ICU nurse tells New York Times readers what it’s like to care for Covid-19 patients
In a strong opinion piece, Simone Hannah-Clark took readers inside the day of a New York City ICU nurse. She captured the drama of caring for gravely ill Covid-19 patients while protecting herself and her family. She also described nurses’ assessments and interventions; portrayed physicians as colleagues (not supervisors); and specifically rejected the handmaiden and angel stereotypes.
April 3, 2020 – Today the New York Times ran a very good opinion piece by Simone Hannah-Clark entitled “An I.C.U. Nurse’s Coronavirus Diary.” Hannah-Clark takes readers through her day caring for critically ill patients at a New York City hospital. She says that it “feels like a war.” We hear about ventilators, monitors, medications, infection control, care innovations, and discussions with colleagues, until she goes home and takes tough measures to try to protect her family from infection. Hannah-Clark takes pains to note that nurses are not handmaidens or angels, but “professionals in our own right.” Nurses are on the “front line,” looking for practical solutions, as they “assess and observe, question and console.” And she makes a point of describing physicians as colleagues with whom she discusses care, not supervisors who issue orders. Yes, the piece is a “diary.” We have noticed that while nurses have been getting more attention than usual during the Covid-19 crisis, that attention has tended to focus more on their experiences than their expertise, in what we might call the diary approach. The Guardian has an ongoing “ER Diaries” feature by an anonymous nurse who cares for Covid-19 patients. By contrast, the media is far more likely to consult physicians about technical aspects of care, public policy choices, and tough decisions in clinical settings that often seem to be staffed solely by physicians (e.g., “how will physicians decide who get ventilators?”; “ED physicians handle Covid-19 care until they hand off to intensivists!”). Hannah-Clark’s piece is in the experiential category. But it combines the dramatic elements of that approach with a good sense of what nurses actually do in the clinical setting, including tasks requiring skill and strength. Our only real issue is with her final point, where she suggests that physicians are the “architects of what happens in the hospital,” but nurses are the relentless “builders.” This presents nurses as strong but working to serve the vision of physicians, rather than their own vision. It seems to us that the professions are complementary and each has elements of architecture, engineering, and construction. Metaphors like this often seem designed to show the public that nurses do something important, but they rarely seem to serve nursing well overall. We’ve seen a nursing advocate suggest that physicians may be the health care generals, but nurses are the front-line soldiers. Another termed physicians the captains of the health care ship, while nurses are harbor pilots, with specific if limited knowledge (we reversed that idea, arguing that nurses are more like visionary ship captains who stay with patients over time). And some nurses have described themselves as physicians’ “eyes and ears,” as if nurses were mindless sensory organs. Anyway, we thank Simone Hannah-Clark and the New York Times for a good look at nursing Covid-19 patients.
Elaborate choreographic sequence
Hannah-Clark starts at the beginning. She says she leaves home in the morning as her family sleeps, sharing a Lyft with her “work buddy” as well as some dark humor as they discuss “the enemy,” Covid-19. Early on, Hannah-Clark wants to get a few things straight.
I am one of the many thousands of nurses who work in intensive care units in New York. We are not handmaidens or angels. We are professionals in our own right. We turn treatment plans into action. We question when things don’t make sense or aren’t going to work. We find solutions that work for our patients. Nurses assess and observe, question and console. We stand between the patient and the enemy. We are the front line.
Then it’s on to specifics of her day. She huddles with colleagues about which patients are sickest and might crash, and which supplies are low. She dons the N95 mask she wears all day. As a float nurse doing many different things, she first helps with the post-mortem of a “Covid” patient that the staff watched “slowly die over the past few days,” despite all their efforts. The nurses prepare the body and collect the patient’s personal effects, because infection control means security is not allowed into the room. Hannah-Clark then spends hours collaborating on how to double the I.C.U.’s capacity, mainly discussing equipment; she says one of “my doctors” jokes about the feng shui of a room. Referring to physicians this way could be an inside joke; no reader will suppose that this nurse has any ownership over a physician, whereas nurses have often been described as belonging to physicians. But the likely impression left by Hannah-Clark’s comment here is simply that ICU nurses are on the same clinical teams as physicians.
The unit gets three Covid patients. The nurses don the rest of their PPE and perform an “elaborate choreographic sequence.” That includes a full body assessment, as well as attaching a cardiac monitor, a urinary catheter, foam adhesives at key spots to prevent pressure sores, and intravenous lines with long extension tubing that reaches into the hallway, so the nurses can manage the drips without having to don PPE. The patient gets a gastric tube so the patient can be fed while intubated and on the ventilator. Doffing the PPE, Hannah-Clark and her colleagues are sweating, haunted by worries that they were not careful enough to avoid infection. She “check[s] in with the doctors to discuss the treatment plan,” calls the pharmacy about a medication, gets a piece of equipment from a helpful nursing assistant, and starts some documentation, while a nurse practitioner places an arterial line to help determine how well a patient is breathing. Hannah-Clark: “I discuss the results with our attending I.C.U. doctor. I need to go back in the room to change the ventilator settings.” Finally, an hour and a half after the supposed shift change—“[t]here is still so much to do”—she hands off to the night nurses, removes her shoe covers, bleaches her shoes, changes clothes, and bags her dirty scrubs to wash at home. She walks into her apartment backwards, spraying Lysol behind her, heading for the shower. Even afterwards, she must maintain distance from her husband, and they sleep in separate rooms.
Summing up, Hannah-Clark explains that this was actually a smooth day, because patients were not crashing and the unit was not short-staffed. She stresses that it is a “team effort,” with heartbreak and triumphs, like when patients can leave the I.C.U. in better health, or when staff come up with an idea to preserve “our precious P.P.E.” She says that ICU nurses are tough, fighting for patients, supporting each other. She adds:
Doctors may be the architects of what happens in the hospital. But we are the builders. And so we build, even amid chaos and disintegration. We build, even as a silent enemy attempts to undo everything we’ve done. We build and we build, shift after shift, as fast — and as best — as we can.
Of course, relentlessly building is far from the worst thing the public could think about nursing. It’s just not enough. Nurses have their own distinct holistic focus and scope of care. They make their own plans and decisions about assessment, therapies, patient education, psychosocial support and advocacy, including resisting physician prescriptions that may be dangerous or inadequate, and working for better alternatives. Of course, that is not always easy, in light of the power imbalance between the two professions and the enduring misconceptions that physicians have the authority to direct nursing care. So nurses must be strong to protect patients. In any case, most of this piece paints a picture of collaboration and teamwork among colleagues, not a hierarchical structure. And the descriptions of what Hannah-Clark and the other nurses do for patients, including the assessments, monitoring, and interventions, as well as the discussions with physicians—in contrast to the one-way command relationship seen on most Hollywood shows—are very helpful. She gets special credit for specifically refuting the handmaiden and angel stereotypes, and for her focus on innovation and questioning as hallmarks of nursing. This piece is not overtly advocating policy changes, as good recent pieces by nurse Theresa Brown have. But it does draw readers into the drama of caring for Covid-19 patients and shows them why nurses need and deserve adequate staffing, PPE, and other resources. We thank Simone Hannah-Clark.
See the article “An I.C.U. Nurse’s Coronavirus Diary: I’ve started to refer to the time before this as peace time. Because this feels like a war,” by Simone Hannah-Clark, published in the New York Times on April 3, 2020.
