"I wanted to be doing what the nurses were doing."
Joan Finch is an RN who works in a San Francisco intensive care nursery and per diem at a surgery center. She is forty-one years old, married and the mother of three boys..
When I was really young, probably eight or ten years old, I decided I was going to be a doctor. I don't think I really knew what doctors did on a day to day basis, although I knew lots of doctors growing up. Chemistry was really a challenge for me. I realize now that I wasn't as motivated to learn it as I should have been if I really wanted to go to medical school. So I graduated with a degree in art history and then I had to decide whether I wanted to apply for medical school or if I wanted to do something else.
I went through this long process of making lists, the pros and cons, and what do I really want to do. What turned up was that I really liked what nurses did. I also liked the flexibility of being able to spend more time with a family. Family and having children were important to me. Going to medical school, doing a residency, delaying having children, then being very busy in my career--I really wanted to spend more time as a mom. That was one of the factors. But the other factor was that the part of nursing I really like is spending time with the patients--the comfort, nurturing, just being able to be with a patient, taking care of them. That's what nursing is.
Once I came to a decision, it was great, because then I was really motivated with school. I went into it with my whole heart. And I never regretted it. I remember being in the intensive care nursery at Children's, which was my first job, and having the role of the nurse and seeing what the doctors did. It was so clear that I wanted to be doing what the nurses were doing.
I went to St. Louis University because I already had a degree from UC Berkeley. It was an accelerated program, one year, and I went with older people who already had been out in the work force. Our focus was different than if I had been with eighteen and twenty year olds in nursing school. I had many of the prerequisites and I had to take anatomy, physiology, sociology, things like that, before I went to nursing school. It was just straight nursing when I went there.
I worked at Oakland Children's in their intensive care nursery the first seven years. After that I came to California Pacific in San Francisco where I work with newborns in the intensive care unit. In an intensive care nursery I've always felt like part of a team. The doctors listen to my assessment and my concerns. I can talk to them and ask them questions. If I were working in a situation where there was definitely a hierarchy, where the doctors were way, way up there and the nurses were these peons who just had to do the orders, I would hate it. That might be why I've chosen intensive care.
Floor nursing probably is more like that. When I went to nursing school at St. Louis, in some of the hospitals the hierarchy was so much more pronounced. There the doctors were always addressed as "Doctor So and So" and we were addressed as our first names. I have never worked in an environment where I called the doctors "Doctor." I always call them by their first name.
If doctors treat nurses with respect, it's much easier for the nurse to respect that doctor. If they're willing to listen to our questions and not get defensive, and they're willing to back up and say, "Well, you know, maybe I need to look at that differently"--if they're willing to have that kind of conversation, that to me is a good working relationship. It doesn't matter if it's a man or a woman.
Sometimes the male-female dynamic does get in the way, unfortunately, but I've seen that it gets less and less in the way for me as I get older. It doesn't matter any more. When I look at doctors I've worked with, there have been women doctors whom I've really respected. The authority comes with respecting them. I would choose a woman's authority or a woman's expertise over the male, if I respected her more. The many more women in medicine now maybe softening it.
When I work well with a doctor I'm not thinking about the authority. What drives me more is that we're working as a team. Sometimes it's easier to work with a woman. If it were all a group of women, in some ways I think that would be easier. I never would have admitted this until recently, but I really like working with women. I like the female bonding that goes on. I like the fact that I go to work and I spend most of my working time with women. If you're a doctor you don't usually do that.
There was a time when it was the thing to say the sexes were the same. After having three children who are boys, I have accepted the reality that boys are definitely different. I don't mean we shouldn't be given equal opportunity, etc., but we're different in how we approach things. That to me is a plus in being a nurse.
I've worked part-time for a lot of my career. For the longest time when I went to work evenings, my husband would be home. One of us would be with the kids, which worked out well. Now my husband is working more and usually if I go to work I find someone else to take care of the kids. The two older ones are old enough so they don't really need a lot of taking care of, except for that three or four hours in the afternoon. It's been very nice having a flexible schedule.
As my youngest, who's five, gets more into school, I'm looking at working more, but I wouldn't work PMs because I wouldn't be home when the kids were home from school. If I had been working long hours for the last ten years I would have felt cheated out of my family life.
In the intensive care setting, if you have a really sick baby, you're at that bedside for eight hours. You can watch that baby and see how the baby reacts to all kinds of different things. You can be an advocate in the sense that you can keep people away from the baby when the baby is sleeping, you can try to get them to coordinate their care--not come in and do an exam at their whim but say, "Wait, the baby just went to sleep and let this baby sleep for a while. You can come back and examine him or her." You can also ask for pain medication and really push for sedation. For years, people, doctors especially, didn't think babies felt pain.
You can create an environment for a baby that is better. You can darken the room, you can keep it quiet, you can keep visitors away, and teach the parents how to touch them so that it's more comfortable for the baby. In that sense you are an advocate. I think parents really like it if the nurse taking care of their baby likes their baby. If you can show that and look at the positive things about their baby, it helps.
Our patient is the baby, but in so many ways we are also the nurse for the parents. Parents will come to us and not be clear on something and be embarrassed about asking because they've already asked three times and it's been explained to them and they don't understand. We help get that worked out by getting the people they need to talk to come talk to them.
Last night at work I had a baby born the night before who they thought might be septic. She'd been real sleepy at first, and then real crabby all day. They had done a lot of tests and interrupted her sleep, and basically tortured her all day. When I came in at three o'clock, the nurse on days said, "She tried to breast feed at noon but she just screamed the whole time. There was no way she could latch on and she really needs to eat or we need to get some kind of an IV order." Having the luxury of spending an hour with that mom and getting the baby to latch on, getting her to breast feed, that was wonderful. I loved it. I thought, This is what nursing does, and it was really fun.
Especially in intensive care, I think you're a better nurse when you understand why things are happening, or why medications are working or not working. To be a good nurse here you need to understand the pathophysiology. But the psychosocial is a big part of our job, and that's the part I really like.
I wouldn't mind taking on more responsibility. In intensive care nursery, nurse practitioners work in a lot of ways like doctors. Sometimes they don't. The ones at Children's Oakland didn't but I liked their position where they were doing more in teaching and more in pain management, things like that. What I would miss in that role is the patient care. I like spending time with a patient or two patients for eight hours. I guess I don't care about the power or the prestige. That's not an issue for me.
Doctors are more prestigious, they make more money, they've gone to more years of school. They have much more responsibility in the sense that they write the orders and have to be responsible for that. I don't view that as being better. I view being a doctor or being a nurse as two very different things.
I did management for a year and a half in nursing. When I was pregnant with my third, I realized I didn't want to do management because I wasn't doing patient care. I didn't want to take care of nurses, I wanted to take care of patients. So many people at that time said, "It's really amazing that you can step down to staff nursing from management." Again, I viewed it as two very different things, and I didn't view staff nursing as inferior.
In my setting, where you have so much more day to day contact with the doctors, they have more of a sense of what we do. That would be a good thing to add to doctors' training, that contact with nurses. With doctors who just come in, write orders and then go to their offices, they don't think about who is carrying out these orders. They might not order so many tests if they did.
I think there is a real difference in how nurses and doctors view extraordinary measures. I can think of one baby as an example. She had practically everything in her body affected. She was born with a cardiac defect. She would have to have some kind of surgery, but it wouldn't be a complete correction. Her kidneys were affected--I mean everything. She had problem after problem. The nurses who took care of that baby came to the feeling a lot sooner that we needed to stop, that this was not fair to her, or to her family. We were torturing her. What kind of life would she have?
It was harder for the doctors to come around. It's something from their training, that they can fix things. And it's an ego thing. And people expect it from them. The doctors are the ones who have the responsibility, who have to write the order that says Do Not Resuscitate. That makes a difference. We nurses have the luxury of sitting back and being an advocate and saying, "Why are we doing this? Why do we continue caring for this baby?"
The sad thing is that so often the nurses feel that way, and a month later the decision is finally made to withdraw care. It's really hard. But all we can do in that situation is say what we feel and try to make the patient as comfortable as possible. Often everyone has to get together and talk because it's really difficult.
I've seen parents have a baby in intensive care nursery for eight months, and then the baby died. They'd had so much hope and put so much into that baby. It was really hard. Another thing that's difficult for me as a nurse is when you have the feeling that a baby is going to die and they do a full code. I want them to stop and pull the tube out and let someone hold that baby. Let that baby be a baby for whatever short period of time it's possible. It's really hard for me to see a baby die on a table with everyone doing these heroic things.
As a nurse what I've done when that's happened is held the baby afterwards. But that's hard. So often in a code you're looking at the doctors like "What are we doing here? This has gone on too long." Sometimes in that situation they get so focused that they're not really thinking about that part of it.
I work in intensive care nurseries because I like critical care and I like babies. But I do have problems with some situations where babies are kept alive. No one wants to talk about money but we need to look at the amount of money that goes into a baby like that and the quality of that baby's life or whether that baby is going to die. It's a dilemma.You think of all that money being spent on prenatal care, on health programs in schools, on immunizations. It would go a long way.
Last night there was a mom whose son was born with a cardiac defect. He had cardiac surgery and afterwards he went to the pediatric ICU. He's still there. His kidneys are shut down and they're waiting for them to start working. He's had a rough course. And the mom was saying that she has insurance through her job, so she has to keep working even though once he comes home she'd like to spend time with him. So she thinks she'll go back to work now while he's in the hospital, then take the rest of her maternity leave when he comes home.
But we had this whole conversation about her probably not being able to get insurance for him anywhere else, because he had all these preexisting conditions. She said--and I was shocked but someone else said, yes, it's true--"I've heard that insurance companies will go to a company and say, "If you don't fire this person who is such a drain we will not insure your workers." That's horrible.
Something has to change in the medical-legal thing because I know doctors are so afraid of being sued that often they will write for lab work and tests when you know it's just because they want it on paper that it's been done, that it's been documented. It's taking away some of their visual assessment skills.
It's not a good job market for nursing. If you're not committed to being a nurse, then you are looking for other things. A lot of nurses are restless. Not necessarily that they want to be doctors. Some of them want to be nurse practitioners. Others want to do totally different things. They want to go into business, they want to own a store, they want whatever.
Nurses work really hard. It's emotional a lot of times. It's physical. It's busy. If you make a mistake you can kill someone or hurt them. It can be a very stressful job. But for me, I don't want to do anything else. Our unit is probably going to close and the NICU will be at the California campus. Because I want to work there, I'll hold out and see what happens. If I have to find another job, I'll look then.
When I went to nursing school fourteen years ago, there was such a push that you did total patient care and you had a care plan. If you like that part of nursing, it's hard to have it changing to where they're bringing in more people who are aides and LVNs, and RNs are becoming the person who goes around passing meds out and is the team leader. That probably won't affect me as long as I'm working in critical care, but I think for the staff nurses it must be demoralizing. Being in charge of the patient, doing everything for that patient, really getting to know that patient--that to me is what's appealing about nursing.
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