Fractured nursing care
How long can nursing survive on gratitude alone?
Content warning: This article explores themes of trauma and death
Disclaimer: The author recognises that not all nurses or patients will identify with these experiences. The stories and names do not represent any specific situation or patient; they are recreated from the authors’ various personal experiences and social media content.
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My routine remains unchanged: I arrive for another long day in the Intensive Care Unit (ICU). I turn the corner of the path towards the back of the hospital where the fountain steals all attention. I pause to admire the calm water, the trees reflected in its surface, and wonder if I’ll feel so serene once my shift starts. I enter the hospital hallway. My steps break the early morning’s heavy silence. Looking up, I appreciate the new building’s glass roof—the first of many rescue ambitions to revitalise nursing care. Suddenly, bing, the doors of the empty lift glide open. I glance at the “thank you NHS heroes” poster and wonder whether gratitude alone has ever made a difference to intensive care nursing.
Bing. The lift opens. It’s the 19th of November 2019
I heave open the doors to the ICU. The vital signs monitoring machine trills its usual song. The nurses offer warm smiles, confirming a well-covered night shift. In the handover room, away from the trilling, I sneak a look at the patient board as my shift begins. Ventilators breathe in and out, supporting lives quivering like spinning tops. I wash my hands while greeting the nurse and my patient, John.
John, you don’t know me. I have been looking after you since your heart attack stopped you dead, literally, figuratively. Just like that, your wife Jane said. Tears well up in Jane’s eyes as she clutches Johns’ hands. I sit near her. Jane tells me you have a dog named Eiffel, and you like playing music. She brought some photos of you; I imagine you awake, breathing, talking, laughing.
We don’t know if you’ll ever wake up. It’s an agonising waiting game of trial and error. We will try to stop sedation today, again; Jane and I won’t give up.
“John darling, wake up”, Jane calls me. Her voice is trembling. In the background, Requiem, one of my favourite symphonies—why is she playing that? What a strange dream. What time is it? Wow, I’m thirsty. No, my throat is tight. I can’t swallow. I’m suffocating! No, I can’t be. I gag, I try to answer Jane. I tense, my muscles jumping, shooting with pain. Jane still calls. My muscles relax, but the pain doesn’t go away completely. Another voice, calm, steady, is explaining. Reality sinks in. It asks me to squeeze my hand, now the other hand. I follow the bizarre commands. Suddenly my throat burns, loosens. I can breathe.
I look at John and think about how lucky he is despite it all. Lucky to have had the best and safest quality of nursing care. Lucky to have experienced intensive care nurses at his bedside, one single nurse assigned to him, 24/7, protecting his brain and providing the technical expertise to protect his life. I think about how increasingly difficult it has become to achieve this level of optimal care over the years.
I remember reading that we currently have 40,000 nursing vacancies, which is expected to nearly triple to 107,000 in 10 years from now. High quality care is created through expertise and experience, which takes years to build up. But what happens when experienced nurses leave for better progression opportunities, improved quality of life, and more pay? I think it’s odd that clinical care does not receive the financial recognition it is due, despite the invaluable return it provides through patient outcomes. I want to provide the best care and feel safe in my work, but I worry about the future of my profession and those I care for.
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Bing, the lift doors open. It’s the 19th of November 2020—one year later
Staff rush across the units. Beds, machinery, stockpiles, and empty crash trolleys block the corridor. Alarms scream. The staff room bulges, and faces strain, everyone wishing three ICUs could be six.
I rush to beds, not names; one nurse to four patients. Another nurse’s eyes are wide, her hands clenched. I remember the feeling. The shouts of nurses reach me. Some dash through doorways, seizing medication and life support before they’re gone.
“I hold up the digital tablets again and again, video calling families, trying to humanise the inhumaneness in the absence of loved ones, of two-dimensional, electronic contact”
Adrenaline has been drip-feeding the ICU for a year. Care feels depersonalised. Nurses’ gazes are hollow, smiles wane, sweaty and uncomfortable protective personal equipment is a sustained injury. I see you, bed 4, gasping, eyes puffy, but I have no time. I am so sorry. I hold up the digital tablets again and again, video calling families, trying to humanise the inhumaneness in the absence of loved ones, of two-dimensional, electronic contact.
I’m exhausted. My chest heaves at the thought of my responsibilities to my patients. To so many patients. With every rare glance in the bathroom mirror, my pupils are more dilated. I know the consequences of fear. Of pushing care to the limits. Of risking permanent consequences for patients. I no longer feel safe. I cannot provide the best care to my patients. To my colleagues. To myself.
Life has become a nightmare. I sit here, in this hospital bed, and observe the nurse I depend on for everything. I breathe fast, feel my heart racing. There’s so much noise. All the time. It’s impossible to sleep. The oxygen mask rubs sores on my nose, making my mouth a desert. Eating is a battle, my own lungs the enemy. Emily got intubated last night. Am I next? The other two patients are on their backs. One of them is dying; they get more attention from the nurses. Nurses discuss, explain, whispering into digital tablets. My chest wrenches when I hear his daughter crying, begging him not to go. It’s impossible not to hear. She’s 16.
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As I look around me, it is impossible to not see all the longstanding cracks that have widened with the pandemic—cracks in quality of care, skill-mix, patient to nurse ratio, job satisfaction of my fellow nurses. Nursing care is at its breaking point physically and emotionally. It breaks me that, despite evidence on the importance of prioritising the wellbeing of healthcare workers, policy recommendations don’t go beyond a clap initiative. During the pandemic, a study found that 30% of nurses had probable signs of post-traumatic stress disorder, resulting from personal and workplace factors. A recent survey revealed that 60% of NHS nurses intend to leave, with similar numbers agreeing that their pay and level are inappropriate. It is already known that appropriate nurse to patient ratios are vital to reduce the risk of avoidable deaths and have been shown to have cost-saving benefits. I ask myself: what else needs to happen for nursing care to be repaired?
Bing. The lift opens. It’s 19th November 2025—dreaming of a better future.
I have finished my clinical academic PhD. I can finally teach, monitor, and research best practises for nursing in intensive care. I reflect on how the past five years were a very challenging time for nursing; decades of disinvestment took a heavy toll.
Poor workforce levels prompted enquiries into the degree of harm caused to patients and nurses before and during the pandemic. Many experienced nurses left, and units became almost entirely dependent on junior and temporary staff with no appropriate support and insufficient training. Patients’ needs went unmet, infection levels increased, and care delays skyrocketed.
As I dream of a time after the years of despair, I see that nursing care is no longer fractured. In this future of hope, there is meaningful investment in the NHS, nursing leaders are essential healthcare advisors at national and international levels. In this future of hope, workforce and pay scale is reorganised, encouraging experienced nurses to continue to stay at their patient’s bedside, and nurses are provided long-overdue pay increases. With those changes, the exodus of nurses from the NHS slow and halt, and defaulted nurses return, starting to feel appreciated and valued.
Healthcare teams become stronger, more efficient, patient outcomes improve, clinical incidents reduce in many areas such as hospital acquired infections, medication errors, and avoidable deaths. Clinical academics, like myself, are integrated into ICUs, implementing evidence-based solutions to improve outcomes.
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Bing, the lift doors open. It’s 21:00 of the 19th of November 2020
The lift leaves me at the hall. I trudge to the bus stop. The bus is filthy red. Around me, on faded patterned seats, most people are immigrants, like me, that have been working late. I finally sit, eat, and reflect. As my eyes follow the enchanting view of Tower Bridge, I wonder if mere vision is enough, or if it’s time to move on.