Researchers have said that when medical students use derogatory slang about patients, they are deflecting their feelings of anger or disgust away from the patients who frustrate them because they don’t take care of themselves and, therefore, waste the hospital’s resources. It is, California researchers concluded, “a safety valve for ‘letting off steam.’ ”

Many nurses described these types of humor as defense mechanisms, as an innate reflex. “It’s depressing when you’re dealing with people hurting mentally, so much that a lot of them want to die. The only way to deal with this is to make extremely inappropriate jokes,” an Indiana psychiatric nurse said. “An example would be joking about ridiculously poor suicide attempts, which sounds terribly insensitive. The other day we got a patient who ‘attempted suicide’ by taking a few of this med, a few of that, a couple sprays of Raid, and a shot of bleach. Like, really? Is that the best you can do? Of course, we already know the answer (a cry for help), but sometimes it’s the inappropriate jokes that make the job a little easier to handle.”

The public would find nurses’ frequent use of gallows humor “scandalous,” said a Texas travel nurse. “Laypeople would think I’m the most awful human being in the world if they could hear my mouth during a Code Blue or Priority 1 trauma. It’s a by-product of being placed in situations where death is common and unimaginable horrors are just another day at work. Gallows humor helps to deal with some of the horrible things we see in a way that bonds us together as a team against the bad stuff. We have to take care of these dying, abused, neglected, sick patients and then turn right around and take care of the minor things without missing a beat,” she said. “Bad things happen, and I can’t stop it. All I can do is try to support my patients to the best of my ability. Keeping that in mind helps me sleep at night. In the midst of those traumas and tragedies, I compartmentalize: I allow a part of myself to mourn and feel sad, while the majority of my attention is focused on the task at hand. I’m trying to save a life and that is my primary goal, but sometimes the stress of doing that task builds and needs a release. We use gallows humor to relieve that stress.”

Joking, even during codes, can empower healthcare workers, provide a fresh perspective, create a sense of control, and locate joy or playfulness in a devastating moment. This is important because nurses must get through the traumas intact so they can be fresh and focused for the next patient and the next. They have to concentrate intensely in critical situations one minute, and then let go so they can immediately move on. Gallows humor helps to ease that transition and to leave work thoughts in the workplace. “Nurses need to blow off the adrenaline pent up after patient care. It’s better to dress up those feelings behind laughter than carry that burden home with you,” said a Washington State hospice nurse.

A Canadian study found that nursing school educators who used humor experienced less emotional exhaustion and higher levels of personal accomplishment than other educators. In fact, experts specifically recommend that healthcare professionals utilize gallows humor as a survival tactic and to combat burnout. Nurse and humorist Karyn Buxman encourages nurses to find humor in their work: “Start a collection of humorous comments, events, or charting notes, keeping in mind that patient confidentiality is paramount.”

Gallows humor in hospitals has not been heavily researched, but the existing literature mostly supports using it. “When is behind-the-scenes gallows humor okay, and when should it cause concern?” Katie Watson, the bioethicist, asked. “To answer, I would first want to think about who is harmed by the joking.” Ultimately, in cases such as the pizza-tipping joke, she concluded, “To me, the butt of the doctors’ tip joke is not the patient. It’s death. The residents fought death with all they had, and death won.” And that’s why the joke is okay.

Humor is a way for nurses to find dawn in the darkness, to self-empower, and to unite with each other, determined and defiant. Above all, humor is a way to locate hope amid hardship, which is exactly what patients need nurses to do.

Chapter 6

The Stepford Nurse

:

How Hospitals Game the System for Patient “Satisfaction”

“The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

—Code of Ethics for Nurses, Provision 3

“Hospitals tend to focus on what they get sued for. Hospitals used to have COWs: computers on wheels. A while ago, a nurse said, ‘What’s up with the COW in Two?’ Well, the patient in Room Two knew she was in Room Two and filed a lawsuit and won. So now hospitals call them WOWs: workstations on wheels.”

—a Washington, DC, ER nurse

LARA

  SOUTH GENERAL HOSPITAL, February

The first few weeks of Lara’s separation from her husband were terrifying, while she tried to figure out whether she could support herself and two small children on her own. She couldn’t afford the mortgage on the house, which broke her heart because she and John had built their home, and her brother lived next door. She let John stay in the house because she didn’t want their children to have to adjust to two new homes. He was sure his gambling could cover the costs.

At first, Lara waited for John to apologize and agree to get treatment. Even as she moved her things out of the house, she thought he would realize that he needed her and he needed help. He watched the children while she worked and attended NA meetings, but when they exchanged them, he showed no signs of wanting to reconcile. In response to people who asked him why Lara left, John said, “She’s jealous about something I wrote on Twitter,” trivializing his years of issues down to one tweet.

As much as it hurt, John’s delight at being single helped Lara move past her initial doubt about her decision to leave him. It was more difficult for her to get over being sad, lonely, and scared. How would she pay the bills by herself and have enough time for her children? How would she resist the temptation to turn to narcotics?

Eventually, Lara’s realtor found a small rental house within her budget and near the kids’ school. Several NA friends helped her move, and a girlfriend gave her two U-Hauls worth of free furniture. The men she knew in NA offered her handyman assistance. Many of the women called to say they had gone through something similar, offering consolation and strength.

Still, Lara was unsettled most of the time. She tried to stay busy, because when she wasn’t, she either dwelled on her anger or cried. She was able to pull herself together only when she was at work or with Sebastian and Lindsey. It helped to focus on getting them through their homework or finding activities to do together on weekends.

Lara had seen a lawyer to begin divorce proceedings, but she didn’t like when the lawyer said, “We’re going to get him.” Instead, she went to a mediator, who worked things out amicably.

Now Lara’s main worry was how to afford her rent. Luckily, South General had been accommodating. The first time she called to ask whether there were any openings on the schedule to increase her hours and her paycheck, the ER director said there were not. “Do you need to just come in to work, though?” the director asked, and created a spot for Lara anyway. She allowed Lara a nontraditional schedule: two twelve-hour shifts plus her children’s school hours. Lara dropped the kids off at school, arrived at the hospital by 11:00 a.m., worked for four hours, and left to make the forty-five-minute drive to pick them up.

Lara pulled this shift every weekday in addition to the twelve-hour night shifts. John was happy to watch the kids because he believed the babysitting got him out of paying child support. Lara knew her children were fine with John; for all of his shortcomings, he was a decent father. But it killed her to spend so much time away from them. Every NA meeting she attended was another hour that she could have spent with Sebastian and Lindsey.