built in, because it’s on call all the time.”
The caring part of healthcare can be risky.
“Can we get too close to patients?” Victoria asks. “We’re not supposed to cry in front of patients, and I understand that, but sometimes it’s hard not to.” But that compassion sustains endurance.
For Victoria and her colleagues, the pain of empathy is balanced by the rewards of appreciation.
“We feel the warmth and gratitude coming from patients and their families,” Victoria says. “That keeps us going. We also feel our own appreciation for being allowed to take care of them. By being trusted with the lives of others, we feel more appreciation for life itself. That makes all the hardship of night work worthwhile.”