The Clinic's ICU is a war zone of sorts, where health-care workers battle advanced illnesses 24 hours a day. Doctors file in and out, ordering tests and medications. But nurses never leave the front lines. They plant themselves in the open bays in front of the patients' beds like sentries, monitoring machines that click and hum with jarring irregularity. They check patients' intravenous medications, their vital signs, their skin color. They turn them, clean them, and console them. Sometimes they even save them.
Despite their efforts, death claims about one in five patients in the ICU. Van Kerkhove recalls her recently deceased patients with the tenderness of someone talking about a lost loved one. One was elderly and stricken with multiple problems, she says softly. But the other two were in their 40s, with young children. The first died unexpectedly of cancer, only six hours after he left the ICU. The second died of liver failure.
"When they're that young, and you've tried to do everything to help them, sometimes you just end up crying along with the family," she says.
To Van Kerkhove, a registered nurse, that's part of her job.
It isn't in the job description. Comforting families is just instinctive to good nurses. But the ranks of good hospital nurses are thinning. Relatively low pay and objectionable working conditions at many hospitals in Ohio have driven them away, says Ohio Nurses Association CEO Gingy Harshey-Meade. In 2000, there were 133,739 registered nurses, down 8,342 from 1999, according to the Ohio Board of Nursing. While the shortage here isn't as pronounced as in some states, emergency rooms and ICUs are particularly feeling the pinch.
Nursing is a 24-hour-a-day, seven-day-a-week endeavor. The work is emotionally and physically draining and -- because it has always been female-dominated -- undervalued. A traditional lack of both advancement opportunities and significant salary increases has diminished the profession's appeal.
Hospitals that can't fill their shifts sometimes require nurses to work overtime -- a practice nurses criticize as dangerous to patients. A nurse entering her 17th hour of work may respond too slowly to a pressed buzzer or forget a dose of pain medication. Maybe she'll make a more deadly mistake.
A Chicago Tribune series published last year found that nursing errors -- many of them made by tired, overworked nurses -- result in thousands of patient illnesses and deaths each year. A recent health-care survey asked nurses across Ohio whether they would feel comfortable having someone close to them treated in the facility where they worked. A stunning 49 percent said no.
Part of the problem is the state of American health care in general. Still reeling from the cuts imposed by the Balanced Budget Act of 1997, hospitals have weathered slashed Medicare and Medicaid payments, low reimbursements from managed-care plans, and rising numbers of elderly and uninsured patients. Nurses make up the largest portion of hospitals' labor force and thus bear the brunt of hospitals' financial woes.
While certain geographic areas and specialties have suffered from a scarcity of nurses, there is no across-the-board shortage nationally, according to a Congressional Research Service report released in May. But that will change in about 2010, when a widespread nurse shortage is expected to take hold. The American Nurses Association calls the situation an "impending public health crisis."
A changing society accounts for a good deal of the shortfall. Even 20 years ago, fewer career opportunities existed for women. Now, nursing's guaranteed labor pool -- women who wanted careers but didn't want to become teachers -- has disappeared. With many more options open to them, young women are less likely to choose nursing. The percentage of RNs under 30 has fallen nearly 40 percent since 1980, according to a Nursing Economics article published last year. The average nurse in Ohio is 47 and getting older.
The dearth of young nurses is responsible for the current shortage in the nation's specialty units like the ICU. They are the ones typically drawn to that fast-paced, demanding environment.
To care for the sickest patients and to perform a staggering array of tasks, ranging from toilet duty to life-or-death decision making, the Cleveland Clinic's nurses are paid between $35,000 and $60,000 a year, according to chief nursing officer Shawn Ulreich. In the ICU, they work one weekend a month and every other holiday. Other nurses around the state don't have it so good.
At another Ohio hospital, a nurse is begging her baby-sitter to stay a few more hours so she can work mandatory overtime. Another has skipped meals and bathroom breaks because there is no one to fill in for her. Another juggles too many patients. Nurses in Youngstown went on strike because the conditions there were so bad. In Akron and Lorain, they came close to striking.
Nurses seem to be more satisfied at the Cleveland Clinic than at many other hospitals, but there still aren't enough of them. After all the Clinic has done to retain ICU nurses -- providing financial incentives and flexibility in scheduling, for example -- there are still jobs that Nurse Manager Jeff Woods can't fill.
Drawing attention to nursing's problems only drives people away from the field, which in turn exacerbates the shortage, says Peggy Noble, a registered nurse working as a government affairs specialist for ONA. Nurses tend to be vocal about the difficulty of the work and the low pay, whereas the "benefits of nursing are very intimate and personal."
Ivanka Zuzic has worked in the Clinic's ICU for four years. On a recent morning, she is taking care of a 37-year-old mentally retarded woman with cerebral palsy, a pancreatic disorder, and brain seizures. When her patient awakens, she blinks her eyes, and Zuzic rushes to turn off the overhead lights. The patient can't speak because of a breathing tube, but the nurse knows her mouth is sore. The patient starts moving her head quickly from side to side.
"It's OK," the nurse says soothingly. "Relax, dear."
It bothers Zuzic that caring for sick people earns her about as much as a friend makes working in a factory. Yet she wouldn't consider moving to a less-demanding work environment.
"I feel this is real nursing," she says. "In a clinic, you're like an aide or something. It's 'Get this for me' or 'Get that for me.' . . . Here, you're important."
Van Kerkhove graduated from a competitive nursing program at the University of Toledo in 1994 before joining the Clinic's ICU. She left for three months to work in the obstetrics ward, but soon returned, because she missed the challenge and the camaraderie of the ICU. She loves seeing the patients recover and knowing that she helped them.
She worries that nursing schools are so desperate, they're recruiting people who aren't cut out to be nurses. She wonders what will happen to the profession if it becomes filled with people who are simply doing it for the paycheck. What would happen if someone like that lost three patients in three days?
"If you get to a point that it doesn't affect you personally, you know you shouldn't be doing it," she says.