Itâs 8:00 a.m. and Christa Thompson, BSN, RN,* is travelling to a local Houston hospital to educate nursing staff on the latest medical device. A typical day is anywhere from two hours up to 12 hours for her, but sheâs not unusually tired or stressed by the end of the day. A nurse for over five and a half years, Thompson is a RN by trade and works part-time as an independent clinical consultant training other people on the use of medical devices. She credits her nursing education and curiosity at an international nursing conference for getting her this job.
âI went up to a medical device booth at the conference and asked the representative if they hired nurses, simply out of curiosity,â says Thompson. âI was pretty much hired on the spot.â She loves her consultant job and knows her new career is a dream job for most nurses, but nursing is not where her true passion lies.
Thompson plans on leaving nursing to become a doctor. Nursing has been a rewarding career for her, but she realizes she canât do nursing forever, even if her intentions werenât to continue on to medical school. She is not alone in the sentiment that nursing at the bedside is not something that most nurses can do for their entire career. Her path to transition from the bedside is unique but not uncommon to many nurses in the profession.
Of the 3,514,679 nurses in the United States, nearly 63.2% of RNs and 29.3% of LPNs work in a hospital setting. The RN Work Project reports an average of 33.5% of new RNs leave the bedside within the first two years. Leaving the bedside to pursue other nursing positions does not necessarily mean nurses leave the profession, but it is a catalyst to do so. Why do some nurses leave the bedside and eventually the profession? Ask any nurse and the answers are varied, but common themes seem to ring true for most.
Why Nurses Leave the Bedside (and, Ultimately, the Profession)
Poor Management. One of the greatest complaints nurses have is the lack of support from their management team. What makes a poor manager? Some nurses may say itâs one who doesnât value open-communication and feedback from his or her staff. Some say itâs the management team that plays favorites amongst staff or a particular shift. Yet, other nurses say itâs the manager who is not supportive of a nurse advancing her career. The list could go on forever, but one common frustration among nurses is the overall lack of support for those at the bedside. It seems to some that once nurses become managers, they âforget where they come fromâ and are oblivious to the struggles a bedside nurse faces on a daily basis.
Management may not even be aware of the stressors their staff encounters working the bedside. It could be that they are so wrapped up with their own job that they canât focus on what would make life better for their staff. Or it could be that they just donât care. Whatever the case, nurses do feel strongly about poor management.
Thompson agrees that management sometimes shows little consideration for those working at the bedside: âI feel like the night shift is ignored by management, like they have no voice.â The same sentiment echoes true for many other nurses. They feel as if management does not value them as part of the health care teamâjust as a docile staff that follows orders without question.
The best form of leadership follows a diplomatic approach; meaning, higher-ups actively engage their employees for input on situations that may arise. The diplomacy allows for everyone to have a voice. This type of management style encourages active participation among all employees and may dissipate some of the negative feelings some nurses feel towards their management team.
Lack of Upward Mobility. Many nurses unhappy with their chosen profession find that job mobility from the bedside is difficult without an additional degree. A nursing degree overqualifies many from other jobs outside of nursing and may not pay the equivalent of a nurseâs current salary. In order to get a job that pays as much or more than the average RN makes, additional years of school are typically required. This is a sacrifice that some may not be able to make, given that going back to school requires time away from work.
For those willing to go the extra mile and complete a higher degree in nursing, many career opportunities abound. Going back for an advanced nursing degree is the way some nurses find personal satisfaction in their career. Although not in a graduate program yet, Brittany Green, BSN, RN, a relatively new nurse of three years, plans on becoming a family nurse practitioner to influence patients in an outpatient setting and prevent some of the morbidity and mortality she sees in her current job as a cardiovascular recovery room nurse.
Green believes nurses leave because they experience burnout. âItâs not a career for everyone. It takes a special type of person to handle the emotional and physical stress that comes along with nursing,â she says. âI know I wonât be able to do bedside nursing forever; the long hours and stress will start to wear more on me.â
Underpayment. A nurseâs job can be physically and emotionally draining. Many nurses feel like they are severely underpaid for the work they do. Twelve-hour shifts can feel more like 16 when you are working the job of four people, but only getting paid for one. Nurses also sacrifice holidays, weekends, and family events because of their long and ever-changing schedule.
On the other hand, one may say a nurseâs schedule is ideal; a three-day work week schedule and having the ability to take long vacations using minimal vacation time sounds appealing to many.
But at what cost?
Nurses are notorious for picking up extra shifts on their day off because they feel like they are being paid not nearly enough for the work they do. Based on the most recent Minority Nurse annual survey results, the average RN salary in the United States is $67,980 per year. This may be considered a solid middle class income for most Americans, but nurses work very hard and feel as though it is not enough most days.
Too Many Tasks. Todayâs nurse does it all; you name it, nurses do it. Administer meds? Check. Assist patients with dressing, bathing, and mobility? Check. Perform bedside procedures once done by physicians? Check. Coordinate care between all disciplines of the hospital? Check. The list is endlessâand thatâs the problem. Nurses are responsible for so many aspects of a patientâs care that it can become overwhelming for one person to manage during a shift.
A typical nurse works a 12-hour shift that translates into much more when the nurse is doing the job of multiple people day in and day out. Sometimes a nurse is so involved in completing everything it becomes difficult to take a much needed and deserved break during her shift. This makes for a very long day. Although the typical nurseâs schedule consists of three 12-hour shifts per week, when the days are packed with multiple tasks and responsibilities each and every day, burnout is inevitable. Studies conducted to rate nurse turnover clearly show that as a nurseâs workload increases, nurse burnout and job dissatisfactionâboth precursors of voluntary turnoverâalso increase.
Nurses performing too many tasks typically boils down to staffing, specifically understaffing, which is also known as short staffing. When nursing units are short-staffed, nurses take on a majority of tasks done by others simply because they know how to do many other peopleâs jobs, but those people cannot do the job of the nurse. How many nurses have had to cover the front desk because there is not a unit secretary on duty? Or how about the nurse who is behind on her nursing duties just because she is trying to complete activities of daily living for a patient that is usually carried out by a nurseâs aide? Nurses wear the hat of many, but no one can take on the role of the nurse.
Short Staffing. A resounding number of nurses blame short staffing as the most common reason nurses leave the profession. According to a recent poll on Allnurses.com, more than one third of 1,500 nurses polled say that continuous short staffing drives nurses from the bedside and, ultimately, the profession. One of the reasons for short staffing is management cutting costs as much as possibleâand what better way to do that than cut staff and work on less than is needed? Nurses are notoriously known to multitask, wearing many hats on a day-to-day basis. Management knows this and may not think itâs a problem to go without a unit secretary or nurse aide on the unit because nurses will pick up the slack. Unfortunately, this unequal distribution of work leads to many unhappy nurses who burn out quickly when doing the job of many people.
Employers can ease the burden on nurses by mandating nurse-patient ratios. Since 2004, California has mandated patient ratios of 1:5 for nurses working in hospital settings. Studies have shown the benefit of such staffing ratios. The Aiken study demonstrated that nurses with California-mandated ratios have less burnout and job dissatisfaction, and the nurses reported consistently better quality of care, leading to decreased turnover.
Decreasing patient-nurse ratios has more benefits than disadvantages that could benefit US hospital systems. The Aiken study followed nurses in three states: Pennsylvania, New Jersey, and Californiaâwith California being the only state with mandated nurse-to-patient ratios. Over 22,000 RNs were surveyed, and researchers found:
⢠RNs in California have more time to spend with patients, and more California hospitals have enough nurses to provide quality patient care;
⢠In California hospitals with better compliance with the ratios, RNs cite fewer complaints from patients and families;
⢠Fewer RNs in California miss changes in patient conditions because of their decreased workload than RNs in New Jersey or Pennsylvania;
⢠If Californiaâs 1:5 ratios on surgical units were matched, New Jersey hospitals would have 14% fewer patient deaths and Pennsylvania hospitals would have 11% fewer deaths;
⢠Nurses in California are far more likely to stay at the bedside and less likely to report burnout than nurses in New Jersey or Pennsylvania.
Maybe other states should follow Californiaâs lead and mandate nurse-patient staffing ratios. What will it take to get the message across to industry leaders and make a change in how staffing levels are managed across the United States?
To Stay or Go?
The nursing profession isnât completely lost on Thompson. She still works occasionally at the bedside on an intermediate care unit simply because of the one-on-one interaction she has with her patients. Many nurses reflect that they love nursing and enjoy spending time with their patientsâsomething that is becoming more and more difficult with everything nurses are expected to do in this day and age.
The decision to leave the bedside affects not only the nurse contemplating such a transition but also the facility and patients who may be taken care of in a facility that is short-staffed. Replacing a nurse is costly. The RN Work Project cites the average cost to replace an RN who leaves the bedside ranges from $10,098 to $88,000 per nurse. Whatâs more astonishing is total RN turnover costs range from approximately $5.9 million to $6.4 million per year at an acute care hospital with more than 600 beds.
There are nurses who love their career and wouldnât ever think of leaving. Kim Hatter, MSN, RN, is one of them. Drawn to the profession because of her mother, she was inspired by her compassion at an early age: â[My mother] was actually one of the first African Americans to graduate from Southern Arkansas University as a registered nurse.â
When questioned whether or not she had plans on leaving the profession, Hatter says no. âIâve never thought of leaving the nursing profession, but I have sought a higher level of education in nursing recently.â Like Green, Hatter is completing her goal of becoming a nurse practitioner. She recently graduated from an adultâgerontology program and will soon leave the bedside to work at an outpatient clinic.
Because the bedside can be brutal on the body, many nurses like Green and Hatter choose to pursue nursing higher education to move from the bedside instead of leaving the profession completely. âIâve heard of a lot of nurses with back and knee injuries,â says Hatter. âNursing is a physically taxing job and does take a toll on your body.â
What is the Answer?
Nurses face a variety of challenges in the workplace that makes their job difficult. Based on the most prevalent and distressing issues identified by nurses, what is the overall answer to keep nurses at the bedside and, ultimately, in the profession? The RN Work Project reported when RNs leave their job, most go to another health care job not necessarily in a hospital. This is great for the general community, but it leaves a gap in coverage in hospitals where most acutely ill patients go. Where does that leave patients who need care in a hospital setting?
Green doesnât think there is any one solution to the problem. âBurnout will always be an issue in the nursing profession,â she explains. âI think one of the most important things is for nurses to feel appreciatedâby employers, coworkers, physicians, and hopefully patients.â
Hatter has a different prospective on potential solutions to this monumental problem: âI think paying nurses a higher rate of pay is always an incentive to stay. I also think nurses should receive more recognition for the valuable role they play in society.â The common denominator between Hatter and Green is that they both believe the nursing profession deserves more credit than it currently receivesâand maybe this is the first step in keeping nurses happy and in the profession for the long haul.
Itâs been said that lesbian, gay, bisexual, and transgender (LGBT) nurses form one of the largest minorities within the profession, and yet they are hardly recognized as a subgroup. To date, limited data are available to determine just how many nurses identify as LGBT (or some variation of those letters, such as LGBTQ, in which the âQâ stands for questioning or queer). But according to a 2013 Gallup poll, approximately 3.5% of the US general population identifies as LGBT; so whether or not you identify as LGBT, itâs likely that you will have to treat patients who do at some point during your nursing career. As patient advocates first and foremost, nurses must strive to provide culturally competent care for all, regardless of gender or sexual orientation.
LGBT nurses and patients alike face a unique set of challenges in the health care system: hostile personnel, lack of insurance, and higher rates of certain disorders, such as substance abuse. Yet both seek to make the health care system more supportive and equitable through changes in policy, education, and advocacy. Their aim: to raise cultural competence of health care professionals and lower the health disparities and barriers to care affecting LGBT individuals, families, and couples. Here are the profiles of five professionals committed to leading the charge for an open and accepting health care environment.
Austin Nation, RN, PHN, MSNÂ
PhD Student at University of California â San Francisco (UCSF)
Veteran nurse Austin Nation has over 30 years of nursing experience to his credit, including stints in hospital supervision and providing AIDS services, before heading back for a PhD program. His aim is to teach nursing, which he is now undertaking as an adjunct professor at San Francisco State University.
He says heâs faced a âtriple-whammyâ of discriminationâsurprising in a city like San Francisco, where he expected more cultural competency around these issues.
âI thought this was the gay mecca, with open, liberal thinkers, but that hasnât been the case,â he says. âIâve experienced racism, sexism, and homophobia. Iâm a black male in nursing. Iâve been blatantly subjected to all this stress while embarking on a PhD journey, which is already stressful enough.â
Nation wonders why the UCSF system, which dominates the city and cares for a larger LGBT population than any other, is âso provincial when it comes to addressing issues closest to the heart of that community.â
âWe have beautiful diversity banners, photos of different kinds of people together all getting along, but it isnât like that,â he says. âIn an academic setting, change happens so slowâitâs like turning the Titanic.â
Nation takes every opportunity to raise consciousness in class. âIâm trying to provide education in real time as it happens.â For example, if a nurse refers to gay patients in a distant or disrespectful way, heâll step in: âHey, thatâs us youâre talking aboutâweâre not those people.â In addition, Nation leads a Men in Nursing group and is spearheading an LGBT Cultural Competency for Healthcare Providers workshop that has generated overwhelming interest.
One part of the problem, Nation suggests, is that âthe health care community tends to be conservative. We come from a paradigm of heterosexuality.â It wasnât too long ago that homosexuality was considered a psychological aberration, he adds.
Nurses are often uncomfortable with the subject of sexuality and reluctant to talk to patients about sexual health, Nation has observed. He suggests that discomfort first crops up during physical assessment class as undergraduates.
âWe learn about the human sexual reproduction system. Then, during a head-to-toe assessment of a patient, you pull the covers up and look. But what are you looking for?â What happens if a nurse pulls up the gown of a male and sees female sexual organs, say? âThatâs a good opportunity to have a conversation about gender variances,â he says.
âThere have been many people that didnât accept me,â explains Nation. âIâm the kid from the ghetto who made good. For me, the saving grace is that Iâve had women whoâve taken me under their wings. They watched over me and protected me in difficult or sensitive situations. I try to create that same sense of belonging for my students.â
Riikka Salonen, MA
Manager, Workforce Equity and Inclusion, Oregon Health & Science University (OHSU)
A bi-national native of Finland, Riikka Salonen leads diversity and inclusion strategy efforts at OHSU in Portland, Oregon. âOur intention is to provide an environment of care which is welcoming and inclusive,â she says, âas well as protective of patient and employee rights and benefits. For instance, weâve had same-sex partner benefits since 1998, and offered transgender health-specific benefits for employees for over a year.â
Family inclusion is one topic that OHSU focuses onâand for patients, that means visitation is a given for everyone, including same-sex couples or a child who has two mothers. âFamily inclusion also means that if a gay employee wants to put out family photos, they feel they can without there being whispering about it.â
OHSU Pride, an employee resource group for LGBTQ employees and allies, was started in 2007 to ensure an inclusive environment. âOHSU Pride has created a significant difference in our campus, which has become very LGBTQ-affirming,â says Salonen.
LGBTQ education and consciousness-raising at OHSU is an ongoing effort, Salonen notes, starting with new employee orientation. From there, it proceeds on an as-needed basis, depending on a nurseâs specialty. For example, Salonen says, OHSU provides âa specific session for pediatric nurses that focuses on providing care for transgender or gender-nonconforming youth.â
Parents worried about a 5-year-old boy who insists heâs a girl, for example, can be referred to TransActive Gender Center (www.TransActiveOnline.org), a national nonprofit with low-cost services for youth and families. (For those living outside Portland, Skype counseling sessions are an option.)
Mary Bylone, RN, MSM, CNML
Regional Vice President, Patient Care Services, Hartford HealthCare, East Region, and Director, American Association of Critical-Care Nurses National Board of DirectorsÂ
âIâm 58 and didnât figure out my lesbian orientation until later in life,â says Mary Bylone. âMy brother is gay and so is my son. I didnât come out at first because of the prejudice and abuse my brother experienced. As a manager, Iâm now out; [but] as a staff nurse, I wasnât.â
Bylone says her sexual orientation doesnât totally define her: âItâs part of me, not all of me.â She has noticed that fellow employees and patients gravitate toward her to talk about gay issues. Possibly, she suspects, they do it âbecause Iâm an out person in a responsible position. One day, a mother started crying when she told me her son was gay. I was able to comfort her as the mother of a gay son.â
Bylone has experienced situations where patients have discriminated against gay nurses. âI remember a patient who asked to see me when I was a head nurse,â Bylone recalls. âShe didnât want to see her nurse that day. âWhy? Is it because heâs a man?â âNo, thatâs just the problem. Heâs no man,â is what she answered. Unfortunately, the nurse was standing outside the door and heard her cruel complaint.â
Bylone adds that managers sometimes treat out nurses differently. âYou may be assigned a gay patient when people know youâre gay, misunderstanding that someoneâs sexual orientation does not define her or his entire person,â she explains. âIâm a nurse who happens to be lesbian, not a lesbian nurse.â
Emily Pittman Newberry
Trans Woman and Recent Surgical Patient in Portland, Oregon
Emily Pittman Newberry says she lived life for 55 years âpretending to be a man,â before embracing her gender identity as woman and transitioning over a period of five years. âPeople often ask me, âWhen did you decide you were a woman?â The question should be: âWhen did you acknowledge it to yourself and choose to live openly?ââ Every transgender person Newberry has met or read about says they always knew.
Newberry maintains that health care personnel have been universally professional and even kind to her during this process, though she had trouble with her insurance company. They wouldnât cover the cost of surgical gender-confirming surgery.
She has some advice for nurses, such as not taking it for granted that you know a patientâs gender. âAsk them to self-identify and tell you what gender pronoun they prefer you use in referring to them,â says Newberry, though she understands that âasking is a tender place for a nurse and a transgender person.â
âSometimes I see someone who is clearly struggling with itâgetting pronouns wrong, getting uptight [such as the time she asked a clerk to change her gender in the clinic patient record system],â says Newberry. âI want to say, âThis is new for everybody.â Itâs my job to educate people, be kind and humane even when I feel angry. Itâs a dance, and weâre all learning the steps.â
Another piece of advice is to not get thrown if a transsexual patient has a health condition that doesnât match their gender as your records show it. âIf you see a prostate problem in a woman, for instance, act like itâs no big deal,â Newberry suggests.
Many health care IT systems only offer âmaleâ or âfemaleâ as gender choices, which is limiting and potentially hazardous. Binary options are also being challenged by popular culture. Facebook now allows users to self-select from 56 gender options, such as âtransgenderâ and âintersexâ and âFemale to Male/FTM.â
There are bound to be many uncertainties and uncomfortable moments for Trans patients and their nurses as we travel this unmarked path. âDo your best to carry on in a professional way,â says Newberry. âAsk yourself: âAm I being tender or am I being rational?â You can be both at all times, of course, but sometimes more on the compassionate side and other times the scientific. Both are a part of every health care professionalâyou can emphasize one or the other, depending on the situation.â
Desiray Bailey, MD
Hospital Chief of Staff, Central Hospital, Group Health Cooperative, Seattle, WA, and immediate past president of GLMA: Health Professionals Advancing LGBT Equality (formerly known as the Gay and Lesbian Medical Association)
âGLMA was a physician-oriented organization originally, but we decided to be more inclusive and include the whole health care team,â says Desiray Bailey. âWe work to provide opportunities to practice openly and more compassionately.â
Nurses are now an active part of the group, as evidenced by GLMAâs annual conference and nursing summit, scheduled for September 10-13, 2014, in Baltimore, Maryland.
One of the aims of GLMA is to improve education and awareness of gay and transgender issues among health care personnel. âItâs a very rare nursing program that provides LGBT education,â says Bailey. âWeâd like to see it as part of the curriculum for all health professionalsâphysicians, nurses, physician assistants, and people in behavioral health training.â
At Group Health, Bailey has been an advocate for equal treatment of LGBT staff and patients for many years, facilitating changes in policy, employee benefits, patient and family visitation, consumer rights, and community outreach.
Additionally, she advocates for equal treatment so that âany professional in a hospital or medical center who is gay, lesbian, bisexual, or transgender wonât experience discrimination as an employee because they canât be out, or their organization doesnât provide benefits that are equitable with straight employees.â
In many states where LGBT employees arenât a protected class, itâs possible to be discriminated against or fired for being gay. Even worse, a few states have âanti-gay lawsâwhere certain sexual acts are illegalâor there arenât specific protections,â Bailey says. âIâm fortunate to live in Washington Stateâweâve had domestic partnerships for a few years and now marriage equality.â
According to Bailey, the Affordable Care Act has benefited the LGBT community. âInsurance plans canât discriminate based on sexual orientation or gender identity. Legally married couples are still recognized, even if they live in a state that doesnât recognize their union, and there arenât lifetime limits for AIDS patients,â she adds.
Among the tools available to improve LGBT equality in a health care setting is the Healthcare Equality Index of the Human Rights Campaign, a civil rights organization. âThis is a tool that really changes the atmosphere for employees and patients,â says Bailey. Once a decision has been made to participate, âthereâs an organizational will to want to score well. They want to put in place the right policies and training for staff,â she adds.
Seeking out legitimate information about LGBT issues is very important âif you want to take care of all your patients,â Bailey says.
Jebra Turner is a freelance health and business writer based in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at www.jebra.com.Â
Romeatrius Moss, RN, MSN, APHN-BC, DNP, doesnât mince words when she advises other nurses about advancing their careers. âIf you arenât geared and ready and have everything in your toolbox, you are going to be left behind,â says Moss, the executive director of the Mississippi Gulf Coast Black Nurse Association. âGetting an advanced degree is extremely important. It pushes our profession forward.â
As more minority nurses advance, they are positioned to assume leadership roles and increase the diversity of nurse leaders, all of which reflects the patient population.
Mossâs outlook mirrors one that is hotly debated in nursing. The Institute of Medicine (IOM) garnered attention with its 2010 report, The Future of Nursing: Leading Change, Advancing Health, which calls for a highly educated nursing workforce to keep pace with the changing demands of both the health care environment and the patients who are served. An 80% goal of nurses with BSN degrees and a doubling of nurses with doctorates are imperative for the nursing community, the report stated.
âItâs good for the professions, but equally good and equally more important for the people who are coming into the health care system who deserve an educated workforce,â says Jane Kirschling, PhD, RN, FAAN, president of the American Association of Colleges of Nursing (AACN). âThe bottom line is about patient safety and providing health care that is high quality, efficient, and cost effective.â
In light of the study and others like it, nursesâwho build careers on changeâare debating the best and most reasonable ways to achieve career satisfaction and advancement. A nursing career includes different options, and one work day is never like another. To achieve maximum career success and optimize your salary potential, learn to embrace the changing atmosphere, says Janice Phillips, PhD, MS, RN, FAAN, director of government and regulatory affairs at Commission on Graduates of Foreign Nursing Schools International, an authenticity credentialing service of foreign-educated nurses.
Advancing Your Education
The 2010 IOM report brings the issue of higher nursing degrees into sharp focus, causing some nurses to reevaluate their goals and some hospitals to implement new minimum requirements for employment. âWhether it is an associateâs, bachelorâs, or masterâs-prepared nurse, the reality is that nursing requires lifelong learning,â says Kirschling.
Nurses have choices about how to advance, but a degree appeals to many organizations. âA minimum of a bachelorâs in nursing will open doors when you are competing for a job, and it shows a level of commitment,â says Marie-Elena Barry, a senior practice and policy analyst at the American Nurses Association. And even Kirschling says that an associateâs degree is often considered a point of entry into nursing now, not the final point.
Nurses are taking notice. Results from the Health Resources and Services Administrationâs (HRSA) â2008 National Sample Survey of Registered Nursesâ showed that half of registered nurses hold a bachelorâs degree or higher, and just over a third hold an associateâs. The rest have a diploma in nursing. Most nurses initially receive an associateâs degree, but about a third start out with a BSN. And for those who eventually earn higher degrees, the study showed approximately half of nurses with masterâs degrees work in hospitals while the rest work in academia or in an ambulatory care setting.
According to a May 2012 occupational employment and wages report by the Bureau of Labor Statistics, an RN can expect to earn a mean annual wage of $67,930. Furthermore, the 2008 HRSA study revealed that RNs with graduate degrees earned an average of at least $20,000 more than RNs with other levels of education. Nurses who graduate with a degree also get into the workforce faster. Data from an August 2013 survey by the AACN revealed that nursing graduates of BSN or masterâs programs are much more likely to have a job offer at graduation than graduates in other fields.
And while the higher salary is great, nurses are finding they need a bachelorâs to even get a job. The AACN study showed that 43.7% of hospitals and other health care settings require the degree and that 78.6% of employers prefer to see the BSN on a resume even if they donât require it.
When you consider how to advance both your professional goals and your personal goals, keep in mind how each job will help you get to where you want to be. âLots of nurses get a degree and go to work and donât think about career development and learning how to grow your career,â says Barry. As a new nurse, you must ask yourself whether you are gaining valuable experience that you can put on a resume. And if you have been in nursing for years and are considering a move to academia, you should consider whether a teaching position will offer you needed benefits and retirement.
A Balancing Act
Working and going to school isnât easy, and adding other obligations, like family, often makes the task overwhelming. But as the demand for nurses with a bachelorâs degree increases, schools are making it easier by offering accessible classes and accelerated degree programs. And Moss advises nurses not to be discouraged by the commitment. âThis is a train,â she says. âJump in when you can.â
In the meantime, anything you can do to make yourself more valuable to an organization will help increase your salary, and often a new degree raises your pay as well. âProvide evidence of how you made a difference,â advises Phillips.
Kirschling suggests talking with your employer about wanting to build on your skill set or your desire to continue your education. âEmployers want to retain nurses and create career mobility within the organization,â she adds.
Keep Your Options Open
âPeople believe the continuing mantra that nurses need to work in traditional venues like hospitals and doctorsâ offices,â says Carmen Kosicek, RN, MSN, author of Nurses, Jobs, and Money: A Guide to Advancing Your Nursing Career and Salary. But the pay for those positions doesnât always match the financial outlay needed to practice there, she continues.
Instead, Kosicek advises nurses, especially those just graduating from nursing school, to look for other opportunities that offer both professional experience and gainful employment. âItâs not all about the money,â says Kosicek, âbut they all have bills.â
According to Kosicek, many graduates are not hired for 4 to 18 months, and many of them are competing for med/surg jobs to gain broad experience. She suggests considering other options where you will use all your skills. A position as a school nurse, for example, where you handle hundreds of varied and often complex cases is an excellent way to use your skills and learn new ones. When you apply for a new grad residency program, you are already starting above the rest of the pack, she says.
If you are unsure what your next move should be, Kirschling recommends checking out www.discovernursing.com to explore opportunities.
Approach Your Career as a Business
When you view your career as a business, you give yourself permission to look impersonally at your experience and your credentials. And you treat any potential job offer, salary increase, or career move with the same consideration as you would a major life change.
Just as you would negotiate the price of a house you are buying, you also must learn to negotiate salary offers, argues Kosicek. âItâs not always about your base pay of dollars,â she says. âYou can negotiate other ways of compensation.â For example, you can ask for more vacation days, a higher match of your 401(k) plan, or tuition reimbursement for classes.
âNo one is teaching that,â says Kosicek, but it is a valuable skill because it will get you closer to your goals. Negotiating shows you are confident and know your worth. âIt is a totally different language,â she adds.
Act Like a Leader
Even if you havenât reached your ultimate career goal, you can act like you have. âYou canât do a BSN [program] and expect to be a manager,â says Barry. âThere are lots of little steps.â
Be a leader in your nursing community and make your presence known. One way to help increase your salary potential is to get involved within your state or with national organizations, says Barry. Donât just become a member. Begin to make a difference by giving your input, showing up at events and meeting others, or volunteering on your state board of nursing, advises Barry. âIt increases your ability to network and puts your face out there.â
Donât overlook the importance of your workplace as well. Barry recommends getting involved with unit-based activities. Join a shared governance committee or work on a quality improvement project. Then give thoughtful input and work hard for the team.
Be More than Just Another Resume
Your resume might be your only shot at a job you want, so make it perfect. Just as nurses need negotiating skills to get ahead, they need a resume that is detailed and exact because it could mean the difference between the slush pile and a job offer.
âNurses are not going to get in with traditional nursing resumes or traditional interviewing skills,â says Kosicek. âThey have to show they are business wise.â
Barry agrees. Your experience, commitment, and education all combine into one package to an employer, but they have to be able to see it. You can do your part with a detailed resume that lists your education and any current classes along with your qualifications.
Become a recognizable name through your professional and appropriate exposure on social media and your networking efforts that bring you in touch with various health care professionals, suggests Barry.
Other Benefits
Of course, taking on a new degree doesnât work for everyone. You have to consider the financial return on your investment, so you arenât trading more education for insurmountable debt.
Chart the financial impact of furthering your education. If you want a degree but canât imagine how you will pay for it, become a sleuth for scholarships or take an alternative path. If your company doesnât reimburse for tuition, see if your professional organization membership gives you access to scholarships or grants. Can you take one class at a time to chip away at the degree?
A less tangible benefit of continuing your learning is confidence. âIt gets you excited and keeps you informed and learning outside your unit,â says Barry. âCertification is important. It shows your commitment to your profession. It also shows your professional role modeling.â When you are learning and advancing by taking classes, even if itâs one at a time, you are demonstrating to your employer that you are actively engaged in your profession, she says.
Phillips knows firsthand the benefits of doing the unexpected. She recently left a faculty job at Rush University and the comforts of family and friends for her current job in a new city. Although the prospect gave her nervous butterflies, Phillips says the job fit perfectly with her career plan, filling a gap in policy experience that Phillips wanted to have. âSometimes you just have to do it,â she says. âI didnât want to sit around and not take some risk. Most people who have a well-rounded professional life have taken some risk.â
Have a Plan
Your career will stagnate if you donât have a solid and ambitious plan to follow. Decide where you want to go and write a plan of action to get there. Put yourself in position to get where you want to be. Do you respect a nurse in a leadership position? Notice how she acts and ask about her volunteer work or about any organizations of which she is a member. âPart of the learning process is going through and collecting along the way,â says Barry. âAs you are getting a degree, you are exposed to all those other areas.â
Even if you are not looking for a job, keep accurate records of your career successes, advises Phillips. âWe donât document our outcomes,â she says, so when the time comes to tell potential employees about them, itâs hard to remember the details. Keep a fileââcall it a happy file,â suggests Phillipsâwhere you record accurate outcomes and contributions from your job successes. Pay particular attention to relevant numbers and dates, so you can retrieve them when necessary. âNurses have to be prepared,â she says. âYou never know when an opportunity will present itself.â
Does an Advanced Degree Equal Respect?
Like it or not, an advanced degree is the first step toward a leadership position. âItâs very important for nurses to get a nursing degree,â says Barry. For nursing as a profession to advance with respect, getting a degreeâparticularly a BSNâwill also bring more nurses into position to take over as future leaders. âNursing education has a lot to do with where you go,â says Barry.
Starting with a BSN is the most important goal because it keeps you competitive, argues Barry. But as Kosicek points out, you will have to find your place in the market and actively seek out nursing roles that both pay your bills and satisfy your professional goals. Sometimes, a career move is your chance to advance professionally and personally and will lead to greater rewards, but you have to be willing to take the leap.
âThe risk is that we have to be open and willing to leave our comfort zone to experience all nursing has to offer,â says Phillips. âAnd itâs scary. But I donât believe anyone should be burned out. You need to find a new perspective.â
Just as each nurse is unique, so is each successful career path, says Phillips. âIâve been a nurse for 37 years, and I am just as excited today as the day I graduated because I see the possibilities,â she says. âAt the end of the day, how do you want to feel about what you want to do and what makes you proud of your profession?â
Julia Quinn-Szcesuil is a freelance writer based in Bolton, Massachusetts.Â
Advanced education and specialty certifications can help minority nurses take their careersâand their ability to improve health outcomesâto a whole new level.
Carmen Paniagua has so many educational and professional credentials after her name that she practically needs an oversized business card to fit them all. In addition to being an RN, she is an ANP (Adult Nurse Practitioner), a board-certified ACNP (Acute Care Nurse Practitioner) and AGACNP (Adult-Gerontology Acute Care Nurse Practitioner), an APNG-BC (Advanced Practice Nurse in Genetics), and a FAANP (Fellow of the American Academy of Nurse Practitioners). Sheâs also a CPC (Certified Procedural Coder) and a CMI (Certified Medical Interpreter), and she holds MSN and EdD (Doctor of Education) degrees.
âSome people probably look at my CV and think this is just a lot of âalphabet soup,ââ says Paniagua, a faculty member at the University of Arkansas for Medical Sciences College of Medicine in Little Rock. âBut advanced degrees and certifications are more than just a collection of letters. Theyâre the evidence and recognition of your competence and clinical expertise. They enable nurses to take pride in the accomplishment of advanced practice knowledge and to demonstrate their specialty expertise to both employers and patients.â
Jose Alejandro, president of the National Association of Hispanic Nurses and corporate director of case management at Cornerstone Healthcare Group in Dallas, agrees that itâs what those abbreviations really stand for that counts.
âYou can have all the degrees and certifications you want, but itâs the tools you learn from having them thatâs the biggest benefit,â says Alejandro, an RN-BC (Registered Nurse-Board Certified), CCM (Certified Case Manager), FACHE (Fellow of the American College of Healthcare Executives), and a MBA who recently earned his PhD. âThey give you additional skills and what I call your âchops.â Thatâs primarily what has enabled me to move up in my career, because I can accomplish things based on more than just having experience.â
Opening Doors
There are many compelling reasons for minority nurses to pursue graduate education and specialty nursing certifications. Acquiring these credentials opens the door to a wide new horizon of rewarding advanced practice careers and leadership rolesâfrom nursing professor and nurse scientist to nurse practitioner, nurse anesthetist, nurse executive, and more. Furthermore, the Institute of Medicineâs (IOMâs) landmark 2010 report The Future of Nursing: Leading Change, Advancing Health calls for all nurses to âachieve higher levels of education and trainingâ and âattain competency in specific content areasâ in order to respond more effectively in todayâs rapidly evolving health care environment.
But the IOM report also underscores an even more persuasive reason. Advanced degrees and certificationsâor more precisely, the specialized knowledge and skills nurses gain from themâare linked to improved patient outcomes and better nurse-led interventions for eliminating minority health disparities.
âThis is a wonderful time for all nurses, and particularly nurses of color, to seriously look at graduate education, because of the millions of uninsured and underinsured people who will now be coming into the health care system as a result of the Affordable Care Act,â says Kem Louie, PhD, RN, PMHCNS-BC, APN, CNE, FAAN, professor and director of the graduate nursing program at William Paterson University in Wayne, New Jersey. âMany of these new patients will be members of medically underserved minority populations. The other issue is that thereâs a shortage of primary care physicians. So thereâs a tremendous need to increase the number of culturally competent advanced practice nurses who can meet these patientsâ primary health care needs.â
Of course, itâs also hard to ignore the âwhatâs in it for me?â benefits. Becoming certified in an in-demand specialtyâfor example, emergency nursing, perioperative nursing, critical care, or pediatricsâincreases your value to employers. Plus, itâs no secret that many advanced practice (APRN) specialties that require a masterâs degree and board certificationâsuch as Certified Registered Nurse Anesthetist (CRNA) and Certified Nurse-Midwife (CNM)âpay substantially higher salaries than the typical staff RN position (see sidebar). In fact, according to the most recent (2008) Health Resources and Services Administration (HRSA) National Sample Survey of Registered Nurses, RNs with graduate degrees earn an average of at least $20,000 more per year than nurses with lower education levels.
But itâs not just about the money, argues Henry Talley V, PhD, CRNA, MSN, MS, director of the nurse anesthesia program at Michigan State University College of Nursing in East Lansing and treasurer of the American Association of Nurse Anesthetists. âAdvanced degrees and specialty certifications do increase your earning powers,â he says. âBut they also increase your ability to make change happen in health care. They make you an expert in your particular field, and they put nurses on an equal footing with other health professionals.â
Breaking Down Barriers
Minority enrollments in graduate nursing programs have nearly doubled over the past decade, according to the American Association of Colleges of Nursing (AACN). Yet racial, ethnic, and gender minority nurses continue to be underrepresented among the ranks of APRNs and certified RNsâprimarily because theyâre still underrepresented in the nursing population as a whole. Fortunately, numerous nursing organizations, from AACN to the American Board of Nursing Specialties, are recognizing the need to identify and remove barriers that may prevent nurses from diverse backgrounds from earning the advanced credentials they need to succeed.
Traditionally, one of the biggest challenges in going back to schoolâfor majority and minority nurses alikeâis finding the funds to pay for it. And thanks to the current economy, with its skyrocketing tuition rates and burgeoning student loan debt, figuring out how to afford graduate school can be a trickier task than ever. Then thereâs the cost of certification examinations, which in some cases can range from about $300â$400 to as high as $725 for the CRNA exam. But even though finances can be a formidable obstacle, theyâre not an insurmountable one.
âWhat I have personally observed is that our potential minority nursing students are much more hesitant to take out loans and incur debt than majority students,â says Courtney Lyder, ND, ScD(Hon), GNP, FAAN, dean and professor at UCLA School of Nursing. âAnd what I tell them is: Nurses make good salaries. Compared with other academic disciplines, the compensation in nursing makes it one of the few professions in which you can actually pay off student debt in a timely manner.â
âOne of the benefits of coming to graduate school now is that there are still scholarships and federal financial assistance programs available,â adds Louie, who is also the founding president of the Asian American/Pacific Islander Nurses Association. She cites HRSA programs like the National Health Service Corps, which provides scholarships for nurse practitioner and nurse-midwife students in return for a commitment to practice in a medically underserved area for at least two years after graduation, and the Nurse Faculty Loan Program, which forgives 85% of student loan debt for RNs who complete a graduate degree at a participating school and agree to serve as full-time nursing faculty.
Talley and his wife, a Clinical Nurse Specialist (CNS), recently conducted research examining some of the other factors that impede minority nurses from pursuing advanced degrees in general and nurse anesthesia degrees in particular. Lack of knowledge about APRN and specialty nursing career paths is another big barrier, he says.
âThere are still people of color out there who have just not had the exposure to these career options,â Talley explains. âNursing specialties have to get the message out to them about these opportunities and what the requirements are. Nurses need to know early on that they will want an advanced degree, because the key to opening that door will be how well they do in their undergraduate studies. Otherwise, theyâll find out about advanced practice specialties later in their BSN programs and decide âI want to do thatâ when their GPAs will not support it.â
But Alejandro believes that perhaps the hardest hurdle for minority nurses to clear is the surprisingly common âfear factor.â
âItâs the fear of failure, fear of the unknown, fear of whatever,â he says. âI tell all the students I mentor: âThe very first barrier you have to overcome in pursuing any advanced education or any certification is removing that fear.â In my case, once I was over that fear, I was able to ask questions. If I didnât understand something in a particular class, I went ahead and asked classmates who understood it a little better.â
Starting the Journey
So youâve decided itâs the right time to return to school, earn an advanced degree, and chart your course toward a fulfilling specialty nursing career. Congratulations! But where do you start? How do you choose which graduate program to apply to? And what type of degree should you go after? Is a terminal masterâs enough or will you need a doctorate?
Lyder, who made history by becoming the first male minority dean of a school of nursing in the United States, as well as the first African American dean at UCLA, says it all boils down to answering one basic question: What do you want to do?
âFind your bliss,â he advises. âIs it pediatrics, geriatrics, psych/mental health, administration, nurse-midwifery, nurse anesthesia? Once youâve figured that out, the next step is to identify schools in your community that may have those programs. Then, contact those schools and schedule a time to talk with the admissions counselorsâand I donât mean an e-mailâto see if this is something you really want to pursue. Also, try to find an opportunity to shadow someone whoâs in that role. Identify that CRNA or that psychiatric nurse practitioner and say, âCan I shadow you for a day to get a sense of whether this is what I want to do?ââ
Getting over the fear of speaking directly with admissions officers or the graduate program director to get the facts you need to make well-informed decisions about a school is key, Louie emphasizes.
âYou have to tell yourself, âJust pick up the phone,ââ she says. âGraduate programs in nursing are competitive and some of them can be very daunting. But I find that I have to invite students to talk to me, to ask me, âWhat support services are available? Tell me about the admission requirements. Help me through the application process.ââ
As for what kind of advanced degree to get, once again it all depends on your goals.
âSome nurses are confused about advancing their education. They think they all have to be PhDs,â says Paniagua. âWell, if youâd like to be a nurse researcher, then a PhD is fine, because itâs primarily a research-focused doctorate. But then there are other avenues. You can get a doctorate in nursing practice (DNP), which is a professional practice degree, or you can get an EdD, which is an education-focused doctorate. So if youâre planning to have a career in academia, you should pursue either an EdD or a PhD. If youâre planning to practice or to work in the clinical setting, you should get your DNP. Or you can just get a masterâs degree [in your specialty area of interest, such as an MBA or an MSN in nursing informatics].â
Above all, the most important thing to consider when shopping around for a graduate program is finding one thatâs the right fit for your specific needsâboth academic and personal.
âYou need to make sure that your value system is in sync with the mission and vision of the institution,â Lyder says. âFor example, here at UCLA we are a research-intensive school of nursing. Our professors infuse research and evidence-based practice into every course, every lecture, everything they do. If thatâs not the type of learning environment you want, then this isnât going to be a good match for you.â
Louie recommends investigating different program formats to find options that will accommodate what she calls âyour life needs.â For instance, if you have to keep working at your job while going to school, or you have young children or other family obligations, the traditional full-time, brick-and-mortar campus model may not work for you. âYou need to know that there are online programs, there are blended online/on-campus programs, there are part-time and weekend programs,â she says.
Another alternative worth exploring is the accelerated (fast track) format. These programs include RN-to-MSNâalso known as a Masterâs Entry Program in Nursing (MEPN)âwhich bypasses the traditional BSN degree, and BSN-to-PhD, which bypasses the masterâs. Their greatest advantage is that they enable nurses to earn graduate degrees more quickly and earlier in their careers. However, because the accelerated time frame makes the academic workload extremely intensive, these programs arenât for everybody.
Taking the Plunge
Achieving the advanced degrees and certifications that will boost your career to a higher level can be an arduous process. But all the nurse leaders interviewed for this article agree that the rewards are worth it. In fact, with the right preparation, the right program, and strong support networks (family, friends, faith, colleagues, mentors, and minority nursing associations), it might just be easier than you think.
Talley offers this advice: âDonât be afraid to take the plunge. I think sometimes we [minority nurses] doubt ourselves, and thereâs no reason to. Believe in yourself, have faith in yourself, and donât let anyone interfere with your dreams.â
The latest Gallup Poll of Honesty/Ethics in Professions says the most trusted profession (for an astounding 13 out of the last 14 years) isâdrumroll, pleaseânursing. When random Americans were asked to âplease tell me how you would rate the honesty and ethical standards of people in these different fields,â more than 85% gave nurses âhighâ or âvery highâ marks.
This yearâs rating is the highest since 1999 when the profession was first included in the poll. The one year nurses didnât top the list? It was 2001, after the terrorist attacks of 9/11, when firefighters were included for the first and only time and scored higher. Gallup conducts the telephone survey in late November each year.
Health care professions dominated the top five most trusted groups: pharmacists came in next at 75%, medical doctors rated 70% (tied with the oddballs in this cohortâengineers), and dentists earned 62%. The lowest rankings go to car salespeople (8%) and, sadly, members of Congress (10%).
What is it that makes nurses so trustworthy? There are as many theories as respondents. Some say intimacy. After all, we stand nakedâboth literally and metaphoricallyâbefore nurses. But would the ratings be similar for massage therapists, say? Not likely. The Gallup data suggest that womenâon the whole and on averageâare seen as more trustworthy than men.
So would male nurses earn the same trust ranking as female nurses? Most likely.
But can nurses count on garnering trust automatically? Definitely not.
In the end, trust is personal. Some minority nurses especially feel that they must battle for respect. Here are a few ways to enjoy high regard in this very special professionâone that for many nurses is more of a âcallingâ than an occupation.
Embrace your role as a caregiver and patient advocate. âOne reason for trust is that nurses have what I call the home-court advantage,â says RamĂłn Lavandero, RN, MA, MSN, FAAN, senior director of the American Association of Critical-Care Nurses. âTheyâre with patients and their families more than any other professionals. In the hospital, itâs 24/7; even with home care, nurses still have more patient and family contact than anyone else.â
Lavandero says another factor is that above all else, nurses keep their patientsâ needs in mind. âThey see nurses going to bat for them when there are rules or systems in a health care setting that arenât effective.â For example, it doesnât serve end-of-life patients, he says, when hospital regulations donât allow visits from a lifelong pet.
Turn up the volume with stellar communication skills. âOne of the things I learned as a man and a nurse and as a native Puerto Rican is that if I was comfortable in a situation, the patient was comfortable,â says Lavandero. âNinety-nine percent of my experience was without problem, and that includes the year I worked in a labor and delivery unit.â
Strong communication skills become even more important when there is perceived bias, such as a patient who believes a minority nurse may be less competent or have a substandard education. âThatâs when your communication needs to shine,â he says, âperhaps by addressing the unasked question with a comment like âDid you know, when I was a student at Columbia University âŚââ A skilled communicator learns that direct confrontation is only one way to address barriers such as mistrust, he adds.
Nurses must communicate with many parties besides patients, including families, administration, and other health care staff members. Itâs not easy to speak to (and on behalf of) multiple constituencies, especially when a nurse isnât familiar with a patientâs desires, circumstances, or cultural background. âThatâs why we need to learn all we can about a patient and have to determine how to be honest without creating or introducing more difficulties,â says Lavandero.
Recognize that ethical issues are a cornerstone of nursing. âNurses are also trusted because their Code of Ethics is grounded in fairness and respect for all people,â says Cynda Hylton Rushton, RN, PhD, FAAN, the Anne and George L. Bunting professor of clinical ethics at Johns Hopkins University in Baltimore. Ethical training is part of every nursing school curriculum, and a code of ethics guides all nurses as they care for patients, she says. This is not a profession that only pays lip service to a moral ideal.
Some common ethical questions that nurses must consider, according to Rushton, are: âHow do we balance what patients or families want with whatâs available? (Often there are limits.) Also, how do we balance quality care with safety and efficiency?â One element of quality care is relationships, she says, but the âhealth care system is relationally depletedâ and devalues relationships in favor of efficiency.
Also, our American society and health care system âwould like to pretend that death is optional,â she explains. âThere is such fear and despair around aging, illness, disability, and death. Sometimes we feel that weâre doing things that are harmful or disrespectful to patients. Thatâs not what weâre called to do as nurses.â Nurses are often at the center of trying to navigate a broken system that causes them much distress, she adds.
Moral distress is a term Rushton uses to describe when a nurse knows the moral thing to do, but feels powerless to act on it. Itâs paramount that nurses become knowledgeable about ethical issues and effective ways to address quandaries, she says.
The future can be brighter, though, if nurses realize the publicâs trust in nurses is âsacredâ and âhard won.â She implores nurses to âmake sure, first of all, that weâre deserving of it. And second of all, uphold that trust.â
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