April

April is in her 30s and lives and works in the Mid-West in the USA. I asked her early on to articulate her relationship to photography, and she had many thoughts and opinions on this. She enjoys taking pictures and described the style that she likes as photojournalism; she even booked a wedding photographer based on her reportage-style photography. As the mother of a 4-and-a-half-year-old baby girl, she was acutely aware of the expectations to photograph her daughter in a particular way and had refused to conform to them. She described the trend as “highly stylized” and said that the photos made the babies look like “little dolls if they’re photoshopped.” April and her husband do generally take a lot of pictures of their children, though, and she shares them on her private Instagram account.

I could tell that April has a general appreciation for photography; she described herself as a visual person and told me that when she does presentations at conferences, she always makes sure to use a lot of images. She was also very aware of the need to credit photographers and described occasions where people hadn’t realized that crediting the photographer was as necessary as crediting the author. This was encouraging for me to hear and demonstrated April’s knowledge of the nuts and bolts of photographic copyright and privacy law, especially when she mentioned that she had been supporting other people to understand how to purchase, credit, or acknowledge ownership. This revealed the value that she places on the medium as a tool for communication.

This time she told me in detail about her career. She had been a nurse for 16 years, and half of those were in her current role as Clinical Nurse Specialist (CNS). She originally wanted to be a meteorologist, but upon realizing that her abilities in physics were not quite adequate, her father suggested that as she enjoyed spending time with elderly people, she should combine this with her talent for biology and chemistry and consider pursuing a career in nursing. Her father worked at a local university, so her studies would be free, which also contributed to the decision. There had been no nurses in her family, and she wasn’t even very sure what nurses did until she was doing her first clinical placement in the hospital, as she wasn’t around anything like that growing up.

She began her career as a general nurse knowing already that she wanted to work in the Intensive Care Unit (ICU). Back when she was doing that, it was expected that nurses do a stint in general nursing before going to work in the ICU, so she did that. Eventually, she wanted to further her career, so she trained to be a CNS, an advanced practice nurse. She describes this role as “solving a lot of problems that frustrated me when I was at the bedside.” She devises policies and streamlines processes; first, she did this in a different hospital for 2-3 years, managing an operating theatre, then at her current hospital for 5 years running the ICU.

She told me that it is common for nurses to start their careers by working in general nursing for a while before specializing in something with more stable and sociable hours—she had worked 5 years of night shifts earlier in her career. For this reason, many nurses do a stint in surgery or emergency nursing.

When I asked her about moral distress, she had a lot to say. Her hospital has developed a nursing ethics program at the hospital, and they offer trainings and ethics rounds to check on the staff. As a CNP in an internationally renowned private hospital, she spoke about the diverse range of patients that they treated. From princesses to people from the nearby housing projects, at any one time, the department might have a very wide cross-section of society. What struck me were the number of examples of moral distress that April had both experienced and witnessed. She spoke initially about the tensions between patients and family, describing frequent instances of moral distress as stemming from “a big disconnect” between what the family wants and what the healthcare staff want for the patient. This then linked to Covid, and she described how this was particularly hard as it was only the nurses entering the room in the ICU, doing all the jobs required because the other staff were afraid. They were the only people in contact with the patients, so the family members would take out any frustrations on them. She was clearly irritated by this; it highlighted the ways that nurses were expected to pick up the slack in difficult times, and Covid was obviously a clear example of that.

The next moral event she described was when nurses are caring for someone who is the same age as them, admitted because of a catastrophic event or very ill from substance use disorders. She said it would inspire disbelief, like “how can somebody be in there in full liver failure? And they’re 40 years old, and they have kids at home?...but like I’m here.” It had been worse at her previous hospital, which was a public hospital system, and during another position at a trauma hospital when they took care of a lot of incarcerated patients. She described how staff can often have “feelings” about doing that work, caring for someone who had killed others “intentionally, unintentionally.” It was also hard for the staff who had to care for pregnant patients who had taken drugs and ended up in the hospital. She again reiterated that a lot of staff had “feelings” about that.

At this point, April became emotional as she remembered an encounter with a patient that had reminded her of her mom, who had died from a stroke. This elderly patient, who had also had a stroke, was making exactly the same gesture with her hand as her mother had made, and it sounded like this had caught April by surprise; she said that she almost couldn’t be in the room. At this point, she also told of many instances of friends of hers, who are working in the ER, finding it incredibly hard to care for children who are admitted, as it often makes them think of their own children. While in her current job, she has also had to navigate the admission of her cousin, who had attempted suicide. She couldn’t have been her patient for ethical reasons, but she described how she couldn’t just go and hide at work either. She knows of nurses who work near their families who have had their parents or spouses die at work, and they need to decide whether to continue working there knowing they could never go in that room again. She described the effect of her mom being admitted to the neurological ICU at her hospital (before she worked there) is that whenever she goes into that department, she thinks about her.

She spoke again about the diversity of her hospital and how it isn’t uncommon to see an Amish family walking in, someone covered in tattoos, a woman in a burqa, and someone in a skimpy dress all at the same time. How sometimes a wealthy patient pays to rent out the whole ICU for surgery while there are people who get poor-quality health care because of where they live. She then made the comment: “I think everybody sees our healthcare system as a little messed up.” It is clear that for April, the advantage of working for a globally renowned hospital chain is the cross-cultural knowledge that is passed on by colleagues and reports from other regions. When this knowledge improves care and best practice in the profession in general, I imagine it might go some way to offset the fact that so many people are denied care based on income. An example she shared during our conversation was the fact that in the UAE, because their laws are different, brain death is not a legal death there, so as a result, they are really good at taking care of patients whose bodies are failing until the body dies. This has enabled them to share their learnings across hospitals. In the US, she explained, once they declare you brain dead, that’s a legal time of death, but they often keep the body alive for organ harvesting. She described a patient who had been declared brain dead, and she wasn’t sure if her husband was “really stubborn or he had dementia a little,” but he was taking a lot of the physician’s time by talking a lot. She offered to spend time with him, and when she left the room and came back in, he had moved his dead wife’s hand to prove she was still alive. Nurses, due to time spent with their patients, had a different type of moral distress than physicians/doctors, April said.

At the end of the interview, April said that there was one more thing, and it would likely show up in her photos. She had recently had a daughter, but she had been initially pregnant with twins. One had died at 19 weeks, and she had to carry the dead baby another 16/17 weeks until birth because she couldn’t have an abortion. She described how hard it had been because she couldn’t hide that she was pregnant, and she had told people she was having twins. When only one baby arrived, she had to have that “weird discussion” with colleagues over and over again, and as it’s a relatively rare situation, she knew that people didn’t really know how to react. She said this difficult personal experience of life and death at the same time, and what her body could do, did impact her work, demonstrating again an example of bringing the personal, unwillingly, into the professional and how visible and vulnerable the nurse’s own body can be in the profession.