Education For Live

They had come to see Katie Duke: a 40-year-old, 5-foot-tall troublemaker in black and mocha suede Jordans who emerged from the pandemic as a nursing celebrity. Duke is a nurse practitioner (NP), content creator and health-care advocate who hosts a society and culture podcast titled “Bad Decisions.” She’s also an Instagram influencer who promotes lifestyle brands to her 143,000 followers. But her 90-minute show — “Bad Decisions: A Night of Healthcare, Comedy and Catharsis” — was her first experience with stand-up. If it went well, a booking agency had promised her a national tour.

When Duke took the stage, she explained that she’d initially balked at the idea of stand-up. “Are you out of your godd—ed mind?” she recalled asking her manager. “Or are you just trying to get me canceled and DNR’d from every f—ing employer in the country?”

Behind their masks, the audience broke into laughter. Duke continued, “Tonight is about some fun, it’s all about some pretty offensive digs at the health-care system, our government and our health-care leadership.” She made an off-color joke about hospital administrators. “Am I going too low?” she asked.

“Go lower!” somebody shouted.

Duke grew serious. “I want you to have a more defined sense of your f—ing worth, and a greater confidence in your voice,” she said. “Because when a lot of voices are stronger together, s— starts to stir. … I’m a pretty good NP, but I’m even better at stirring s—.”

Duke has been pushing back on expectations about what a nurse is and how she (it’s almost always a she) should act for nearly a decade. Among them, she told me later that week: Nurses should work in hospitals; nurses are merely support staff for doctors; nursing isn’t creative or entrepreneurial; nurses are tireless and have endless reserves of patience; nurses keep their discontent to themselves.

Since the start of the pandemic, nurses have taken to social media in large numbers to share their experiences and vent. The corner of the internet known as “NurseTok” is full of truth-telling: about the experience of working with incredibly sick — and sometimes dying — patients day after day. But also about the frustrations of working a demanding service job. In December, four nurses at Emory University Hospital Midtown in Atlanta were fired for making a viral TikTok video that mocked maternity patients and their families. A statement from the hospital suggested that their lack of empathy was unforgivable.

Nurses don’t dispute that patients deserve compassion and respect, but many feel that their roles are misunderstood and their expertise undervalued; as Duke repeatedly told me, people don’t respect nurses like they do doctors. As a result, nurses are leaving hospitals in droves. And they’re establishing new careers, not just in health care but as creatives and entrepreneurs. Successful influencers such as Duke are leading the way, providing empathy, mentorship and a license to speak out. It’s a tricky balance. Duke wants — and needs — to work as a nurse to stay relevant. But her hospital employers don’t love the movement she’s aiding, that’s encouraging nurses to criticize working conditions and culture or to leave bedside work entirely. Hospitals were chronically understaffed before the coronavirus pandemic, and the shortfalls have only worsened. America desperately needs more health-care providers but not necessarily the wellness entrepreneurs and career consultants that many departing nurses have become.

But why should nurses be held to a different standard than other workers pivoting during the Great Resignation? Duke argues that nurses are especially fed up and burned out. And yet, as caretakers, nobody expects them to put their physical and emotional well-being first. But that’s starting to change. Once a lone voice, Duke is now a representative one.

Nurses make up the nation’s largest body of health-care workers, with three times as many RNs as physicians. They also died of covid at higher rates than other health-care workers, and they experience high rates of burnout, “an occupational syndrome characterized by a high degree of emotional exhaustion and depersonalization, and a low sense of personal accomplishment at work,” according to the World Health Organization. Wendy Miller, associate dean of the Indiana University School of Nursing at Bloomington, told me high stress and anxiety are the “antecedents” to burnout. But you know you’ve hit the nadir when you become emotionally detached from your work. “It’s almost like a loss of meaning,” she said.

Before the pandemic, between a third and half of nurses and physicians already reported symptoms of burnout. A covid impact study published in March 2022 by the American Nurses Foundation found this number had risen to 60 percent among acute-care nurses. “Reports of feeling betrayed, undervalued, and unsupported have risen,” the ANF study said.

Miller said nurses are experiencing “collective trauma,” a conclusion she reached by studying their social media usage through the pandemic. She and her colleague Doyle Groves, a data scientist, oversee the Social Network Health Research Lab at IU. In April 2020 and between June 2021 and September 2022, they collected more than 249,000 tweets that referenced nursing-related topics from more than 97,500 users. In April 2020, Miller said the public was “exalting nurses as these superheroes and angels,” while nurses themselves were tweeting about “the horrible working conditions, enormous amount of death without any break … being mentally and completely worn down and exhausted.”

Miller and Groves also found a fivefold increase in references to quitting between the 2020 study and the 2021 study. “Our profession will never be the same,” Miller told me. “If you talked to any nurse who worked bedside through the pandemic, that’s what they’ll tell you.” From this, she says, has grown a desire to be heard. “We feel emboldened. We’re not as willing to be silent anymore.”

On her podcast, Duke tells a story about her early days in nursing school. She was 20, working minimum wage at a deli and living with an abusive boyfriend in her hometown of St. Louis. Her parents were covering her school tuition, but they were otherwise estranged.

So when Duke’s instructors announced that all students needed clean, white shoes to start clinicals, she felt unable to ask for more money. Instead, she walked into a shoe store wearing her “dirty, terrible, disgusting” sneakers, put on a pair of pristine white ones, and walked out. She was caught, the police were called, and Duke spent the weekend in jail. The store never took the shoes back, so Duke started clinicals without incident.

It wasn’t her only arrest. A year later, she spent a couple of nights in central booking for fighting with a woman who she says was sleeping with her boyfriend. The assault charges were dropped, “but I definitely started it,” Duke said, in her typically matter-of-fact way. She doesn’t try to rationalize these missteps, but she’s not exactly remorseful. The shoe incident, in particular, was something of a Jean Valjean moment — the scrappy underdog taking the necessary steps to survive. Yes, she says, it was embarrassing to own up to having a record when she took the nursing boards. But she’s more than made peace with her mistakes. In fact, she named her podcast “Bad Decisions” after them. “What society tells us we should be ashamed about,” she said, “we need to start encouraging people, especially women, to embrace as part of our story and our truth.” Duke has seen the benefits of this approach. Arguably, it has fueled her success.

In 2010, she was an ER nurse at New York-Presbyterian Hospital in Manhattan when ABC approached the hospital about filming a docuseries there called “NY Med.” Duke said there was plenty of skepticism about the idea. “People were either like this is unethical, ridiculous, or why would the hospital agree to let a camera crew in?” But she was intrigued. She hated how nurses were generally depicted in popular culture. “Have you ever seen [the news media] reach out to a nurse or an NP to deliver public health news?” she said. The producers quickly identified Duke as on-camera material. “There’s no way Katie would have said no,” said Duke’s older sister Rebecca, also a nurse practitioner. “That’s her personality.”

“NY Med” was well received when it premiered in July 2012. Duke recalls being interviewed and taken to publicity events; she started getting attention on Twitter and Instagram. When the second season was announced, the producers decided to stick with many of the same cast members. Jealousies emerged among people who’d hoped for a shot at the spotlight or believed that Duke’s sudden fame, limited as it was, had gone to her head. She attests that her supervisors began to micromanage her and hold her to stringent disciplinary standards for small infractions. She was suspended for a week, she says, for telling a VIP patient that he had to wait in the regular waiting room like everyone else instead of cutting the line. (New York-Presbyterian declined to comment for this story.)

And then, in late February 2013, Duke was abruptly fired. She’d posted a photo on Instagram showing an ER where hospital staff had just saved the life of a man hit by a subway train. It looked like a hurricane had blown through. There were no people in the photo, but Duke titled the post, “Man vs. 6 train.” She told me she wanted to showcase “the amazing things doctors and nurses do to save lives … the f—ing real deal.”

Before long she was summoned, without cameras, by her director of nursing and the patient care director. Duke says her superiors called her an “amazing nurse and team member” before they told her that “it was time to move on.” Her director handed her a printout of the Instagram post. According to Duke, he acknowledged that she hadn’t violated HIPAA or any hospital policies but said she’d been insensitive and unprofessional. She was escorted out of the building by security. When the episode aired, it showed Duke crying on the sidewalk outside the hospital.

Duke was crushed. The hospital was reimbursing her graduate tuition and provided her health insurance. She also loved the hospital: Her life, her friends, her purpose was there. “It was a really bad feeling,” she recalled. “Being disposable and disposed of is really uncomfortable.” She was also angry. She’d reposted the photo, with permission, from a male doctor’s Instagram account. He faced no repercussions. She now admits her caption was rather “cold” — especially compared with the doctor’s, “After the trauma.” In hindsight, she said, she might have been more sensitive. Maybe not even posted the photo at all. And yet this frustrates her. Why shouldn’t the public see nursing culture for what it really is? Man vs. 6 Train. “That’s ER speak,” she told me. “We say ‘head injury in room five.’ We don’t say ‘Mr. Smith in room five. We talk and think by mechanism of injury.”

But this is at odds with the romanticized image of the nurturing nurse — which hospitals often want to project. In some cases, nurses are explicitly told not to be forthright with their patients. “I know nurses in oncology who are not allowed to say to a patient and their family, ‘This will be the fourth clinical trial, but we all know your family member is dying,” said Barbara Glickstein, 68, a longtime nurse who also runs a consulting firm aimed at helping nurses become more media savvy. “People are tired of not being seen for who they are and what they know.”

In 2010, Duke was Glickstein’s student in a program for nurses finishing their bachelor’s degrees. Even then, Glickstein admired her moxie, but she acknowledges that Duke’s approach can sometimes be counterproductive. Over the years, Glickstein has encouraged Duke to channel her fire and be more strategic about building relationships with administrators. This approach, she said, would better help Duke “mobilize nurses around issues of importance.”

And yet Glickstein acknowledges that some health care administrators are simply not persuadable. During the pandemic, Duke applied for a position at Mount Sinai Hospital in New York, where she’d worked before the pandemic. She’d relocated to D.C. for a relationship and resigned from the hospital on good terms. Her manager seemed happy to bring her back. But Duke found her application stalled, even though friends at the hospital said they were short-staffed.

“Somebody in the power structure didn’t like Katie’s very public platforms and her speaking and [her] feeling free about what she says, and that ruled out Katie for that job,” Glickstein said. (Mount Sinai declined to comment for this story.)

Duke’s stand-up performance in Manhattan and another pilot show in Los Angeles went very well. She expected to begin a 15-city tour in September 2022. Meanwhile, she was taking short-term contract gigs as a travel nurse and nurse practitioner. She was also earning money by promoting various brands — previous clients included Warby Parker, Moen, Betterment and Neutrogena, along with a variety of health-care-related companies. But these partnerships didn’t cover her bills, credit card debt and nursing school loans in the long term. “Maybe if I had 1 million YouTube followers,” she said.

Duke appreciated the short-term gigs, because they gave her flexibility and helped her avoid the burnout trap that often accompanies full-time bedside work. She is still recovering emotionally and physically from her covid experiences. In the spring of 2020, she worked for two “terrifying” months on a covid crisis contract in New York City before getting covid herself and spending 11 nights in a hospital bed. She was put on oxygen and given Remdesivir. She still talks with disbelief about that time — how the staffing agency that handled her assignment assembled scores of nurses for an orientation. “We were given one N95, and told to make it last until it broke,” she said. “Meanwhile the CEOs of those health systems took home millions in bonuses.”

On her podcast and in her show, Duke wields such experiences as a rhetorical weapon, encouraging other nurses to leave hospitals. For a time, she mentored nurses, with sessions starting at $150 an hour. She now offers events and workshops that teach nurses how to start a side hustle. And over the past year, she’s hosted wellness and networking retreats for health-care workers in exotic foreign destinations, including the Galápagos Islands, Bali and Egypt. Some of Duke’s attendees, all of whom pay their own way, want more advanced nursing roles. But increasingly, she says, they want a way out.

“The most frequent question is, ‘Katie, I have to get out of the hospital, but I don’t know what else to do.’” Her advice: “You have to create your own definition of what being a nursing professional means to you.” She has a ready list of alternative jobs, including “med spa” owner, educational consultant and YouTuber.

“It’s why she has such a big, loving following,” said Amanda Guarniere, a nurse practitioner and career mentor, whom Duke has advised. “Because she shows nurses what else is possible.”

Guarniere left nursing during the pandemic because she was burned out and unable to balance work and child care. Guarniere’s business, the Résumé RX, took off, but she eventually returned to clinical practice part time. The reasons, she said, included “concern about my credibility in my field if I were to be away from clinical practice too long.”

Ultimately, Duke’s tour didn’t happen. She’d recently started a new contract job, and her employer wouldn’t give her time off. She said she couldn’t afford to pass up the paycheck.

But a different opportunity soon arrived. Duke had recently been named a brand ambassador for the popular scrubs company Figs. As it turned out, Figs was getting into the advocacy game. The company had drafted a legislative proposal aimed at improving conditions for health-care workers and invited nine ambassadors, including Duke, to pitch legislators on Capitol Hill.

For two days in late September, Duke traversed the Hill with another Figs ambassador, Kamilah Evans, an OB/GYN resident who has been open on Instagram about the physical and emotional toll of her work, the racism she’s experienced as a Black health-care professional and the seemingly superhuman expectations of her job. As she approached residency, Evans worried about the antagonism she might face from colleagues and staff because of her social media presence. “I reached out to Katie in a very desperate way,” Evans said. “I didn’t know if I should delete my social media completely or lay low. How do I move forward as an honest resident?”

Duke assured Evans that it was okay to be strategic in the short term — to occasionally moderate her voice or withhold criticism — in service of the end goal: becoming a doctor. It was advice Duke probably wouldn’t have offered a decade ago. But it seemed she’d been taking some of Glickstein’s lessons to heart. “If you’re signing up to be a public figure or influencer, you have to understand that not everyone speaks the same language [you do],” Duke said.

Duke and Evans delivered impassioned pleas to members of Congress and aides, detailing their burnout and the pressures they faced on the job. They shared their experiences during covid, underscored by dramatic statistics on the nurse exodus, and made sure to emphasize their social media reach. They were especially persuasive during a meeting with Congresswoman Jan Schakowsky (D), a longtime Illinois supporter of health-care workers, who seemed genuinely moved by their appeal. But as Duke discussed the problem of staffing shortages, Schakowsky turned to her aide. “You know I’ve had nurse staffing ratio bills now for how many years? Six? Eight?”

Duke returned to New York from Capitol Hill on a high. It didn’t last. The following week, she showed up at the financial district location of New York-Presbyterian hospital ready to start a 13-week contract. She’d gotten the placement through AMN, a reputable travel nursing agency. When she arrived, she was greeted with enthusiasm by the staff. Some people were a little star-struck, but mostly, they were relieved to have a nurse with 20 years of experience in the ER with them. According to Duke, the current team of nurses was short-staffed on nearly every shift. And many of them were young; on her first day, she was training young women who’d only been on the job for a few months.

According to Duke, the recruiter from her staffing agency called the very next day. She explained that hospital administration had contacted them to say that Duke “wasn’t a good fit” and to ask that her contract be canceled. The agency, she says, tried and failed to elicit a more concrete reason. The recruiter apologized to Duke and said she’d never heard of such a thing happening before, but Duke found the situation all too familiar.

A spokesman for AMN said company policy prohibits the discussion of specific contractual arrangements and interactions between the nurses the company places and its clients.

She explored other options. But it was hard to find the daytime shifts in Manhattan that she needed. So, for the time being, she was picking up sponsorships with Nurse.com, Pfizer and Tommy John. And she was talking with her manager about relaunching the “Bad Decisions” tour. In January, she was hired full time by a health-tech start-up. She said she enjoyed the return to clinical work but sorely missed the camaraderie and teaching opportunities offered by her hospital career.

I asked Duke if she ever wanted to be anonymous, to simply do the work she’d been trained to do. She sighed. “I want to have it both ways,” she said. “I wish I could work at a hospital that would allow me to take great care of patients and help train and educate new people coming on board and, at the same time, use my platform as an opportunity to spread awareness about the value of nurses and supported working environments and safe staffing.

“But that’s just unrealistic.”