In this essay, I present my firsthand account of my experience as an African American nursing student in a predominantly nonminority nursing program as well as my perceptions and interactions with fellow students. As an autoethnographer, I sought to answer the following question: What is the African American student nurse’s experience of education in a predominantly nonminority school of nursing and university, and how does that experience affect her as an individual?
Pre-Nursing School: Being “White”
In high school, I was called “white” by the majority of the few African American students in a high school of nearly 500 students in the Northeast. Initially, when they said this to me I was shocked. I had been on the receiving end of racially charged comments by white peers, and now I had to deal with this from my own race and ethnicity, too? I wondered why I could not catch a break. I remained confused but focused on my schoolwork. Since being a freshman, I was in honors classes, those with the maximum rigor in the entire school. It was viewed as if only the elite were in these classes, but I surely did not feel like the elite. My white peers in those classes assumed I came from the ghetto and asked me to teach them Ebonics and about rap music (which I did not listen to). I was isolated in those classes because of such stereotypical comments and the competition to be number one of the entire graduating class, but mainly because I was the only African American student in such classes. The comments from my African American peers only intensified as I was enrolled in both cosmetology in vocational school and Advanced Placement courses (which could alleviate me from taking college courses, once enrolled).
One of my African American acquaintances, who I thought seemed amicable, approached me purposefully one day in the hall. She looked like she was on a mission to find me as I put my things in my locker. I met her with a kind hello—I did not have many friends in school. I blamed myself for that, being so quiet. She stated loudly with a greeting, “Do you think you are better than us?” I said, totally confused, “Us? Better than who?” She quipped, “You know exactly who I mean, the few blacks in this school.” My face must have looked blank. I just stared at her with curiosity due to the fact that, besides the “white” comments, there was never an extended conversation or association besides my distant friendship with several other minorities. She continued to badger me, “You know you think you are better than us since you are in those special classes. Who do you think you are?” I simply responded, “Nothing.” At the time, my self-esteem was low; I had become tired of my lack of association. She was not buying it. “You know what? It must be true that you are white because you even talk like them,” she said. “Don’t ever think you are better than us. We are just as smart, although we may not be in the AP classes.” Taken aback, I explained, “I never said you weren’t. You should talk to your advisor about enrolling in one of the classes.” Without acknowledging my reply, she stormed away, saying, “Wow, you are white.” As she walked away, I blinked at her and said to the dust trailing behind her, “It is funny because my skin is black like yours.” I went on to finish my day; however, the episode never stopped playing in my head, even after I became a nursing student.
Katie Love, PhD, APRN, BC, AHN-C, wrote about the lived experience of African American nursing students in a predominantly white university in a 2010 article published in the Journal of Transcultural Nursing. One of the themes of her phenomenological study was that of fitting in and “talking white.” She reports about a study participant who had grown up in a predominantly white secondary school and had become accustomed to experiences with white students. African American nursing students who did not have such an experience described some African American students as being “Oreos…Black on the outside and white on the inside.” Such “Oreos” are described as African American students who are black but “act White, socialize, and talk like White people.” One of the participants of the study shared the following observation: “To me it’s kinda a funny thing that it’s such a problem in the Black community that you could not talk in a certain way…but if you start talking slang, then to them you’re trying.”
I could identify with Love’s study as my isolation from peers—from within my own race and from without—began in high school. In high school, I was excluded by white students because of the color of my skin and, at the same time, excluded by my African American peers because of the way I carried myself and spoke. In nursing school, my isolation continued. It would eventually lead to my depression.
Nursing School: Feeling Isolated and Excluded
Fast forward to nursing school. The faculty and advisors began our edification with a talk about the rigor of the courses. I remember a gentleman announcing, “Look around the room. See everyone here? Not all of you will be here in four years. The truth is, nearly half of you may not make it to graduation.” I remember sitting in the warm amphitheater and feeling intimidated by his words. When I looked around, as instructed, I noticed the class was made up of only three African Americans. The largest minority group were of Hispanic background.
The first few semesters were full of straight science courses, which translated into nonstop studying. I spent my days in the library enjoying my books and learning. The days went so fast, when all I did was read and study the day away. In the blink of an eye, the end of the first year arrived. All of the Hispanic students were eliminated either by not meeting academic requirements or by choosing to leave the program. I was afraid that I would be next. My classmates were mostly white students. At times, I felt I did not belong. None of my professors looked like me. The nonminority students studied together and did not invite me, much less speak to me.
I remember our professor addressing the class during our sophomore year. She advised everyone in our small section to avoid driving alone to a distant clinical site and to carpool instead. I looked around the room attempting to make eye contact but did not receive any response. My nonminority peers turned around in their seats and, within minutes, had arranged themselves into two car groups, which left me out. I told myself, “You really thought it would be different, huh?” I laughed to myself and stopped looking for a group. That experience solidified the divide for me.
In 2004, Nancey France, PhD, RN, and her colleagues at Murray State University published a pilot study in Visions: The Journal of Rogerian Nursing Science that examined the lived experiences of black nursing students and found many reported feeling isolated and discounted. One of the themes of the data was “You’re just shoved to the corner.” One African American student nurse clarified, “You may get one or two that wants to include you…You may go up to them, you’ll risk to say ‘are you going to study?’ If you think that you know them and everything’s o.k., you’ll say, ‘are you all going to have a study group this weekend?’ And they’ll say ‘yeh’. But, when the time comes…you can’t get in.” Another student reported, “I’m the only black, in all my classes I’ve been the only black. It’s hard because…you got to prove yourself. If you don’t do as well as the other students they just single you out. That’s why I have to strive to do the best I can.”
Black students also reported feeling they were only admitted to schools of nursing to meet a quota. They described the increased pressure exerted on them when minority attrition rates were high in their class. As a result, they experienced emotions such as self-doubt, fear, lack of confidence, and diminished self-esteem before attending class. Many students reported these feelings pushed them “even harder to prove they could be successful.” There seemed to be a consensus that there was an unspoken expectation of African American students to fail, which propelled these students to greater levels of determination to prove that “they were as smart as anyone else.”
Moving Up: The Benefits of Exclusion
During my third semester in nursing school, I became tired of sitting in the back of the classroom. What had once seemed comfortable became an annoyance to me. The students who supposedly knew all the answers sat in the front, always the first ones to raise their hands. However, their answers were the same as mine—always. They weren’t any better than I was. I decided to beat the caste system within my own classroom. I felt my sitting in the back row was perhaps contributing to my isolation and depression that had begun to develop. Humans are not meant to be excluded—we need contact. As a result, I started moving forward, slowly but purposefully, to avoid and overcome my feelings of exclusion.
I remember deciding I would not allow myself to sit in the back anymore. I felt like Rosa Parks as I migrated up to the middle rows of the classroom. I began to raise my hand more. I found that studying alone was beneficial to me, as I knew the full answers to questions that other students merely answered in a general way. As a result, I started raising my hand and answered insightfully each time.
I wasn’t sure of myself until my anatomy and physiology professor approached me and asked if I wanted to become a physician. He tried to convince me to enter the premedical program. I was flattered and taken aback, but I knew it was not what I wanted. I had fallen in love with the few nursing courses we were allowed to take. I could not betray my passion for nursing and really “being” with the people. However, he had not approached anyone else in the class with this offer.
It was after that discussion that I moved up and became the snob who raised her hand to answer every question, at every opportunity. It was not until then that I had my first contact with nonminority students, other than a glance. They soon began asking how well I did on my exams. When interrogated, I replied without emotion, saying I did “okay” when I knew I got an A. They soon lost interest in me again. They did not know that their exclusion of me in their study groups was paying off greatly for me. I had become an independent and successful learner.
As the years progressed, I think they began to suspect I was doing better than just “okay” as I began to earn scholarships and recognition from my professors in class. It was unwanted attention for me because I wanted to keep my head low. What began as a business venture to simply gain a skill that would sustain me as an adult turned into a love for the profession of nursing. I had not expected that—it just happened. As my love grew, I began to excel. As I excelled, I felt the isolation increase. I had become used to it; it didn’t really bother me on the surface. It seemed other students were in school to make lifelong friends and to have a good time. I was in nursing school solely to earn my degree, focusing intently and singularly on my studies; so, most nursing students tended to avoid most nursing students avoided me.
I soon began to wonder if I had isolated myself, but then I noticed in my junior year that professors began to assign more group assignments. In those voluntary group assignments, I observed minority students chose to work together in the same groups, while nonminority students chose to work together in their own groups. I wondered if the professors noticed the same thing I did. It went on like this until the end of the nursing program.
A 2015 integrative review published in Nursing Education Perspectives reaffirmed that there are several studies where African American nursing students reported feeling “voiceless, not part of the important conversations, left outside of the cliques, alienated and insignificant.” Many minority students coped with these conditions by forming their own network among other minorities and “sticking together.” Additionally, Love noted in her study that African American students familiar with “being left out” from high school experience were better able to accept exclusion and move beyond the experience.
All that studying and exclusion seemed to work better for me. It worked out because I graduated. During graduation, I knew a select few would earn special acknowledgement for their achievements. I was sure it would not be me. I was so focused on getting out of there. I had the chance to extern on a unit in a teaching hospital where nonminority staff embraced me as if I was family. I just wanted out of nursing school. At the end of four years, it felt like prison only being able to talk to and connect with six minorities who made it to the end of the program. Now, I was free to explore the world as an adult with a real job—not just a student building up debt.
These were my thoughts as I was called up to shake hands with all of my professors. I was so focused on receiving my degree that the moment when they called my name seemed only a second. When they began to announce the special recognition awards for academic and clinical excellence, I kept looking back at my family and realized I was one of the few students wearing a purple tassel, which meant we were part of a special group: the Honor Society of Nursing, Sigma Theta Tau. We had high GPAs.
Then I heard one of my professors say my name. I looked around and those around me whispered, “That’s you! Get up! They called you!” I had earned the award for clinical excellence. I was speechless and nearly stumbled up to the stage. I thought my professors were not interested in me, but they had nominated me for this award (and I assume they voted that I receive it). I was flabbergasted but filled with pride because I—the quiet African American student nurse—had earned this great honor. I thought I had not deserved it, because there were so many things I did not yet know, and I knew I was not the perfect student. I critiqued myself for those few senseless Bs I had earned. It was not until I returned to my seat the second time that I realized maybe I did deserve this award. Just maybe, I had worked hard enough in that I enjoyed putting the entire patient picture together—staying in their rooms, discussing how they felt about their illnesses while taking it all in, and figuring out how I could use my knowledge to prevent one less complication. I was more than a student nurse in those moments with my patients; I assumed the role of nurse and took such opportunities with the utmost seriousness. I remember a great exhalation as everyone threw their caps to the roof of the auditorium. I was deserving.
Soon after graduation, I passed my licensing exam on the first try and began working on a medical-surgical floor at a teaching hospital. My work was challenging and kept my attention, but I soon began to crave schooling. I decided to enroll in an online program. The main reason for doing so was so no one could see my face and perhaps I could fit in for once. And I did. I felt since no one could see the color of my skin or the youth of my face there would be no divisions. It proved true. I enjoyed my online schooling and soon pursued a doctorate program online after completing my master’s in nursing education.
In a 1998 study published in the Journal of Nursing Education, author Mary Lee Kirkland, EdD, RN, concluded that the most successful coping strategies of female African American nursing students are active coping and social support. She explains that “although they may have faced times of discouragement or despair, they did not waver in their pursuit of their goals. They relied on their inner strength to take the action needed to conquer their stressors and move on successfully.” I had a support system of my spirituality, my family at home, and my friends of the same faith that kept me strong. They probably were unaware how they were the one thread that held me together through emotional turmoil and numbness.
Enlightenment Upon a Return to the University: Six Years Postgraduation
Aside from the anatomy and physiology professor, who was from the biology school, I was never sure how the true nursing faculty viewed me. It was not until I returned six years later as a clinical nurse specialist to become a mentor for nursing students like I had been—of the minority. I was also pursuing a scholarship for my doctoral education with a focus on nursing education.
When I met with one of the professors, I was sure she had forgotten me by the e-mail she had sent back when I asked for a letter of reference and to meet to discuss a mentorship program for minority nursing students. However, when I walked in the door in my professional attire, she told me, “Wow, I remember you. I wasn’t completely sure in your e-mail, but now I know who you are exactly…You were always so bright. I knew it then, and look at you now and all you have accomplished. You have your master’s and are a clinical nurse specialist….[Another professor] and I are rooting for you to get this scholarship.” Our conversation ran long before a student showed up for her advisement. The professor told me warmly, “Keep in touch. We are so proud of what you will become and have become already!” She had written my letter of recommendation. However, the recognition she provided in those moments proved to me I did not know myself those years as well as I did right then.
I had not been invisible, after all, and the award I received upon graduation was not for show, but because my professors saw such great potential in me. I had become visible to myself and the world. My confidence soared as I left the campus. I had driven in, but I seemed to fly home, alongside the clouds.
Increasingly, nursing students are being introduced to health policy and are encouraged to play an active role in some aspects of the policymaking process. Yes, I know, so much to do and so little time! However, opportunities to enhance one’s level of awareness and engagement regarding the policymaking process have never been greater. Planting the health policy seed has become important to professional nursing organizations, nurse educators, and even nursing students who applaud the push for integrating health policy and advocacy content in today’s nursing curricula.
Today’s nursing students must acquaint themselves with a number of policy issues that may impact their practice, the delivery of health care, and the profession of nursing. Nursing students are encouraged to develop increasing levels of knowledge, skills, and competencies related to health policy and advocacy commensurate with their advancing levels of nursing education. The American Association of Colleges of Nursing (AACN) has identified key health policy competencies to include in nursing curricula starting at the baccalaureate through the doctoral level. Nurse educators are encouraged to incorporate these competencies when designing and implementing health policy courses for nursing students across all levels of nursing.
Starting at the baccalaureate level, nursing students are introduced to aspects of health care policy, finance, and regulatory environments. Students at the master’s level are engaged in analyzing health policies and their impact on health care financing, practice, and health outcomes. Nurses at this level are expected to help interpret research findings as well as advocate for policies that will improve the health of the public and advance the profession of nursing. Building on these skills and competencies, students at the doctoral level are expected to acquire the necessary skills to demonstrate a higher level of involvement of leadership in developing policies, influencing policymakers, and assuming influential leadership responsibilities at the local, state, national, and/or international level.
Early on during nursing education, one should begin thinking about how legislation informs nursing practice and how public policies influence the health outcomes of the patients and communities that one serves. For example, funding for nursing education and research is an ongoing issue for the profession. This need requires ongoing and persuasive advocacy and communication with state and federal legislative officials. Each year, numerous organizations lobby at our nation’s capital to make the case for funding to support nursing education and research. In fact, increased funding levels for nursing education and research are, in part, attributed to the diligent advocacy by the nursing community and other stakeholders.
Opportunities for Policy Development
Recognizing the need to introduce nursing students to the policymaking process, the AACN hosts an annual Student Policy Summit. This three-day summit is open to nursing students enrolled at AACN member institutions and is designed to familiarize students with the policymaking process and nurses’ role in professional advocacy. Students journey to Washington, DC, to take a glimpse at the policymaking process at the federal level. Speak with your school and/or faculty to ensure that there is representation and support from your academic institution during the call for applications. For information about future offerings, I encourage you to visit the AACN’s website.
Recognizing the need to foster the policy development of its members, the National Black Nurses Association offers an annual Health Policy Institute at their annual meeting. Speakers with expertise and experience in the health policy arena have presented on topics, including health equity, prescription drug abuse, reproductive rights, and mental health, to name a few. Another example is the Oncology Nursing Society, which provides an online tutorial on the policymaking process and ways to become an effective patient advocate. Many nursing organizations hold virtual and in-person annual lobby days empowering its members to advocate on behalf of patients, communities, and the profession.
Be sure to check with your student, professional, and specialty organizations to see what opportunities they have to help supplement your classroom education. Volunteerism is yet another way to develop familiarity with the policymaking process and gain experience in advocacy. For me, I volunteered for a long time with the American Cancer Society and the Susan G. Komen for the Cure. These experiences enabled me to establish the linkage among practice, research, and patience advocacy. This in turn fueled my passion for learning more about the policymaking process and the various legislative initiatives informing the health and well-being of communities of color.
Although numerous bills are introduced each year, only a small percentage will make it through the entire process, culminating in action at the executive level and signed by the President for passage. Similarly, numerous bills may be introduced or reauthorized that will have some implications for patients (e.g., reimbursement for care, increased access to care, support for clinical trials) or the profession of nursing (e.g., funding for nursing education and research). One bill that has implications for patients and the profession is the Nurse and Health Care Worker Protection Act of 2015 [H.R. 4266/S. 2408]. This piece of legislation was introduced by Representative John Conyers, Jr. (D-MI) and Senator Al Franken (D-MN) on December 16, 2015, during the 114th Congressional Session. This is the only national legislation that improves the quality of patient care and protects nurses and health care workers by addressing the safe handling of patients. To track the progression of this legislation, visit www.congress.gov.
During your nursing education or even in the workplace, stimulate some discussion and support around legislation and health policy issues and topics that have implications for nursing. Nursing in the 21st century demands that we take our rightful place at the table and advocate for patients and the profession. Developing the wherewithal to do so at the student level is an important first step.
As you know, health care is opening to a world of opportunities, as we’ve seen sweeping changes unlike any other in the last five decades. Social, political, economic, and technological trends form a “perfect storm.” Today’s nurses are trailblazing new roads in the profession, as they adopt different roles and operate in nontraditional workplace settings.
Nurses today still care for patients, but they must also provide it in the right manner, at the right time, and in the right place. Health care organizations still seek to provide the best patient experience, but they also must cut costs, boost outcomes, and ensure safety. There is growing demand for registered nurses, both in and outside hospital doors, that demands caretakers develop a new skillset and a new mindset. Below are five ways that demonstrate how nursing has morphed and shape-shifted recently, and how nurses can make the most of tomorrow’s opportunities.
Trend #1: Jobs are moving outside of hospitals.
Inpatient units—and sometimes whole hospitals—are being closed and patients are being moved into alternative settings, such as long-term care, rehab, and subacute care facilities. Case in point: Experts estimate that today 65% of health care services are delivered in ambulatory settings, rather than hospitals. That transition from inpatient to ambulatory care settings occurred slowly over the past decade.
Why the switch? The Patient Protection and Affordable Care Act of 2010 was a major factor that hastened what hospitals were already doing: offering services outside their doors. Health care organizations want to cut down on admissions (and re-admissions), and they seek to do that by pumping up preventive care and caring for patients at home, or on an outpatient and community basis.
Andrea Higham leads Johnson & Johnson’s Campaign for Nursing’s Future, launched in 2002 to recruit and retain more nurses and nursing faculty, including minority, male, and other underrepresented groups. “Nursing is at a very exciting time, and nurses are on the frontline of health care, providing delivery of care across the board,” says Higham. “So many people are entering health care because of a confluence of so many forces, such as the Affordable Care Act and an aging population. Nurses are working not just in hospitals, but also in home health care, at clinics, as advanced practice nurses, and managing the entire health care journey. There’s a strong need for nurses in many places outside of the traditional health care setting.”
Think about opportunities outside of the hospital. For example, if you’re interested in pediatrics or working with adolescents, consider openings in pediatric long-term care, pediatric home care, pediatric rehab, or at group homes for children or teens.
According to Phyllis Quinlan, PhD, RN-BC, president of MFW Consultants to Professionals and a nursing coach, nontraditional settings, such as subacute care, are fine places to practice if applicants can overcome their preconceptions. “Long ago and far away, it was considered grandma’s nursing home, but now it’s a combination of residential care and short-term rehabilitation. It could even include pediatric or non-geriatric care,” she explains. “Hospitals are shutting down med-surg floors, and shifting patients to other, lower-cost venues for treatment. Say someone falls and breaks a hip—now they have to learn how to walk with that new hip. That’s when they need bridge care—skilled care, rehabilitation, nursing care—until they can go back home. It’s not about disease care anymore, but about preventative care and home care for managing diseases today. Hospitals soon will be only for emergency care, cardiac care, burns, traumatic injury, [and] cancer centers.”
In addition, health care organizations within the private, government, and nonprofit sectors also need qualified registered nurse candidates to fill the high demand for traditional and alternative roles.
Trend #2: New or returning nurses must develop job-search savvy and resolve to land coveted hospital positions.
“For those new graduates hoping for good med-surg experience after nursing school but can’t get a job in a hospital, don’t despair,” says Quinlan, even though hospitals have adopted stringent nurse recruiting requirements and sought to cut costs in every way without compromising care.
“Most urban area hospitals aren’t hiring, but in other areas, that’s not the case,” she explains, suggesting that new grads and nurses with some experience apply for residency or internship programs to “fast track” their careers with intensive preparation for 12 to 18 months.
“Some health care systems are rich with nursing training resources, others do it but in a more conventional way,” she adds. Another way to get your foot in the door at a hospital: “Move to [an] area where they are hiring. The State of Texas is hiring new nurses, and other states are recruiting nurses to serve a special need or a growing population.”
Nurses who are open to filling short-term temp assignments also have a leg up on other candidates; hospitals are offering six-month contracts rather than making long-term commitments they may not be able to honor.
Trend #3: Nurses must further education, clinical skills, and knowledge to keep up with complexities.
Once, a two-year associate’s program could prepare a nurse for a secure and fulfilling career. Not anymore. “Most places now will hire a nurse with an associate’s degree but ask that she sign a hiring agreement to get a baccalaureate within five years or so,” says Quinlan. “Across the 50 states, the culture varies, but independent facilities and major health systems tell me ‘we’ll only hire baccalaureate-trained nurses,’ so you need to make your peace with the fact that the minimum preparation for practice is now a bachelor’s in nursing.”
The other source of tidal change is digital technology and big data, which make it possible for nurses to do more with their expertise and deliver care from practically any corner of the world, while enjoying the advantages of telecommuting, like other professions.
“Technology allows nurses to practice off the beaten path in more ways than ever before,” says Brittney Wilson, RN, BSN, also known as The Nerdy Nurse. “With jobs like remote case management, telephone triage, and even informatics consulting, nurses can use the clinical knowledge and technical skills to help patients from the comfort of their home.
“Opportunities to work from home and attend to patient care needs virtually do come with a price,” adds Wilson, who is a nurse expert with experience as a clinical informatics nurse. “You have to have above-average computer skills and must be able to learn new software quickly.”
There’s a big need for nurses who have a business background. Traditional nursing programs do not address business aspects of health care. Nurses who go on for a master’s degree in business administration or health administration will understand policies and procedures that are governing health care now.
Trend #4: Nurses must focus on their own personal and career development to progress in the profession.
Clinical and other technical skills are important for any nurse to develop, but so are “soft skills”—for example, effective communication and problem-solving know-how.
“New to nursing? Maybe you have great ideas, but maybe you’re missing skills in how to talk to a patient or family members or how to collaborate with others,” says Higham. “You can always access our avatar-based online program, Your Future in Nursing, on the Campaign’s website.” The cutting-edge format, a game-like simulation environment for practicing key on-the-job concepts and skills, helps a student nurse prepare to make the often tough transition to practicing nurse.
Accelerating change in the health care workplace may require that new and seasoned nurses adjust their attitude and become more flexible about new ways of doing things. According to Quinlan, author of the recently published Rediscover the Joy of Being A Nurse: A Holistic Approach to Recovery from Compassion Fatigue, there’s no point in lamenting the good old days. “Nurses are some of the most creative people on the planet; they’ll make something out of nothing on a daily basis,” she says. “Some feel that they’re expected to adjust instantly to changing conditions and expectations, and they resent it. Those nurses must make peace with the new health care environment, themselves, and their profession.”
Until then, “they’re at a crossroads, and risk starting to swing to the dark side, having lost connection with the joy of practicing,” Quinlan adds.
Trend #5: Nurses will take on expanded and pivotal roles as part of tomorrow’s health care team.
How will we prepare nurses to transition to these advanced practice roles? That question has long been central for Donna Tanzi, MPS, RN-BC, NE-BC, director of nursing education and innovation at North Shore-LIJ Huntington Hospital in New York. “Nurses are going into master’s programs early on in their careers—after getting a baccalaureate, they’re going straight into a master’s or even doctoral degrees,” she says. “They have less clinical experience prior to getting an advanced degree, so we have an obligation as a profession to support them. Entry to DNP takes seven years from entry to graduation, similar to the medical model.”
Tanzi recommends nurse residency programs or fellowship programs for an extensive, tiered approach as students make the transition into their complex new roles.
“Nurses were tending to leave a job in the first year, or to leave nursing totally, because they weren’t prepared for the demands of the role,” she explains. “The bottom line and the message that I want to get out there is go into nursing for the right reasons. Recognize it’s an art and a science and we have the ability to impact people’s lives every day. Continue learning—there [are] always new directions and avenues to explore. There’s no reason to ever become stagnate or get bored in nursing; there are too many opportunities.”
There are many areas where advanced practice nurses apply their expertise gained through a master’s (or increasingly, a doctorate) in nursing or a related field. Clinical nurse practitioners are opening independent practices, or working with an academic affiliation in hospitals, or affiliated with physicians in their practices. Administrative leadership roles usually call for an MBA or MHA. Demand for nurses continues, so we need nurses to teach in nursing schools. At a minimum, instructors must have a master’s in nursing or in nursing education. Entrepreneurship, consulting, and research and development are also growth areas for advanced practice nurses.
Everywhere we look, nurses are being called on to surf the tidal waves of a changing health care environment and the emerging opportunities that come forth from it. Tomorrow’s nurses, with the right technical skills and personal qualities, can look forward to a rewarding career where they can deliver even greater value to their patients and communities.
Photo courtesy of Johnson & Johnson
It is an enviable opportunity to provide healing services to a country in need by combining a fairly large, diverse, multidisciplined medical team. Three nurses on missions did just that, and in the process, they saw that one person can make a difference. They share their experiences in the Dominican Republic (DR), Haiti, Kenya, and Uganda here in the hopes of inspiring others to do the same.
Marie Etienne, PhD, MSN, with Haitian children
The Haitian and Dominican cane cutters and their families in the Dominican Republic are spread over some 350 bateyes (cane-cutting communities). They were in dire need of access to health care—and Marie Etienne, PhD, MSN, a professor of nursing at Miami Dade College, responded.
Etienne, who was born in Haiti, came to the United States at the age of 14. From her youth, she has seen herself as a servant leader and believed a career in nursing would provide opportunities to fulfill her aspirations. She has been a member of the Haitian American Nurses Association of Florida (HANA) and served as president from 2005 to 2007.
Today, she serves as the chairperson of the International Nursing Committee of the Red Cross. In 2005, an attorney and member of the Miami Haitian community visited the bateyes in the DR, and when he returned, he told her that he had seen living conditions of the migrant workers and they were être traités comme des esclaves (being treated as slaves), with no access to health care. He suggested that HANA do something to shine a light on the conditions in the bateyes and devise ways to help the workers and their families. Etienne took the findings of the attorney to the Haitian American Professionals Coalition (HAPC) and obtained support to conduct a needs assessment of the situation. One of the objectives of the HAPC is to examine and address issues affecting Haitians in the United States and abroad.
“We went on the first mission trip to the DR in 2005 to assess the need and take care of the people in the bateyes,” recalls Etienne. The team saw over 1,000 patients in the week they were there and realized the level of need was so great that they decided to do two medical missions each year.
Haitian cane cutters in the DR are not recognized as citizens, and children born in the country do not receive birth certificates. The sugar cane farming sector of the DR depends fundamentally on Haitian migrants, who represent 90% of the labor force in sugar cane cutting and are paid $1 per day.
The team, once assembled, included a diverse blend of medical and health care competencies and others who offered their availability in a supporting role. “But in 2006, I decided that we needed to get nursing students involved because there are certain things you can teach students in the classroom and certain things you can’t,” explains Etienne.
She received the support and participation of the college’s administration and trustees, who quickly approved and funded the project. “As a professor, I inaugurated this project as part of the students’ learning activity to get them engaged and to give back to the community so they may become global citizens and in the process enhance their cultural competence,” she says.
Twelve nursing students from the associate’s degree program were added to the team. The team travelled to the DR to do a one-week mission trip twice each year from 2006 to 2009—each time serving some 1,200 patients ranging from children to the elderly with a wide spread of medical and health conditions.
In 2010, an earthquake struck Haiti, killing over 200,000 people, and the mission’s focus shifted to Haiti. “Our attention turned to the needs in Haiti as relief efforts, and other nurses who were members of the [National Black Nurses Association] came together to share in the relief response treating wounds, stabilizing the injured, triaging patients according to symptoms, and whatever else was necessary,” says Etienne. “I went to Haiti about five times that year going back and forth. I also went to one of the universities to teach the nursing students basic skills and show how they can be empowered to take care of their own country.”
In 2012, the team was asked back to the DR because the health care needs persisted and the living conditions were deplorable. The people in the bateyes were doing their level best by any means necessary to survive, but the team decided not to go back in 2013 because the DR Supreme Court had ruled that the government could proceed to deport all persons who are in the country illegally, and that put a lot of fear into the workers needing health care.
Many Haitians arrive in the DR through open borders without legal documents and stay in the country this way. The living conditions of these communities are extremely poor, and immigrants generally live in impoverished barracks that have no electricity, no basic sewage services, and no potable water. There are no health services, recreational spaces, or schools. The workers work 12 hours per day on average and face the threat of deportation when they attempt to organize to obtain basic rights. “As the impact of the Supreme Court’s decision began to be felt, violence subsequently broke out and, for the sake of the students, I could not take them there that year,” Etienne explains.
On their visits, the U.S. team partnered with the Universidad Central del Este, which assigned 50 medical students for a week. They gave one rotation in the morning and one in the evening to work with Miami Dade College students. “We were assigned a primary school in one of the towns outside Santo Domingo, the capital, where we set up the clinic,” says Etienne. “We had registration in one area, a room for triage, and vital signs in another area. Then we sent the patients to see the primary care doctor, or the PA, and then they went to pharmacy, where all the medications were donated by U.S. Catholic charities and others. We designed a pediatric area, and it had balloons, coloring books, toys, and games just to make the children comfortable where we did play therapy. And for the elderly, we would triage them by themselves, keeping them hydrated so they can see the primary.
“Some have asked us if we feel like we are putting a Band-Aid on the conditions of people’s lives in the bateyes. I would explain that our purpose of going there was so we could save lives. One of the patients had a seizure, and if we were not there he would have died. Another had an asthma attack, and because of the ventilator machine we brought along with the administration of some albuterol and follow-up care, that patient recovered. We feel we are saving lives and making an impact. The people know that someone cares about them and that they are not forgotten,” says Etienne.
“God puts us here to serve other people, and if we can put a smile on someone else’s face—if we can change someone’s life—we should not think twice about it,” she says emphatically.
Sharon Smith, PhD, with Maasai tribesman
At the tender age of eight, Sharon Smith, PhD, believed that one day she would be a missionary. She knew she would go to Africa and serve in some capacity, but she never really knew how that would happen. “I just figured it would somehow come through my interest in health care,” she explains. As a young person, her aspiration was to be an oral surgeon, but she knew she would not like some of the situations she would see, so she chose nursing. She is currently a nurse practitioner at the Family Health Centers of San Diego.
“Nursing offered me more career flexibility. My roles as a nurse just fit my personality, so I am glad I chose nursing instead,” says Smith. “I didn’t know I would go to Kenya, but that is where I landed, and I have really enjoyed the connections and my experience working with the people there. That is what kept me going back.”
Smith’s first trip to Kenya was in 2006 with 12 members of a Pentecostal church group out of Carlsbad, California. A physician friend was unable to go and suggested that she go instead. Since then, she has been back twice on her own. Nairobi served as the primary hub on each visit, but on her first visit she went to the town of North Kinangop, about a two-hour drive from Nairobi, the capital.
She also visited the town of Tumutumu and spent time doing crafts with the children in a home for the deaf and hearing impaired. This was possible because the group from California included a young woman who could sign. The home for the deaf was adjacent to the Tumutumu Hospital, which provides care to approximately 3,000 inpatients and more than 16,000 outpatients each year. Tumutumu Hospital is one of the three mission hospitals in Kenya sponsored by the Presbyterian Church of East Africa (PCEA). Smith and her team came with hospital supplies that they delivered to the staff. The hospital had a large HIV clinic, and while the children waited on their parents, they were provided with school supplies and toys as gifts from Smith and her team.
As the visitors toured the hospital wards (floors), they were exposed to the differences between nursing practices in Kenya and the United States. They saw how much was lacking by way of resources and training. In a ward, there would be a patient with pneumonia next to a surgical patient with an open wound, who may be next to a patient with HIV. There was no segregation based on medical condition. In the pediatric ward, however, three or four rooms were set aside for preemies or small children who were intubated or on ventilators. Smith says that at this hospital there were one or two experienced nurses, but all the work was done by student nurses from the PCEA Tumutumu Nursing School. “They ran the hospital with the number of beds at about almost 200, inclusive of the maternity ward. There was no ICU, however,” she explains.
On her third trip to Kenya in 2010, Smith, who was at that time one of two nurse practitioners in the U.S. team of eight, visited an orphanage of 250 children and did physicals on over 100 of them, from newborns up through teenagers. This provided the orphanage with the children’s first medical records. While on this trip, Smith also had an opportunity to work with some of the nurses of Kenya on a very large, day-long health expo in the Maasai village. They performed health screenings, vaccinations, physicals, oral examinations and extractions, working alongside physicians and dentists from Kenya.
Smith did have an opportunity to see up close the delivery of care inside a hospital in Nairobi after a dog bit a member of the U.S. team and required medical attention. Her assessment is that the hospital provided care comparable to that found in most U.S. hospitals. “My focus and concern was, however, the care delivered by the rural hospitals,” she says.
For Kenyans, Smith is the sister returning home, so they go through the villages and alert the community that “our sister is coming home.” “They plan for my arrival ahead of time,” she says, “and I am planning my return in 2016.”
Angela Allen, PhD, with the head nurse at a Uganda hospital
Raised by her community-minded grandmother, Angela Allen, PhD, took her mission trips to Uganda with concern for both the physical and spiritual well-being of the people of Uganda. The Detroit native received her doctorate from Arizona State University with a focus on geriatric and dementia patients, and now she is the clinical research program director with the Banner Alzheimer’s Institute in Phoenix, Arizona.
Allen visited Uganda in 2010 and 2012 for periods up to three weeks each visit. Her visits allowed her to interact with the elderly who might have some form of cognitive impairment. What she uncovered was that cognitive impairment was less of a concern than physical impairment, which prevented the people in the community from caring for themselves. Even though she had gone with a religious purpose sponsored by the Church of God in Christ, Allen did have an opportunity to do research in an area of interest to her. Virtually all of the team’s time was spent in towns like Jinja, a town of approximately 70,000 people and a two and half hour’s drive from the capital, Kampala.
The team fully identified themselves with the Ugandans they sought to reach by sleeping in their huts and immersing themselves into the life and rhythm of the communities. “The people were hungry for knowledge more so than food, so I taught them, spending time with the women to help them develop a sense of community and even preached to them,” Allen says. “I was well received because, after my first visit to the hospital in Hoima, I was invited back by the hospital. So, I took what I had learned from the qualitative observations I had conducted and returned in 2012 as part of a team of 25 people and a fully developed plan, including a full curriculum for the nursing students.”
Allen’s plan included addressing the needs of adolescents, especially girls, who needed to hear that they were appreciated and acknowledged as persons of value. With the help of town officials, she recruited young girls and, using an interpreter, exposed exposed them to two days of instruction on self-esteem and self-pride.
She also worked on securing hospital supplies through Project C.U.R.E. (Commission on Urgent Relief and Equipment) in Phoenix, as well as surplus supplies from hospitals where she had worked in the past. These filled several crates that were presented to the hospital in Hoima.
Lastly, Allen sought to teach a two-day class to the nurses, but in the process she realized that the level of training the nurses had received was comparable to the training provided to nursing assistants in the United States. Her observations of the accommodations provided to the patients was comparable to those Smith observed in Kenya (e.g., patients were not segregated by medical condition in the wards).
“This was a life-changing experience for me,” says Allen. “I never imagined that this visit to the continent of Africa would affect me so much. It was a very emotional experience because the need is so great. I reaffirmed that my purpose in life is to help others.”
From electronic health records (EHRs) to smartphone apps, today’s health IT tools can help nurses develop innovative strategies for closing the gap of racial and ethnic health disparities.
One of the top priorities of President Obama’s Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 is to reduce health disparities—such as disproportionately high rates of chronic diseases in racial and ethnic minority populations—through the “meaningful use” of EHR technology. Seven years after the passage of HITECH, how much progress have we made toward achieving that goal?
In the 2013 report Understanding the Impact of Health IT in Underserved Communities and Those with Health Disparities, the U.S. Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) showcases many innovative examples of how health care providers nationwide are using EHRs, as well as other types of health IT, to increase access to care and improve health outcomes in communities of color. From the rural Mississippi Delta to immigrant and low-income communities in large metropolitan areas, “health IT offers promising tools to address chronic diseases by facilitating the continuity of care and long-term follow-up needed for successful management of these conditions,” the report concludes.
That, of course, is where nurses come in. Take a close look at successful model programs that are deploying health IT to help close the gap of unequal health outcomes and you’ll see nurses—including hospital and clinic RNs, nurse practitioners, informatics nurses, case management nurses, nurse researchers, and more—playing leadership roles.
“Nurses are coordinators of care for patients. We’re typically the first person they see when they seek health care,” says Joyce Sensmeier, MS, RN-BC, CPHIMS, FAAN, vice president of informatics at HIMSS. “It’s really a natural extension of the nurse’s role with patients to connect the dots from the information technology side.”
For most nurses, health IT begins with the EHR. This essential platform enables them to instantly access a patient’s complete health record, document patient data in real time, monitor changes in the patient’s condition, and use clinical decision support tools—such as computerized alerts—to respond to those changes. But increasingly, nurses are also waging war against health inequities by arming themselves with an arsenal of other high-tech tools, including the following:
• patient portal websites, which give patients convenient access to their personal health information and enhance communication between clinicians and patients;
• health information exchanges, which allow patient data to be securely shared between different providers—such as hospitals, ERs, and primary care providers—to improve continuity of care;
• wireless and mobile health (mHealth) technologies, such as smartphone apps and text messaging;
• external databases, such as state and national disease registries and immunization registries, that collect clinical information about specialized populations of patients across a large geographic area; and
• population management software (PMS) systems, which help nurses track health trends among specific groups of patients they care for—for example, pediatric patients, or patients with diabetes.
Seeing the Bigger Picture
For nurses who are working to improve minority health outcomes, one of the biggest advantages of using health IT is that these tools make it easier than ever before to capture, compare, and analyze patient data. And that translates into unprecedented opportunities for leveraging that data to better manage the needs of patients with chronic illnesses, identify gaps in care, and develop targeted interventions.
“Clinicians have always been information workers,” says David Hunt, MD, FACS, medical director of patient safety and health IT adoption at the ONC. “It’s just that so often we’re focused on that one patient, that one chart. IT tools give you the ability to step back and look across groups of patients to really get insight into how to make care better.”
In other words, these technologies maximize nurses’ ability to address health disparities from a population health perspective. You can “slice and dice” the data stored in the EHR to classify and group patients in many different ways—for example, by race, ethnicity, age, and gender. Nurses can also zero in on patients who have particular conditions—such as heart failure, asthma, or HIV—to generate condition-specific reports and action plans, says Wanda Govan-Jenkins, DNP, MS, MBA, RN, lead nurse informaticist for the ONC.
“You can look at the EHR and extract these groups of patients to see which patients’ blood pressure was elevated at their last visit, or which patient hasn’t been seen for a while,” she explains.
Patient portals are another vehicle for communicating chronic disease management reminders to whole populations of patients, adds Lisa Oldham, PhD, RN, NE-BC, FABC, vice president of practice operations and chief nursing officer at the Institute for Family Health, which provides care to medically underserved communities at multiple facilities in New York City and state. The institute’s portal, MyChart MyHealth, is available in both English and Spanish (MiRecord MiSalud).
“We can create an electronic letter for the entire organization’s patients who fall into a specific category and send it to them through the portal,” Oldham says. “The patient will get an e-mail that says, ‘Please go into your MyChart,’ and that’s where they’ll see the letter. For instance, we just sent out an e-mail blast to all our geriatric patients reminding them to come in for their annual wellness visit.”
At the Cherokee Indian Hospital (CIH) in North Carolina, a tribal health system that serves more than 14,000 members of the Eastern Band of the Cherokee Indians, care management nurses develop outreach campaigns using the hospital’s PMS, which works in conjunction with the EHR.
“By pulling data out of these platforms, our nurses can target in and pinpoint things like how many people need to get a colorectal cancer screening or a Pap test,” says Sonya Wachacha, MHS, RN, CCM, executive director of nursing at CIH. “Then the nurse generates a reminder letter to that person, such as ‘Mrs. Smith, it looks like you’re due for your mammogram. Can you please come in and get that done?’”
On an even larger scale, says Hunt, “disease registries are wonderful resources, because you can identify characteristics and trends that you don’t have insight into when you’re just looking at a group of patients within your own practice. Having the benefit of looking at large amounts of data from many, many providers gives you tremendous insight in terms of being able to infer more information about your patient population.”
Educate, Engage, Empower
Nurses are also finding that consumer-driven health IT tools, like patient portals and mHealth technology, can offer exciting new ways to help patients who are living with chronic diseases become better educated about their conditions, more engaged with their treatment, and more empowered to self-manage their own health.
Patients can log into their care provider’s portal and access disease management educational materials, which health systems can tailor to meet the needs of limited-English-speaking and low-literacy patients. For example, the Institute for Family Health’s portal has links to patient education resources in more than 40 languages.
At the Institute’s Ellenville Family Health Center in Ellenville, New York, a rural community with one of the highest poverty levels in the state, “the most prevalent disease processes in our patient population are diabetes and cardiovascular problems,” says staff nurse Santiago Diaz, RN. “The portal has information specifically for these patients. We walk them through the basics of where to find the information, and we show them the shortcuts so that they don’t get lost in all the information that’s up there.”
Because nearly everybody today seems to have a smartphone or cellphone, these devices can help nurses connect with hard-to-reach populations, such as young people. Jo-Ann Eastwood, PhD, RN, CCNS, CCRN, associate professor and advanced practice program director at UCLA School of Nursing, recently conducted a research study that used custom-designed smartphone apps to teach young African American women who were at high risk for heart disease how to make heart-healthy lifestyle changes.
“When we look at chronic disease prevention in minority populations,” she says, “we have to look at the population that’s between 25 and 45 years old, or even younger. If we’re going to develop prevention strategies that are relevant to this population that is very technologically astute, that is fast-moving, that is busy, we have to hit them where it’s salient.”
Govan-Jenkins, who is also a professor of informatics in the graduate program at Walden University School of Nursing, recommends teaching patients how to download and use the many free or low-cost mobile apps that are available in the consumer health marketplace. For instance, there are diabetes management apps that let patients monitor their blood glucose levels and upload that data to their patient portal for nurses to track.
“Patients who have smartphones or mobile devices can download continuous self-monitoring apps that let them see things like how many steps they took that day and how many calories they burned,” Govan-Jenkins continues. “The nurse can also send weekly or monthly text messages to condition-specific groups of patients, such as reminding them to take their medication.”
Ultimately, Wachacha believes, being able to interact with their own health data and personally follow their progress toward meeting their health improvement goals can make a big difference in engaging patients to take a more active part in their care.
“With our EHR, we can create graphs that let patients see how their blood sugar or blood pressure readings are going up or down over time,” she says. “When our tribal members who have diabetes, for example, can look at that graph and see that their A1C levels are going down after they start exercising, it’s meaningful for them. It gets them motivated to do more with their care, because they can see that the things they’ve done are having an impact on their results.”
Reaching Across Barriers
According to the ONC report, health care providers must find solutions for overcoming “challenges and barriers to the use of health IT” in medically underserved communities of color. Some of those challenges include limited access to Internet service and cellphone connectivity in underdeveloped rural areas, cultural and linguistic differences, and low rates of technology literacy among these patients.
Telehealth remote monitoring systems (software-based IT tools that let nurses collect data via a device they install in the patient’s home) are an effective strategy for reaching patients in rural communities who don’t have access to computers, says LaVerne Perlie, MSN, RN, senior nurse consultant at the ONC.
At the initial home visit, telehealth nurses show patients how to record their health information, such as blood pressure readings, and enter those numbers into the system. “That data is sent directly to the nurse in the provider’s office so that he or she knows when to come out and visit the patient and make recommendations for ongoing care, such as scheduling an office visit or even a hospital admission,” Perlie explains.
As members of the nation’s most trusted profession, nurses are ideally suited to educate patients who are unfamiliar or uncomfortable with technology about how to use health IT tools and become more computer-literate.
At Institute for Family Health facilities, patients receive information about MyChart MyHealth as soon as they walk in the door. In the examination room, says Oldham, nurses explain how the portal works and the benefits of using it. They answer any questions the patient has. Then they help patients register for the portal right there, guiding them through the process of how to log in, create a correctly formatted password, and navigate the website. For patients who don’t have a computer at home, “we encourage them to use the computers at the public library [or to download the MyChart MyHealth mobile app to their smartphone if they have one],” adds Diaz.
Still, another challenge cited in the Understanding the Impact of Health IT report is that “customization of off-the-shelf health IT products often necessary to ensure that they [meet] the needs of underserved populations.” For example, the Cherokee Indian Hospital serves a patient population that has a high risk for suicide, substance abuse, and tobacco use. Because its EHR and PMS didn’t include functions for monitoring these risks, the hospital had to add them.
Hunt and Perlie emphasize that the best way hospitals can make sure their investment in technology will provide information that’s the right fit for their population health management needs is to get nurses involved in the design of health IT systems right from the start—before the technology is implemented. Many health IT projects fail, Govan-Jenkins cautions, because the implementation team didn’t seek input from frontline nursing staff. “And then they had to rebuild and re-implement the system, because it was just not capturing the data they needed to capture for their specific type of patients.”
That, says Sensmeier, is what reducing health disparities through the meaningful use of health IT is really all about. “It’s not just about adopting the technology. It’s about using it in such a way that we can capture the data that’s been entered and learn from it—learn what makes an impact in different patient populations, what care models and treatments work, what outcomes are being realized, and how we can change our practice.”
Tears build behind your eyes. Your mind plays over and over how much you want to turn and run, but you can’t. No matter what, you have to keep going because you are strong and people are relying on you. How can you endure it, though, when one part of you wants to scream and one part of you wants to break down and sob? You can do neither, and instead, you hold yourself as taut as a wire over the Grand Canyon.
You are in the elevator on your way up to your unit. Your shift hasn’t started yet, but these feelings are already invading your mind, spreading like tree roots into concrete. It will be worse once you are there, but nurses don’t crack. Nurses don’t break down. They get used to it. Except you can’t get used to it. It is killing you.
You are a nurse with clinical depression, and no one knows—not even you.
Depression is an epidemic in nursing, but no one will talk about it. According to the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), nurses experience clinical depression at twice the rate of the general public. Depression affects 9% of everyday citizens, but 18% of nurses experience symptoms of depression.
If this is such a common occurrence, why don’t nurses talk about it? They are afraid that they will not be trusted with patients and they will not be part of the team. Some of them cannot accept that they need care when they have always been in the caring role. Unfortunately, many nurses just don’t know they have it.
Causes of Nurse Depression
Since depression is so common in nursing, what is causing these men and women to feel this way? The fact that it is ignored is almost inconsequential when you consider the fact that the causes are also ignored. If the causes of this epidemic are not addressed, more nurses will become depressed, patients may be put in danger, and the profession could wind up losing yet another nurse to the stresses of the job.
“Medicine is a profession that doesn’t give much thought to mental illness,” says John M. Grohol, PsyD, the founder, CEO, and editor-in-chief of PsychCentral.com. “It is not within their realm of treatment.” Since medicine is concerned with what it can see, touch, and heal, mental health concerns are often shunted to the side. Nurses not only dismiss the idea of depression in their profession, but they also do it to themselves. This only causes the feelings to multiply.
It also doesn’t help that nursing culture is ruthless by nature.
“Depression is like a cardiac disease: you don’t know you have it. You don’t realize the subtleties,” says Louise Weadock, MPH, RN, the founder and president/CEO of ACCESS Healthcare Services. “Leaders need to create a culture that lifts nurses up. It shouldn’t be a culture in which only the strong survive. Nurses should not be proud of eating their young. Some managers brag, ‘If you can make it on my floor, you can make it anywhere.’”
The culture of survival leads nurses to feeling like they are always under tension—and this can cause anxiety, stress, and depression. Some nurses seem to take great pride in the amount of horrors they have endured, but for those who struggle with depression, living up to this standard and living in the culture only makes them feel like failures.
What are the evidence-based predisposing characteristics of depression, besides culture and neglect? The INQRI study found that certain factors, such as body mass index, job satisfaction, and mental well-being, can lead to clinical depression in nurses.
Furthermore, family problems can exacerbate the stresses a nurse feels, and often nurses feel out of control. They can’t control their shift, their patient load, or even if a patient lives or dies. Helplessness is a feeling that pervades the depressed nurse. When all of these causative factors are coupled with the disruptive cycle of shift work, can depression be far behind?
What does clinical depression look like in nurses? All nurses have covered mental health in their schooling and some work on mental health units. It is safe to say that most nurses know the general symptoms of depression, but it is far more subtle than what they were taught. In nurses, the symptoms are nearly buried under a continuously thwarted attempt to hide their feelings.
Guy Winch, PhD, a licensed psychologist and TED speaker, describes the different nuances in sadness and depression on the Squeaky Wheel blog at PsychologyToday.com:
“Sadness is usually triggered by a difficult, hurtful, challenging, or disappointing event, experience, or situation. … [but] when that something changes, when our emotional hurt fades, when we’ve adjusted or gotten over the loss or disappointment, our sadness remits. … Depression is an abnormal emotional state, a mental illness that affects our thinking, emotions, perceptions, and behaviors in pervasive and chronic ways. … Depression does not necessarily require a difficult event or situation, a loss, or a change of circumstance as a trigger. In fact, it often occurs in the absence of any such triggers.”
Nurses often feel this way as well, but other factors and symptoms appear. “Nurses deal with depression by doing more, keep moving, not standing still, not putting their feelings into words,” says Michael Brustein, PsyD. “They power through it.”
Blake LeVine, MSW, founder of BipolarOnline.com, also makes this point about nurse culture and the medical status quo in general: “There is more detachment in medical professionals who are depressed. It is normal to be slightly detached. When a nurse is depressed, they can also become more detached with their family. They are used to being detached, but they can’t bring it home and cry over people [who] are sick. Depressed nurses may cry more over a patient who died. They may get very emotional. Something they used to deal with in the past can get more difficult for them.”
Of course, this need for detachment and getting past the pain can lead to self-medicating. Usually, that takes the form of alcohol or opiates—both downers that can make depression worse.
“All studies show that those with substance abuse problems have depression or anxiety,” states Nikki Martinez, PsyD, LCPC, a verified mental health counselor on BetterHelp.com. “Prescription drug problems are often present, and that becomes their drug of choice. Just take a pill, and the pain is gone. When a nurse is having a bad day, they can’t wait to come home and have a glass of wine.”
In addition to various negative coping mechanisms, nurses exhibit many other symptoms that are obvious to those looking in on the situation. Weadock explains them this way: “Nurses can experience difficulty concentrating, are slow to respond in a crisis, are accident-prone, and have a limited ability to perform mental tasks, such as care mapping, calculating doses, or intervals required for biometric interpretations. They are reclusive with poor interpersonal skills, struggle with time management, and have lower total productivity outcomes than nondepressed workers. They often have a ‘short-fuse,’ leading to explosive outbursts toward patient, family, or coworkers.”
Stigma against Mental Illness
Nurses are usually willing to talk about the problems in the profession, such as short staffing, poor ratios, and lack of managerial support. However, what they are not willing to talk about is depression and mental illness in their ranks. It is arguably nursing’s best kept secret. Eighteen percent of nurses are suffering from some form of clinical depression—and no one will talk about their experiences with it, what to do about it, or what causes it. What is behind this stigma?
Grohol breaks down the problem by focusing on the two parts of stigma: prejudice and discrimination. “There is a great deal of misinformation and misunderstanding of what depression is,” he explains. “Many in the medical profession hold antiquated beliefs about mental illness, such as the condition was brought upon the self. Nurses are taught not to complain about it, and this is why they don’t talk about it.”
Then, nurses must deal with discrimination when they are found out. “Discrimination comes about when people with mental illness see nurses talking about those who have other medical issues, and don’t want things said about them,” Grohol continues. “Nurses would assign a person a label and boil down their personality to one word, and that is insulting and discriminatory.”
A primal aspect comes into this discrimination, as well. Nurses, for lack of a better reference, are a “band of brothers.” If you suspect the nurse beside you can’t handle the pressures, then you tend not to trust them.
Weadock has experienced this. “I don’t think nurse leadership or the workforce sees depressed nurses. When they perceive some sort of injury, then they throw the nurse out of the wolf pack. When you backslide into your disorder, that’s when people don’t know whether to trust you.”
The stigma has become so bad that many depressed nurses fear for their jobs. “Nurses know that admitting a mental health problem puts their job at risk,” says LeVine. “People are scared to admit it. That’s when mistakes happen. Get treated. Nurses feel they have to hide it to protect their jobs, but a nurse that seeks help for depression ends up a better and stronger nurse. Those who seek help have more longevity in their career.”
Psychologically, the prospect of losing everything rewarding about nursing is scary, and LeVine cites that as a reason for keeping quiet. “The hard part of admitting to depression is that nursing is a good paying job and losing it is hard. You are on a big team as a nurse. When you can’t do that anymore, you lose that sense of team. It is hard to give that up. Therapy means you can work on that and possibly avoid leaving the profession.”
One of the most prominent reasons for nurses to keep quiet about their mental health is the stigma associated with an “unhealthy” caregiver. Martinez describes it this way: “Nurses feel they need to be perfect and healthy at all times. It is just not possible when they are doing so much for someone else. Mental health professionals realize that this is a huge problem. Openly talking about it is the only way to break the cycle, but no one talks about it. When they do talk about it, it takes away stigma and shame.”
For these reasons and more, many nurses are living with depression in silence—afraid for their jobs, afraid that they are weak, and ignoring their own health in favor of others. In addition to education, treatment for nurses specifically is important for recovery and retention.
Self-Care and Treatment for Nurses
Nearly all experts agree that education is the primary method to get nurses treated for depression. This means educating management on what to look for, and for nurses to know the symptoms to recognize the condition in themselves and others. Sometimes coworkers can see symptoms far better than a manager can. If the stigma is reduced with education and support, those nurses can get the help they need from a team effort.
Weadock suggests that this reform starts with the manager. “A manager should say, ‘I’m going to put you on the bench and help you get better.’ Assignments should be given out just a dose at a time, because you don’t want to ruin the reputation of a good nurse. The nurse can’t help it when they are feeling depressed. Management needs to lift the RN up by promoting them to other suitable, supportive work environments, and to make reasonable accommodations for nurses whose cyclic phase of depression is negatively affecting their work performance.”
After management has identified a struggling nurse, that nurse should be introduced to treatment and encouraged to keep attending. Many nurses terminate their therapy because they think they don’t need it, they don’t feel they should be sick, or they are afraid someone will think they are weak.
“Seek medical treatment with a professional that understands depression,” LeVine suggests. “Find a therapist who understands a nurse’s career and life. Openly assess your situation. Do you need to take a break? If it is all too much, it is okay to do something else. It is better to admit that you are struggling and seek help. It’s like trying to fit a round peg into a square hole.”
What can nurses do when they are in therapy and still working? According to Martinez, it all comes down to self-care. “Nurses often don’t have good self-care. It can be as simple as starting the day off right, instead of waking at the last minute and rushing around. Start off slowly: have some coffee, do meditation or yoga. Do things at the end of the day, too. Have rules with your family that the first half hour after work is for you when you come home.”
Alejandro Chaoul, PhD, is an assistant professor in the integrative medicine program at the University of Texas MD Anderson Cancer Center. Working for a hospital, he often instructs nurses in how to better handle the stresses of their jobs.
“The motivation for nurses is that they feel like they shouldn’t focus on self, but they can focus on how their own mental health can help patients,” Chaoul explains. “We don’t need an excuse to take care of ourselves. It is an important part of being, not just a nurse. We have forgotten this. Showing how busy we are is the way to go. If you tell someone you are happy, it is almost like a sin.”
Nurses are practical, though. Self-care, therapy, and meditation are great ideas, but how is a depressed nurse supposed to handle the rigors of their fluctuating mood while actually working on the floor? One helpful technique is known as grounding. Grounding can be done anywhere, anytime, cannot usually be seen, and can last as long as you need it.
Lisa Najavits, PhD, describes grounding in her book, Seeking Safety: A Treatment Manual for PTSD and Substance Abuse, as follows: “Grounding is a set of simple strategies to detach from emotional pain (for example, drug cravings, self-harm impulses, anger, sadness). Distraction works by focusing outward on the external world—rather than inward toward the self.”
Najavits breaks it down into three categories: physical, mental, and soothing. A physical grounding exercise would comprise breathing in and out, thinking a soothing word on every exhale. A mental grounding exercise would include describing an everyday procedure, such as passing meds, in as much detail as possible. Finally, soothing grounding might be picturing your loved ones—or actually looking at a picture of them. For each type, there are many types of grounding, and these techniques can be learned through therapy.
Although the reasons for nurse depression are multi-factorial, part of the problem is the stigma. With education and a decrease in the antiquated notions of mental health, these nurses could get help. Registered nurses are leaving the profession in droves. Some of those defections are due to injury, but a large part is likely due to undiagnosed or unacknowledged depression. If nurses hope to keep the profession vital and solve such problems as short staffing and poor ratios, they need more nurses to stay working as nurses. Helping, instead of ostracizing, nurses with depression is exactly what nurses need to help solve other problems that they face.