A Nurse’s Powerful ER Exit Letter


By Jessica Nandino, RN

Dear hospital,

The last three years, I have had the pleasure of working in our state’s renowned emergency department and level-1 trauma center. My departure closes out a decade of my nursing career as an emergency room and flight nurse. This department — the staff, in particular — will forever hold a very special place in my heart. I leave with a great amount of respect and thanks for this exceptional team and its leadership. I am blessed our paths have crossed and leave with nothing but admiration for all of the hardworking individuals. I wish all of you the best.

As I leave, please hear this ER nurse out, one last time. I am concerned.

The emergency department is a dynamic environment — one day rarely looks like the next. The incalculable nature draws us in. ER staff, we are at our best in times of high demand and limited resources. However, what happens when the daily demands are no longer coming from the nature of our job but also from the inherent design of the system that has been implemented? What happens when the system itself is capitalizing on the ethics of its employees? Systems implemented by the Studer/Huron Group have been made at the detriment of staff and patients.

As an ER nurse, I have always enjoyed the challenge of working with limited resources in the face of the unexpected. Our group excels at rising to meet the call when our community needs us most. That call comes in all forms: an unfortunate MCI, a particularly bad flu season, a celebratory holiday weekend. I even enjoy the days when the root cause of the patient surge cannot be clearly defined. Those busy shifts when the only explanation is — Albuquerque woke up with just a little extra crazy. Those shifts leave us tired and bring us closer together as a team. At the end of the shift, we walk through the sliding glass of the EMS bay filled with personal and professional satisfaction. Another job well done.

In the last three months, the demands have taken a palpable change. Our department has been functioning at near-maximum capacity every single day. We walk into work, knowing we will likely have staffing conditions barely sufficient for the number of patients we have, not considering the inevitably of the unexpected. The staff continues to work hard, our ethical standards unchanged, the standards that drew us to health care in the first place. The increasing demand of the system, along with our individual moral obligation, has left many of us fighting to find a way to rise to the call to meet the demands of the new normal. We have sacrificed what little space we once had to attend to our own basic personal and emotional needs. We are sacrificing our own well-being to support our co-workers and maintain a safe and appropriate level of care for our patients. That rally can only last for so long.

Over the last three months, the majority of shifts I have worked have been, at best, completely unsustainable, and at worst, dangerous. My ability to deliver appropriate patient care has been, at times, rendered impossible due to insufficient numbers of nurses and support staff.

Specifically, in these areas:

Triage being staffed with one nurse from 0700–1100, or even 0700–1300.

No medical screening exam (MSE) nurse before 1300, if we have one at all.

Two trauma nurses from 0700 to any time after 1100.

Even “regular assignments” within our department consist of complex ER, admitted, total care patients, and can often become overwhelming considering that tech support is almost half of what it was when I came to the department in May of 2016.

Our ever-caring and superhuman charge nurses do what they can to answer our calls for help. However, they are not a solution to staff shortages. When a charge nurse is filling the role of bed medic or MSE nurse, they are still pulled in ten different directions. The remaining workload that once assigned an FTE position falls onto already overworked staff or simply doesn’t get done. Inevitably, when things don’t get done, patient care suffers.

I can say with certainty, in recent months and with the changes made, patient care and employee well-being has suffered greatly. When I have vocalized my concerns to leadership, I was given the same response that they likely received to their own protest. This is just how it is right now.

The hospital has given the final say in the staffing of the front lines to a private consulting firm. The necessity of a nurse is dictated by algorithms unconcerned with the human dynamics of acuity and illness. Data sets of questionable validity. Simple input and output.

Where were the supposed experts this last week? The department was at a standstill with close to 40 admissions, some with admission orders others still waiting for consult. The trauma room was staffed with two nurses, all bays and hall beds full. The nursing responsibility of caring for nine critical care patients was placed on two nurses and an overburdened charge nurse. I was in triage with a new hire on his second day.

It was me, supposedly training him, and one other nurse. No dedicated MSE nurse. There was a waiting room of 65 patients, a sub-triage bursting at the gills. Where were the experts when a patient with severe post-op complications and bleeding went from a side room in sub-triage directly to the OR? We cared for an acutely ill patient in a room usually reserved to store supplies and wheelchairs. All while still attending to the line of untriaged patients that snaked through the lobby. Was that reflected in their algorithm?

The solutions to the staffing problem being passed around the department consist of nothing more than adding additional meaningless workload. At what point do we stop discussing how to play the game better and ask, why are we playing the game at all?

My ER exit letter is to advocate for all patients who seek our care. To advocate for my nurse co-workers who feel unsupported by this institution. Patients may not realize that behind the curtain, changes are being made that directly affect the level of care we are able to provide them.

But we do.

The overworked and underappreciated nurses certainly do. High-caliber ER nurses, the ones you want taking care of you and your family should, god forbid; you need it. Many of these nurses are grappling with the same concerns I have outlined above. All of us are disheartened. Some are considering employment elsewhere.

I am leaving a job and a department I love because the hospital continues to place value on faulty analytics and chooses to ignore our concerns regarding safe patient care and employee well-being. I am leaving because my personal and professional morals are regularly colliding with misdirected values of the system being put in place.

Compromises I am unable to make. An erasure of ethics I am unwilling to live. I am leaving because the response to my concern has been: accept it, bend to it or leave. I was told we all have an expiration date in this field. Sadly, the current practices and apparent values of our hospitals’ administration are expediting that date for many of us.

Health care is currently facing unprecedented challenges. It is impossible to work day in and day out on the front line and remain ignorant to what is crumbling all around us. There is an absolute need to refine our approach and continue to address the problems our industry is facing. I respect and welcome novel and innovative system design into the emergency department. However, I ask you, the current changes are being made at what cost — and to whom? Are we fixing a problem or just creating a new crisis? A crisis that will be faced without the strength and spirit of undervalued experienced employees who have not or cannot be replaced.

I implore our department and its leaders to rise up — to do better and be better. We have an obligation to care for our community and for each other. We are falling short.


A concerned ER nurse


Articles in this issue:


  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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