Nursing students with disabilities are increasing in number throughout the United States, thanks in part to the passage of the Americans with Disabilities Act (ADA) in 1990.1 Although exact numbers are unknown, anecdotal reports of students with a wide variety of disabilities, including hearing loss, vision loss, paralysis, chronic illness, learning disabilities and mental illness, are documented in the nursing literature.2-10
The ADA, like the earlier Rehabilitation Act of 1973, was intended to level the playing field. The general mandate of the ADA is for students with disabilities to have the same access to educational programs as students without disabilities. But even though the ADA has been the law of the land for 15 years, many nursing schools continue to struggle with issues relating to admissions policies for students with disabilities, such as core performance standards, essential functions and providing accommodations.
Under the law, entrance requirements cannot include any criteria that would screen or appear to screen for disabilities. The ADA also mandates that educational institutions provide “reasonable accommodation” to individuals with disabilities.
Accommodation only ensures equal access to education; it is not a guarantee of success.
In the case of nursing students, criteria that would identify disabilities prior to admission are not only in violation of the ADA, they have no legitimate purpose. It is unfair to evaluate a nursing applicant in one brief session on his or her ability to perform skills that are intended to be developed over several years. Yet this is precisely what is happening today at all too many of the nation’s schools of nursing.
Jumping to Conclusions
A number of research studies have shown that when nursing educators find themselves caught between the legal requirements of admitting a student with a disability and their perceptions of what it takes to be a safe and competent nurse, the latter concerns often tip the scales toward discriminatory pre-judging of students. Additionally, when administrators and staff nurses are notified that a student with a disability will be part of a clinical group or will require accommodations, they often voice concerns and hold preconceived notions of success or failure before the student even steps onto their floor.
One study found that nearly 60% of nurse educators making admissions decisions “preferred” to assess the applicant’s disability and need for accommodation prior to making a decision as to whether the accommodations were viable or could be provided.11 This is in direct conflict with the mandate of the ADA. Students must be admitted to the program before accommodations are discussed.
The educators in this study failed to recognize that neither they nor the nursing applicant with the disability may know beforehand what accommodations will be needed. Developing accommodations is often an ongoing dynamic–a step-by-step process that evolves and changes as the student faces new experiences in the classroom and clinical settings.
One of the most commonly given reasons for denying admission to a nursing applicant with a disability is concern about patient safety. Even if the student is admitted to the program, faculty and administrators often continue to harbor these concerns. Yet a 2002 study by Sowers and Smith reports that there is no data to suggest that health care professionals with disabilities pose any greater safety risk to patients than those without a disability.12
Furthermore, in many cases nursing programs may be focusing on the physical attributes of some applicants with visible disabilities and be unaware of the “hidden” disabilities of other applicants. For example, students with undisclosed mental health issues may be a risk to patient safety but are admitted to programs without question.
Setting the Wrong Standards
Since the passage of the ADA, many nursing schools have adopted the practice of evaluating applicants with disabilities against a list of “technical standards” or “essential functions” deemed necessary for success in the program. For example, the Southern Regional Education Board’s Council on Collegiate Education for Nursing (CCEN) developed core performance standards for admission and progression, covering such areas as critical thinking, interpersonal skills, communication, mobility, motor skills, hearing, visual and tactile skills.13
In one study, eight nursing programs reported addressing essential functions by describing the physical requirements for each skill. Examples included hand washing techniques, sharps management, isolation techniques, range of motion, transfer and
computation of drug dosages and administration of medications.14
These types of guidelines were developed for nursing education programs to use in complying with the Americans with Disabilities Act. But ironically, they often have the opposite effect: Instead of eliminating barriers to admission for students with disabilities, they create new barriers.
Sowers and Smith argue that using physical attributes such as hearing, visual and communication skills as standards causes students who cannot hear, see or speak to be excluded from nursing programs. Instead, they recommend that essential functions and technical standards more appropriately focus on specific behaviors that nursing students will be expected to perform.
For example, an essential function may be “detecting a heart murmur.” A student who is hard of hearing may be able to detect a heart murmur using an amplified stethoscope and a deaf student may use a stethoscope that provides visual output. These students cannot “hear,” but they can perform the essential function with a reasonable accommodation.
When core performance standards and/or essential functions are used to make admissions decisions, it is all too easy to exclude students with disabilities by making premature assumptions about their skills. At this stage of the process it is very difficult to accurately predict the skills a student may or may not be able to achieve over time. This approach fails to level the playing field for students with disabilities, limits equal access to the educational experience and violates the Americans with Disabilities Act.
A Personal Case Study
References1. Americans with Disabilities Act (1990), Public Law, No. 101-336, 42 U.S.C. 12101 3. Chickadonz, G.H., Beach, E.K. and Fox, J.A. (1983). “Breaking Barriers: Educating a Deaf Nursing Student.” Nursing Health Care, Vol. 4, No. 6, pp. 327-333.4. Creamer, B. (2003). “Wheelchair Fails to Deter Paraplegic from Nurse’s Life.” The Honolulu Advertiser. Available at http://the.honoluluadvertiser.com/article/2003/Dec/28/ln/ln10a.html.5. Eliason, M. (1992). “Nursing Students with Learning Disabilities: Appropriate Accommodations.” Journal of Nursing Education, Vol. 31, No. 8, pp. 375-376. 6. Huyer, S. (2003). “The Gift of ADD.” Advance for Nurse Practitioners, Vol. 11, No. 4, p. 92.7. Kolanko, K. (2003). “A Collective Case Study of Nursing Students with Learning Disabilities.” Nursing Education Perspectives, Vol. 24, No. 5, pp. 251-256.8. Maheady, D. “Jumping Through Hoops, Walking on Eggshells: The Experiences of Nursing Students with Disabilities.” Journal of Nursing Education, Vol. 38, No. 4, pp. 162-170.9. Maheady, D. (2003). Nursing Students with Disabilities: Change the Course. River Edge, N.J.: Exceptional Parent Press.10. Pischke-Winn, K., Andreoli, K. and Halstead, L. (2003). Students with Disabilities: Nursing Education and Practice (Proceedings Manual). Rush University College of Nursing. Available at www.rushu.rush.edu/nursing/studisable.html. 11. Christensen, R.M. (1998). “Nurse Educators’ Attitudes Toward and Decision-Making Related to Applicants with Physical Disabilities.” Journal of Nursing Education, Vol. 37, No. 7, pp. 311-314. 12. Sowers, J.A. and Smith, M. (2002). “Disability as Difference.” Journal of Nursing Education, Vol. 41, No. 8, pp. 331-332.13. Davis, L., Bowlin, L., Futch, K.J. and Hazzard, M. (1993). The Americans with Disabilities Act: Implications for Nursing Education. Recommendations of a task force to the board of directors of the Southern Regional Education Board’s Council on Collegiate Education for Nursing (CCEN). 14. Davidson, S. (1994). “The Americans with Disabilities Act and Essential Functions in Nursing Programs.” Nurse Educator, Vol. 19, No. 2, pp. 31-34.
The following case study illustrates how putting too much emphasis on standards and functions can result in discrimination against students with disabilities. Susan Fleming, one of the authors of this article, was born without a left hand; she wears a prosthetic hand. Susan worked as a nurse’s aide in high school and was passionate in her desire to become a nurse. She completed the prerequisites and applied to a nursing program, where she was given a skills test. This test evaluated skills that a graduate nurse would be expected to perform, such as mixing IV fluids, giving injections and donning sterile gloves.
Susan was denied admission to the program because she was unable to demonstrate some of the skills on the test. She was told that she would “endanger a patient’s life.” This test was created exclusively for her and was not administered to any other applicants. This constitutes singling out of certain students for “special testing” and discriminates against applicants with disabilities.
On admission to a nursing program, most students do not yet know how to perform skills such as these using appropriate techniques. These skills are practiced in the nursing lab and in clinical settings, and are mastered over time. Some students may master these skills sooner than others. The same scenario applies to nursing students with disabilities. All students need time to practice and hone nursing skills.
Many students with disabilities are able to find accommodations that will work for their particular needs. Faculty, administrators and staff nurses cannot “assume” that a student with a disability, such as having only one hand, will be unable to achieve a particular skill. Patients with hemophilia routinely learn to start IVs on themselves quite competently with one hand.
Susan was aware of her legal rights but chose not to fight the nursing school’s decision. The lack of time, resources and energy to pursue a discrimination case in the courts is common to many students with disabilities. Often, they are driven away from nursing forever.
But Susan focused her energy on moving forward. She applied to another nursing program, where she was accepted. While in nursing school, she worked in a busy emergency room in order to gain more clinical skills. Susan was successful in her nursing program and recalls that she did not discover all of the accommodations she needed until she had almost completed the program.
The primary accommodations Susan required in nursing school were large gloves, special scissors and a hemostat. Today, she still uses these accommodations after many years of successful practice as an RN. She is able to draw blood, start IVs, work in labor and delivery, and work as the baby nurse in the OR during cesarean sections. She is a respected and valued member of the team.
An Equal Chance to Succeed
Nursing educators need to be mindful that their next star student may be a person with a disability. This case study of a student with a disability who learned to perform nursing skills over time, with a little help from reasonable accommodations, serves as an example of the resourcefulness and compensatory abilities that students with disabilities often possess.
On admission, students with disabilities should not be required to demonstrate skills that nursing students routinely demonstrate and master over time. Rather than pre-judging them, nursing educators, administrators and staff nurses should offer them a welcoming hand. We should honor the spirit and true intention of the ADA by helping these minority students become successful and productive members of the nursing profession.
Today, the career paths open to nurses are immense and wide-ranging–from floor nursing and intensive care unit nursing to telephone triage and pharmaceutical sales. In a profession that offers such a diversity of opportunities, students with disabilities can bring valuable skills to the table, such as empathy, sign language and lip reading, as well as personal experiences that both colleagues and patients can learn from.
Nursing students with disabilities need the support of the nursing “village” in order to be successful. They may “play their hand” differently, but at the end of the day they bring value to the nursing profession and to patient care. Together, we can give more of these students the chance they deserve.
Unlike many professionals these days, nurses can launch a job search with the confidence that they will find work–and quickly, at that. Thanks to one of the most severe nursing shortages in history, good nurses are in high demand all over the country. Hospitals, clinics, doctor’s offices, nursing homes and surgical centers are all looking for skilled clinicians from diverse racial, ethnic and cultural backgrounds who have a way with people and, often, specialized skills in areas like critical care, perioperative nursing and neonatal care.
But if you are in the market for a new job in 2004, or even a whole new career, look beyond the usual opportunities. Today’s hottest nursing jobs mirror important trends in American society: an aging baby boomer generation, growing consumer interest in fitness and holistic medicine, and advances in computer technology. The care delivery settings for these emerging careers vary widely–from the hospital room to the yoga studio–but they all share nursing’s traditional goals of caring for the sick and promoting good health.
“What makes each of us a nurse is a combination of skills and our capacity to give,” says Donna Wilk Cardillo, RN, a nursing career consultant and president of Cardillo & Associates in Sea Girt, N.J. “Nurses are multitalented and there are many ways to make a difference out there.”
Here’s a look at some of the most promising career growth areas for minority nurses in the new year and beyond.
Hot Career #1: Nursing Informatics
Angela Lewis, RN, found her niche in nursing the day she volunteered to be a “super-user” in the home health agency where she was working as a case manager. Her office was installing a new computer system and Lewis agreed to be a first-line user who would learn the system and then teach coworkers how to use it.
Lewis, who is African American, discovered that she loved learning the technology, sharing her knowledge and trouble-shooting problem areas for new users. She enjoyed it so much, in fact, that she asked her boss if she could do computer work full time. The answer was no, but the seed was planted: The experience set Lewis in motion on a new career in nursing informatics.
Demand for nurses like Lewis is high. More than 40 job ads were posted in a single recent month on the Web site of the American Nursing Informatics Association (ANIA).
Nursing informatics is a relatively new specialty that combines nursing, computer science and information science to manage and communicate data, information and knowledge in nursing practice. It pulls all this information together in a streamlined, computerized way to facilitate patient care and other clinical work in hospitals, physicians’ offices, surgical centers and other health care settings.
Job opportunities in this field vary greatly. One ad on the ANIA Web site sought an information systems clinical analyst with an RN or allied health background for a children’s hospital. Another sought to hire nurses to teach clinicians how to use information management systems and technology. A third wanted a systems analyst with a nursing background who could work on teams that implement computer-based OR information systems around the country.
While the opportunities are plentiful, nursing informatics is not an entry-level career. RNs who find work in this specialty typically have several years of experience and professional education in both information systems and nursing.
Lewis got her first informatics job by default when, as a nursing supervisor, she was tapped for an informatics coordinator role. Her previous experience as a super-user made her a shoo-in. Today she is project manager for clinical information systems at La Rabida Children’s Hospital in Chicago. Among other responsibilities, Lewis manages the information systems that clinical staff use throughout the hospital. Doctors, nurses, radiology, pharmacy–all are linked by a common computer system that helps them track and manage patient care, from ordering and administering a dose of Tylenol to sharing lab test results.
Nursing informatics specialists serve as high-tech traffic cops for all the information swirling around their facilities. This calls for a well-rounded, well-organized person with a big-picture understanding of how the different departments in a facility interact and a solid grasp of the way things get done.
It is not a job for the easily frustrated. Part of Lewis’s function is to ensure that information systems are running properly. If the system goes down, it’s her job to get it back up, sometimes amid frantic or angry clinicians who need access to crucial medical information. At times like this, she relies on her clinical experience to prioritize demands.
This is the primary challenge of nursing informatics: to be a facilitator between technical staff and clinicians. It means being conversant in the languages of both technology and medicine. It also involves educating non-technical staff on the use and merits of computerization.
Often, nursing informatics specialists’ role is to help people make the transition from old paper-based systems to today’s new “paperless” workplaces, says Lewis. “[You’re] part educator, part scientist, part interpreter,” she notes.
If the health care sector has been slow to adopt computer technology, it’s because some patient care advocates worry it could dehumanize the patient-caregiver relationship. But these concerns are at least as old as the stethoscope, which was viewed with similar suspicion in its infancy, argues Lewis, who is president of the Midwest Alliance for Nursing Informatics.
“There are still a lot of people who think that if it’s technical you lose the human touch,” she adds. “A lot of times clinicians feel that way about computers, but the reality is that computers can improve patient care and the delivery of health care services.”
For more information: American Nursing Informatics Association,
www.ania.org.
Hot Career #2: Fitness Nursing
Non-traditional career alternatives in nursing have always existed, but most new graduates still come out of nursing school with the traditional bedside image in mind, Cardillo says. They may be so fixed on that image, in fact, that they are reluctant to move into new territory.
Lori Radcliffe, RN, BS, CPT/CFC, wasn’t afraid to make that leap, although she says it took her some time to connect the dots that led her to open her own business. A lifelong love for fitness and sports, a degree in kinesiology, a short career as a standup comedienne and an RN license all come together in her company, “Jest” for Fitness & Food in Tinton Falls, N.J.
As a fitness nurse, Radcliffe, who is African American, helps her clients regain strength and vitality through exercise and nutrition. Working with a dietitian, she offers seminars, exercise classes, videos and audiotapes to people who are recovering from surgery, trying to lose weight or have chronic health problems.
For example, resistance training for osteoporosis prevention is one of her specialties. She also works with people who have lymphedema (swelling of the arm after lymph node removal), fibromyalgia and chronic fatigue syndrome. Some of her clients have gone through post-surgical therapy but are not yet ready for the gym. Certified as a personal trainer, fitness counselor and kickboxing instructor, Radcliffe offers them a bridge between therapy and regular fitness classes.
Some of her business comes from hospitals that are ramping up wellness programs. Because these programs prefer fitness instructors who have medical backgrounds, being a nurse has helped her get a foot in the door. “People say, ‘Why don’t you just do fitness [training]?’” says Radcliffe. “But I’m a nurse first. These doors wouldn’t open up for me if I wasn’t a nurse.”
As the link between physical fitness, wellness and disease prevention grows, hospitals are opening fitness facilities to respond to increasing demand, according to the International Sports Sciences Association. In addition, hospitals and HMOs are offering wellness programs on topics such as nutrition, stress management and exercise, and are opening fitness centers targeted to specific groups, like children and senior citizens.
Radcliffe, too, seeks out pockets of special need. For instance, she has found that nurses are often so focused on caring for others that they put their own health needs last. Some follow ill-advised diet trends. Others smoke or do not exercise. The nurses she meets through her work with hospitals are curious about how she stays fit, observing her during lunch in the cafeteria and peppering her with questions. Some have signed up for one-on-one fitness sessions with Radcliffe.
“Nurses are known not to take care of themselves,” she says. “They think they’re exercising because they’re pushing and pulling patients. [Starting an exercise regimen] is like anything when you first take it on. The hardest part is accepting that either you’re going to change or it’s going to be you lying in that hospital bed next.”
Through networking, Radcliffe has found a way to serve another population that faces barriers to fitness. She teaches a kickboxing class two days a week at a community center in an inner city neighborhood. Her initial group of four adult students has grown to a dozen in the year since the class began. Sometimes they bring their teenage children, many of whom already suffer from Type 2 diabetes.
According to various studies conducted by the Centers for Disease Control and Prevention between 1999 and 2001, 38% of American high school girls and 25% of boys do not get the recommended amount of moderate or vigorous physical activity. Twenty-eight percent of women and 22% of men over age 18 perform little or no physical activity, while 34% of women and 28% of men are obese. In recent years, the obesity epidemic has become a critical minority health concern. For example, the CDC reports that half of all non-Hispanic black women are obese.
“There’s no Gold’s Gym in the ’hood,” Radcliffe explains. “And they’re not going to walk [because the neighborhood is unsafe].” She adds that being African American helps her connect with the students in her class. “When you talk to people one on one, when they feel you care about them, [they’ll confide in you about issues like that].”
For more information: Aerobics and Fitness Association of America,
www.afaa.com; National Nurses in Business Association, www.nnba.net.
Hot Career #3: Holistic Nursing
For many years, American medical experts have relied primarily on prescription medications, surgery and other traditional Western practices to treat illness. But that tradition is slowly changing. Today’s health care consumers are looking for a broader range of options and are increasingly willing to try new approaches to wellness.
As a result, holistic medicine and nursing is an emerging field whose time has come. This blend of complementary and alternative healing methods, many of which are long-practiced traditions in Asian cultures, is starting to make inroads into the Western health care system. Today holistic nurses practice in a variety of settings, including medical offices, hospitals, wellness programs, fitness and meditation centers and their own businesses.
Unlike traditional Western medicine, with its focus on treating symptoms when and where they arise, holistic medicine treats the whole body as a system that works together, emphasizing harmony between body, mind and spirit to promote healing. It is an approach that Western medical practitioners are beginning to embrace, even at the most official level. For example, the National Center for Complementary and Alternative Medicine (NCCAM), a department of the National Institutes of Health (NIH), conducts clinical trials and research aimed at broadening available therapies.
Cancer patients, in particular, are seeking alternative treatments. In 2001, cancer was the second-leading cause of death in the United States and had an economic cost of $171.6 billion in medical bills and time lost from work. A recent NIH survey found that 83% of cancer patients sought alternative, non-mainstream medical solutions. According to NCCAM, some of the most popular of these alternative therapies are meditation and prayer, traditional Chinese medicine (TCM), herbs, vitamins, special diets, exercise and relaxation techniques such as guided imagery.
With their one-on-one patient contact, nurses are in a unique position to nurture people toward wellness using a holistic approach. Some of the key healing techniques used by holistic nurses include stress management, Ayurveda, massage therapy, Reiki, acupuncture, meditation, aromatherapy, exercise and therapeutic movement.
For example, holistic nurses who practice Ayurveda seek to remove the cause of a patient’s disease, rather than merely treating the symptoms. This may include the use of herbs, meditation, yoga and changes in diet. Reiki is a therapy that directs energy to the body to promote healing and relaxation. TCM is an ancient practice that looks for the underlying causes of imbalances in the body and tailors treatment to an individual’s physical makeup, using herbs, acupuncture and massage. Therapeutic Touch is a technique that balances energy flow in the body through human energy transfer.
This past summer, AHNA Past President Charlotte Eliopoulos, RN, served as the association’s representative on a liaison panel for the Institute of Medicine’s Committee on the Use of Complementary and Alternative Medicine (CAM) by the American Public. Unfortunately, she reported back to AHNA that the committee seemed to be more interested in “safeguarding the use of [dietary] supplements and establishing consistent credentialing of acupuncturists, homeopaths, naturopaths, massage therapists and chiropractors” than in “the significance of the [holistic] nurse in impacting the use of CAM.”
Eliopoulos also reported that the committee members “definitely viewed the touch therapies as ‘out there’ and off the radar screen for consideration. The fact that these are the therapies most widely practiced by nurses should give us concern when major policy influencers do not even acknowledge their value.”
Nurses who believe in the benefits of holistic health care must make their voices heard at the policy-making level or else “the CAM train will leave without us,” Eliopoulos argues. “It isn’t just about adding new therapies and products, but changing the philosophy and approach to health and healing. The larger issue is the development of a holistic paradigm of health and healing, not the continuation of a fragmented, illness-oriented medical model.”
For more information: American Holistic Nurses Association, www.ahna.org.
Hot Career #4: Gerontological Nursing
At first glance, gerontology does not seem to fit the profile of a hot, emerging career option for nurses. It’s been around for a long time and tends to be seen as, well, old-fashioned and unexciting.
But if this is your perception of what caring for older persons is about, think again. With the aging of the large baby boomer generation, and the fact that people today are living well into their 90s, the future of gerontological nursing is a busy one. The U.S. Department of Health and Human Services predicts that 5.7 million to 6.5 million long-term care workers will be required to meet the nation’s elder care needs in 2050, up from about 1.9 million such workers employed in 2000. This includes nurses, nurses’ aides, home health care providers and personal care workers.
Even today, gerontological nurses are already in great demand in ambulatory care centers, assisted living facilities, community centers and patients’ homes. Furthermore, the booming business of long-term care and assisted living facilities is bringing new opportunities to RNs who understand the complexities of providing health care to elderly people in these specialized residential environments. Many nurses are rising to corporate management positions within the companies that own these facilities, Cardillo says.
Still, the gerontology field has a reputation as a dumping ground for the very old and feeble. But for Carlo Sipaco, RN, this stereotype couldn’t be further from his experience as a shift supervisor for the Masonic Home of New Jersey, a nursing home in Burlington, N.J. Knowing his patients as individuals is the best part of his job, he says.
“We have about 300 residents and if they know you by name that means you did something for them to remember you personally.”
Working with elderly patients, many of whom suffer from chronic pain and loneliness, requires a can-do attitude every time a nurse steps onto the unit, Sipaco emphasizes. “If you don’t have patience, you have no business working in a nursing home setting,” he says. “[Patients] will come to you every day with the same complaint. If you don’t have the patience, that [behavior] is very annoying.”
Sipaco has found that the personal touch goes a long way toward minimizing the grumbling that stems from chronic pain. “Maybe that simple interaction with the patient will help ease the pain,” he explains. “Most of those depressions, most of those pains, can really be minimized by listening. Seeing a depressed [patient] smile after you’ve talked with them is rewarding.”
Because Sipaco was raised in the Philippines, where elderly people are honored and revered for their wisdom, caring for older patients comes naturally to him. But this same cultural tradition made it hard for him to delegate tasks to older nurses when he became a charge nurse in 1994, and he often ended up doing the work himself. That changed over time as he became more comfortable with American culture, he says.
Today Sipaco is one of two night shift supervisors for 11 nurses and 24 CNAs at the Masonic Home, where he has worked since 1991. He is using his position to nurture a new generation of caregivers for older Americans. As he puts it, “If I can influence them, especially the younger ones, the new graduates, to see the beauty of working with the elderly, then that’s very, very rewarding.”
For more information: National Gerontological Nursing Association,
With a near crisis-level RN staffing shortage now affecting just about every part of the nation, today it seems like all you have to do to find a city with an urgent demand for nurses is to throw a dart at a map of the U.S.
But choosing the right city in which to live, work and play is a more than just a matter of where the jobs are, or where the salaries are highest. It’s a highly personal choice based on your pace, lifestyle and professional goals. For example, do you prefer bustling, big cities with lots of nightlife or quiet, small-town living? Do you enjoy watching the seasons change or would you rather have sunshine 365 days a year? Are you more comfortable working in a large urban medical center or in isolated, medically underserved rural communities?
In compiling our selection of top cities for minority nurses in 2003, we placed special emphasis on these “personal factors” in order to come up with a list that would truly offer something for everyone. Our choices are also based on such factors as demand for nurses, RN salaries, cost of living, opportunities for educational and professional development and all-around livability (“fun factor”). And, of course, we looked especially hard for cities that lead the nation in racial and ethnic diversity, demand for culturally and linguistically competent nurses and the presence of magnet hospitals and other nursing employers with outstanding reputations as good places for minority nurses to cultivate their careers.
The Biggest: New York City Metro Area
The Big Apple and its boroughs and suburbs form the largest metropolitan area in the U.S., with more than 21 million residents. Not only does more people mean more need for nursing care, but RNs can also make big bucks in New York, earning an average salary of nearly $61,000 a year.1
Of course, living in New York City is not cheap. The median home price in 2000 was $230,200,2 and apartment rents in Manhattan’s trendy areas average $1,800 a month for a studio and $2,500 for a one-bedroom.3
New York has a long and rich history of cultural diversity. From 1892 to 1924, 12 million immigrants entered the U.S. through Ellis Island, and today New York continues to be a vibrant area for residents of all races and ethnicities. The metro area is currently home to more than 5 million recent immigrants, nearly half of them from Latin America.4
According to the Survey of Nurse Staffing in Hospitals in the New York City Region 2002, published by the Greater New York Hospital Association, demand for nursing staff is especially high in critical care, perioperative care and emergency departments. Hospitals in the region experienced an overall vacancy rate of 7.8% for direct patient care RNs, with higher vacancy rates reported in the Bronx (14%), Staten Island (10%), Westchester County (12%) and other counties north of New York City (12%). Nearly 60% of the city’s RN workforce is over age 40.
The New York State Nurses Association is an active lobbyist on behalf of nurses statewide. Thanks to their efforts, in recent years New York has passed laws to prevent needlestick injuries, protect health care whistleblowers and create a statewide peer assistance program for nurses. Bills are currently under consideration that would ban mandatory overtime and establish statewide minimum staffing guidelines.
In October 2002, the 7,000 RNs who work for New York City’s Health and Hospital Corporation reached a tentative agreement on a new 27-month contract. The agreement bolsters “merit pay” for performance and increases wages by 8.4%. The nurses are represented by the New York State Nurses Association and work at the city’s 11 acute care hospitals, four long-term care facilities, six diagnostic and treatment centers and the mayoral health agencies.
Last but not least, New York City’s theaters, restaurants, museums and other cultural attractions are known worldwide. The “city that never sleeps” has something special for everyone, from Central Park and Yankee Stadium to Coney Island and Broadway.
Next Bests–Other Big Cities:
• Chicago
• Dallas-Fort Worth
• Detroit-Ann Arbor
• Philadelphia
• San Antonio
• San Diego
• San Francisco
The Fastest Growing: Las Vegas
Las Vegas’ burgeoning population growth and especially severe RN shortage are creating excellent career opportunities for nurses looking to relocate to this oasis in the desert. The city’s population grew a blistering 83% between 1990 and 2000,4 and is expected to reach 2 million by 2005. This surge in population also increased Las Vegas’ cultural diversity: The percentage of Hispanic residents nearly doubled and the percentage of Asians increased by one-third.
This rapid growth spurt has had its consequences for the local health care industry. A report released in 2001 by the U.S. Department of Health and Human Services revealed that Nevada has the worst nurse-to-population ratio in the U.S., with only 520 nurses per 100,000 people. “And it is going to continue to be the worst as we keep leading the nation in population growth,” said Bill Welsh, president and CEO of the Nevada Hospital Association, at a recent Nevada Business Journal breakfast for local health care organizations. Nevada’s six nursing schools produce a total of 300 to 350 graduates each year, far short of the 767 new nurses a year needed to meet the state’s growth expectations, according to Welsh.
To try to keep up with the growth, Las Vegas is making investments to expand its health care infrastructure. The area is currently serviced by 23 hospitals, with five new ones planned over the next five years. In addition, the 2001 legislature required the state’s university system to develop a plan and budget for doubling its nursing programs. The proposal will be evaluated during the 2003 legislative session.
Las Vegas nurses earn an average of $48,955 a year. Housing costs are reasonable, ranging from a median of $152,000 for existing homes to $183,456 for new ones.5
This city is known for its casino splendor, and the Las Vegas Strip has its own museums, roller coaster rides, theatrical performances and round-the-clock entertainment. Yet the region offers much more than slot machines and bright lights. Lake Mead, Red Rock Canyon and the Hoover Dam are all within a two-hour drive, and the Grand Canyon and Death Valley are close enough for a weekend getaway.
Movie stars, palm trees, sunny 70-degree days and a population that is 45% non-Caucasian. Welcome to Los Angeles, one of the country’s most diverse metro areas!
Los Angeles, the nation’s second largest city, is a tremendously multicultural community. Thirty percent of its population are U.S. immigrants and the city has large numbers of Latino and Asian residents.4 In a recent study examining the impact of immigrant, gay/lesbian and artistic populations on technological innovation, LA was cited as the “most diverse” city in the U.S.6
This huge demand for culturally and linguistically competent health care is just one of many reasons why Los Angeles needs more minority nurses. California’s nurse-to-patient ratio is the second worst in the country (544 nurses per 100,000 people) and its nurses are among the oldest. Half of the RNs working in California were educated in other states or countries. In addition, the state’s population is growing, as is the percentage of residents over age 65.
Recent legislation mandated minimum nurse staffing ratios in the state’s acute care facilities, making nurse recruitment efforts even more aggressive. In July 2002, Tenet Healthcare Foundation, a philanthropic arm of Tenet Healthcare Corp., awarded $1 million to help train Latino nurses in the Los Angeles area. According to Tenet (which operates 30 hospitals in Southern California, including seven in East Los Angeles), more than 40% of the patients served in this market are Latino, yet Latinos account for fewer than 4% of California’s health care professionals.
Salaries for RNs in the Los Angeles metro area are above average–nearly $55,000 a year in the city, but slightly lower in nearby Riverside and Orange County.1 While homes in Los Angeles County sell for a median of $220,000, housing prices can vary dramatically depending on size and location. Tiny fixer-uppers in modest neighborhoods can go for $125,000, while prices in wealthy areas like Malibu, Brentwood and Beverly Hills can reach eight figures. Rentals generally range from $700 to $5,000 a month.3
As for livability and “fun factor,” Los Angeles offers an appealing mix of natural and man-made delights: thriving, culturally rich communities with easy access to some of the most beautiful beaches and mountains in the nation.
Next Bests–Other Culturally Diverse Cities:
• Austin-San Marcos, Texas
• Boston
• New York City
• San Diego
• San Francisco
Most Magnet Hospitals: Houston, Texas
Founded as a riverboat landing in 1836, Houston is now the fourth largest city in the U.S. and the largest in Texas. This thriving city offers a robust economy, racial and ethnic diversity, beautiful tree-lined neighborhoods and all the cultural and recreational attractions of a major urban center.
Houston was selected as one of Minority Nurse’s top cities because it has more magnet hospitals than any city in the U.S. Of the 58 facilities nationwide that have been granted the magnet designation by the American Nurses Credentialing Center for their outstanding commitment to nursing excellence, cultural diversity and career advancement opportunities for RNs, three are located in Houston:
• The Methodist Hospital
• St. Luke’s Episcopal Hospital
• The University of Texas M.D. Anderson Cancer Center.
Houston is also home to the Texas Medical Center, the largest medical complex in the world. Incorporating 11 academic and research institutes and 10 patient care institutions (including the three magnet hospitals), TMC employs 52,000 people and serves 4.8 million patients each year.
Housing in Houston is affordable, with prices averaging 39% lower than those of many comparably sized cities. Nursing salaries range across the region, from an average of $48,452 a year in Houston and $47,277 in nearby Galveston to $43,461 in the northern suburb of Brazoria.1
More than 90 languages are spoken throughout the Houston area, and 90 of its 500 visual and performing arts organizations are devoted to multicultural and minority arts. The metro area’s population grew by more than 25% between 1990 and 2000, with the most significant increase (7.5%) occurring in the Hispanic and Latino population.
While Houston’s notoriously hot summers may take some getting used to, it’s a highly livable city that offers a wide variety of entertainment and sports events. Houston is one of only four U.S. cities that have resident opera, ballet, symphony and theater companies, and there are professional teams representing every major sport. NASA’s Johnson Space Center and the country’s largest Livestock Show and Rodeo are located in the Houston area as well.
Next Bests–Most Magnets:
New Jersey boasts the highest concentration of magnet hospitals in a single state. New Jersey’s 12 magnets are located in the cities of:
• Brick
• Englewood
• Hackensack
• Lakewood
• Morristown
• Neptune
• New Brunswick (2)
• Paterson
• Red Bank
• Trenton (2)
Largest Population Over Age 65: Fort Myers and Cape Coral, Florida
Where do you find resort-style living, beautiful waterfronts and an elderly population facing a severe nursing shortage? Welcome to Fort Myers and Cape Coral, located two hours south of Tampa, on Florida’s southwest coast.
Situated directly across the Caloosahatchee River from each other, Fort Myers and Cape Coral have the largest percentage of residents over age 65 of any city in the U.S.–more than 25%, compared with Florida’s statewide average of 17.6%.4
The two cities, which are connected by four bridges over the river, are very different from each other. Fort Myers is smaller and more historic. It was founded with military roots and grew into a resort community in the early 1900s. Inventor Thomas Edison wintered in Fort Myers and helped the town develop its reputation as “the City of Palms.” Edison’s home, lab and gardens are a major tourist attraction, and the stately royal palms are one of the area’s most photographed scenes.
Other attractions include the Gulf of Mexico (about 20 miles away), the Boston Red Sox spring training stadium, and Imaginarium, a hands-on children’s museum.
Fort Myers is also one of the region’s most racially and ethnically diverse cities. Its population of 48,000 includes almost 7,000 Hispanics–the fastest-growing minority group–and 16,100 black or African-American residents.
Cape Coral, which is much newer than its riverfront neighbor, is the region’s largest city, offering residents 400 miles of canals and many waterfront living opportunities. Single-family homes can range from less than $100,000 to more than $1 million, but the median price is $130,000. Registered nurses in the area earn an average of $38,754 annually,1 so the relatively low cost of housing compared to many other parts of the country is a big plus.
Like most Florida communities, Fort Myers and Cape Coral need nurses to serve their growing elderly population. Lee Memorial Health System is the regional health network, offering a full range of medical specialties. Cape Coral Hospital, a 281-bed facility, has the area’s largest emergency room, along with strong specialties in rehabilitation, pediatrics, obstetrics, oncology, general surgery, urology, endocrinology and gastroenterology.
Florida is struggling with a growing nursing shortfall that is predicted to reach a need for 34,000 more RNs by 2006. In an effort to combat this pending crisis, the state has put forth a plan to allow eligible nurses to apply for affordable home and education loans. Funds are targeted to full-time licensed nurses–RNs, LPNs or LVNs–but may also be available to full-time nursing assistants certified by the Florida Board of Nursing and/or to nurses who have completed board-approved training.
Next Bests–Other Large 65+ Communities:
• Clearwater, Florida
• Hollywood, Florida
• Honolulu
• Philadelphia
• Scottsdale, Arizona
• Tampa-St. Petersburg, Florida
• Warren, Michigan
Data Sources 1. SalaryExpert 2. The National Association of REALTORS® 3. Homestore 4. U.S. Census Bureau 5. Home Builders Research, Inc. 6. The Brookings Institution
You’ve spent four years in nursing school, reading, training and practicing. Then it happens. You graduate. Suddenly, someone else’s life is in your hands.
The transition from student nurse to practicing RN can seem abrupt, even after years of preparation. Many nursing educators believe it’s too sudden—and one reason why so many newly graduated nurses leave the profession after just a few years.
“If students don’t understand what a nurse does [in an actual workplace setting], they don’t know what to expect. They tend to burn out early and leave the profession,” says Connie Rowles, RN, DSN, CNNA, a clinical associate professor at Indiana University School of Nursing (IUSON) in Indianapolis.
Indeed, nurses are leaving the field at a record pace. A recent study conducted by Julie Sochalski, RN, PhD, of the University of Pennsylvania reveals that new nurses are abandoning the profession at much faster rates than they did just 10 years ago. Four percent of new female nurses drop out within four years of earning their RN licensure; for males, the figure is almost double (7.5%).
Making a smooth transition from the college campus to the “real world” of that first nursing job is difficult for everyone. But new graduates who are racial, ethnic or gender minorities often face unique transitional challenges that majority nurses are spared. In many parts of the country, new minority nurses entering the RN workforce may find that they are the only person or color, or the only man, on their unit or even an entire floor.
Shanae Monger, RN, BSN, a recent IUSON graduate who is African American, has experienced this situation firsthand. “Some people still assume that I am an assistant,” she says. “They ask me to get the nurse. That could be because of both my youth and my race. Either way, it’s their problem and I don’t let it get to me.”
This feeling of being “alone in a crowd” can not only cause minority nurses to burn out early in their careers but also prevent them from planning for future leadership roles, believes Marsha Tahquechi, RN, CNM, director of the Diversity Mentorship Program at Brigham and Women’s Hospital in Boston.
“Nursing in general does not have a very diverse workforce,” she notes. “This makes it harder to make the transition from student to professional. It can be a very stressful time when you’re joining an organization, and it’s complicated when others are unfamiliar with our cultural backgrounds. A lot of the problems minority nurses have to overcome can be seen in the fact that there’s not a lot of nurses from diverse backgrounds in hospital management.”
Tahquechi, an American Indian of Mohawk and Comanche descent, has had her own experiences working in culturally insensitive environments. Because her skin is fair, she says, people often assume that she is Hispanic or Caucasian.
“It’s very disheartening when everyone makes a general assumption about who you are in terms of your culture and background,” she adds. “That seems to happen less often when you have nurses of diverse backgrounds on the floor.”
Tahquechi encourages new nurses who are the only person of their race or ethnicity in their work group to seek support outside their immediate area, such as befriending nurses of color from other units and joining the local chapter of a minority nursing association. She also hopes that minority nurses will embrace their situation as an opportunity to educate others. “You can serve as a good resource for other nurses who may not be familiar your culture,” she says.
Virginia Hicks, RN, MSN, CLNC, an associate professor in the School of Nursing at historically black Grambling State University in Grambling, La., feels that new nurses of color who suddenly find themselves transitioning from college campuses where they were in the majority to workplaces where they are in the minority can sometimes lack the confidence and assertiveness of their white counterparts.
“Assertiveness ties in with self-confidence and it comes with more experience,” she advises. “Be assertive when seeking opportunities to develop strong clinical skills. Seek those out. Don’t be passive and wait on people to bring those opportunities to you.”
Welcome to a Woman’s World
For men, moving from the co-ed world of college to the 95% female world of the nursing workforce presents its own special challenges.
“The biggest problem for males is just the pressure that some female nurses put on us,” says Martin Joplin, RN, MSN, NP-C, ARNP, a recent graduate of the MSN program at Case Western Reserve University in Cleveland. “There are still a lot of old-school nurses out there who think nursing should be a woman’s profession. They see a man on the floor and the first thing they say is, ‘I’m so glad you’re here. You can help me move or turn my patients.’”
Joplin is currently training in an emergency room to prepare him for working independently in a clinic in rural Kentucky. This is the second time he has experienced the “school work to real work” transition. The first came after he earned his BSN degree and secured his first job as an RN. Joplin feels lucky that his first work experience was in an environment that was welcoming to men. “It was a very supportive environment,” he recalls. “The other nurses helped me a lot. When I had questions, they were very understanding.” He also had a male preceptor, someone with whom he could share a common perspective and interests. “I can’t say that it made the transition easier just because he was a man, but during the down time we could talk about football or baseball.”
Joplin encourages new male nurses to “make some good friendships with other guys at the facility.” He suggests becoming active in nursing professional organizations if guys are in short supply at your particular workplace. The important thing is to avoid the isolation that many male nurses feel.
“There’s nothing wrong with making friends with the women you work with,” he adds. “Some of my best friendships in nursing have been with female colleagues. You are spending eight or 12 hours a day together, so it’s much better if you get along.”
Men entering the RN workforce should also be prepared for the inevitable “heavy lifting” requests they will receive from female nurses. While it’s fine to be helpful, Joplin cautions, make sure that assisting other nurses in this way doesn’t cause a drop in the quality of care your own patients receive. “Don’t sell yourself out,” he advises. “Don’t be intimidated. You might be a new graduate, but you’re just as important to the facility as any other nurse.”
Practice Makes Perfect
For education majors, the transition into the professional arena is handled a bit differently. New elementary and high school teachers face a total immersion period in a “real world” classroom before graduation: For several weeks, it’s just them and their students. Of course, veteran teachers are always nearby, ready to step in when a second grader gets a little rowdy or a fifth grader falls off the monkey bars.
Many nursing schools and health care employers feel that nurses deserve the same opportunities to test the waters before they’re thrown into the deep end, and are taking steps to create programs designed to better prepare new nursing graduates for the unfamiliar experience of working independently on understaffed units where chaos may be the norm.
Indiana University’s Connie Rowles oversees one such program, the Capstone Practicum course. The class was added to the curriculum about two years ago as the last step before IUSON nursing students hit the real world.
“The faculty wanted something that would help ease the transition from student to RN,” explains Rowles. “We felt that it was very important to give each student a realistic preview.”
The course was designed through a collaborative effort that included local hospitals, nurses and the college. Students are paired with a mentor or preceptor at the unit and facility of their choosing for four weeks, working a total of 112 hours. The student nurses work closely with their preceptors, taking on their schedules and shadowing them.
Shanae Monger, who took the Capstone Practicum last spring, says the only thing she would do to improve the course is to make it longer. She spent her practicum working in the emergency room at Indianapolis’ Children’s Hospital.
Monger likens the practicum to breaking the apron strings. “By the end of the four weeks, we were supposed to be able to do all the things we learned in school,” she remembers. “The goal was to reach the point where we could take care of patients on our own.”
For Rowles, watching the transformation as unsure students become confident nurses is rewarding. “At the beginning of the course, they feel like they’re not quite ready for it,” she says. “But midway through, they start gaining confidence and thinking ‘maybe I can do this.’ By the end, they are sure they can. It’s a very enabling and empowering course. Students are able to see their own competence and realize they know far more than they think they do.”
Since the practicum is relatively new, data on whether it is helping to reduce the burnout and dropout rates for newly minted nurses hasn’t been collected yet. But Rowles feels certain that the program will indeed make a difference. Students so far have given it rave reviews.
Transitioning Into Diversity
Today a growing number of health care employers realize that offering programs to help about-to-graduate nursing students transition into the workplace can do more than just increase retention rates for new nurses. They can also be powerful recruiting tools, particularly for hospitals that want to attract a culturally diverse nursing staff. Brigham and Women’s Hospital’s Diversity Mentorship Program, which pairs up minority nursing students with minority mentors, is one such transition program designed with multicultural recruitment in mind.
“Eighteen percent of the Boston-area population is made up of people of color,” explains Tahquechi. “The Diversity Mentorship Program has been very beneficial in helping us attract more nurses from diverse backgrounds, to reflect the diverse patient base we serve.”
Like the Capstone Practicum, Tahquechi’s program also revolves around one-on-one relationships between students and preceptors. “It’s almost like having a big sister or brother,” she says. “The mentor becomes someone that they can talk to.”
Students begin during the summer before their senior year of nursing school. After returning to school in the fall, they are often hired as patient care associates part-time or when they’re home for the holidays. Most participants go on to become full-time employees of Brigham and Women’s after graduation.
“The students get comfortable and want to stay here,” Tahquechi notes. “It’s not threatening. They don’t need to prove themselves. They’ve already created relationships.” Nine of the last completed program’s 10 participants are now employed at the hospital.
The students receive no college credit for participating in the mentorship program, but they usually watch their clinical skills—and their confidence—increase. “During the time they are here, they work with their mentors and are engaged in critical thinking, looking at care plans and learning to interpret physician orders,” Tahquechi says.
Learning to Think on Your Feet
Many nursing educators believe that critical thinking is one of the hardest things to teach students in a classroom setting. As a result, many newly graduated nurses are thrust into the workplace with critical thinking skills that are not fully developed.
“Students tend to want everything to go step one, step two, step three when they are learning procedures,” says Hicks. “When they get out in the real world, they often get frustrated because situations don’t go the way they learned it in the book.”
Based on her Capstone experience, Monger feels that practica can help new nurses develop their critical thinking abilities, enabling them to become independent caregivers sooner and with more confidence. “My preceptor was someone I could go to [when I needed help],” she recalls, “and I was confident that I had someone to check my work. But she made me do my own critical thinking.”
Another common misconception that catches new nurses off-guard is the volume of patients under their care. “Students have such limited experience,” Hicks explains. “They have the false perception that they will have only one or two patients to care for. In the academic setting, it’s a learning environment, so the number of patients is limited. But it’s not that way on the job.”
As the old saying goes, there’s simply no substitute for experience.
“I would advise everyone to get some work experience on a unit, as a student nurse or as a nursing assistant,” suggests Monger, who worked as an assistant in the labor and delivery ward of Indiana University Hospital, the same unit where she ended up taking her first official job as an RN. “It will make you feel more comfortable. Things like your bedside manner become second nature. If you get that stuff down, you can concentrate more on your nursing skills when the ‘real’ time comes.”
Look Before You Leap
A smooth transition into the nursing workforce also involves choosing the right employer to work for. When you’re shopping your skills around, don’t focus just on salary and benefits. Ask questions about the hospital’s orientation program and how committed the facility is to the success of new graduates and minority nurses.
Start with the length of the orientation and training program. Experts recommend a minimum of three months, 40 hours a week.
“Find out what opportunities are available for cross training,” Hicks adds. “Will you work in one unit or several? Will you work under the guidance of a preceptor or be thrown to the wolves?”
Although preceptorship programs are often very helpful in easing new nurses into the profession, the one-on-one format can have its drawbacks. “You have to have very strong preceptors to mold new nurses. Sometimes it’s better for new grads to work with a variety of nurses,” Hicks advises. “Unfortunately, some facilities have such large staffing shortages that they will put any nurse in the preceptor role.” The danger, she cautions, is that the novice nurse may pick up bad habits or hear too much negativity.
Being paired with a bad preceptor can be enough to cause a new nurse to reconsider his or her choice of a career. If you find yourself in this situation, says Hicks, you should notify your supervisor, or the person in charge of orientation, immediately. Be tactful but be honest.
Joplin thinks nursing grads interviewing for their first RN job shouldn’t just rely on information provided by the human resources department. Instead, try to talk to a variety of people who work at the hospital, including new hires if possible.
“I’ve heard people say that orientation was supposed to be six weeks but it was actually two,” he warns. “The facility was so short-staffed that they saw a warm body and couldn’t resist putting them to work immediately.”
Monger agrees that nurses entering the workforce need time to adjust. Your first year may be a blur of frustration, tears and aching feet. Things do get better, though.
During one of Monger’s first shifts after starting her first job, she was responsible for discharging three patients. At first, it was intimidating, but that changed quickly. “By the end of the day, I knew how to do it,” she says. “Once you do something the first time, you’ll begin feeling more comfortable and more confident.”
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