Hospitals in Europe where nursing staff care for fewer patients and have a higher proportion of bachelor’s degree-trained nurses had significantly fewer surgical patients die while hospitalized, according to a new study. These findings underscore the potential risks to patients when nurse staffing is cut and suggest an increased emphasis on bachelor’s education for nurses could reduce hospital deaths.
The study, supported by the European Union’s Seventh Framework Programme and the National Institute of Nursing Research (NINR), part of the National Institutes of Health, is the largest and most detailed analysis to date of patient outcomes associated with nurse staffing and education in Europe. Known as Registered Nurses Forecasting (RN4CAST), the study estimated that an increase in hospital nurses’ workloads by one patient increases the likelihood of in-hospital death by 7%. Also, a better educated nurse workforce was associated with fewer deaths. For every 10% increase in nurses with bachelor’s degrees, there was an associated drop in the likelihood of death by 7%. The results of the study are published in the February 25 issue of The Lancet.
“Building the scientific foundation for clinical practice has long been a crucial goal of nursing research and the work supported by NINR,” said NINR Director Patricia A. Grady. “This study emphasizes the role that nurses play in ensuring successful patient outcomes and underscores the need for a well-educated nursing workforce.”
For the RN4CAST study, a consortium of scientists led by Linda Aiken of the University of Pennsylvania School of Nursing, Philadelphia, and Walter Sermeus of the Catholic University of Leuven in Belgium, reviewed hospital discharge data of nearly 500,000 patients from nine European countries who underwent common surgeries. They also surveyed over 26,500 nurses practicing in study hospitals to measure nurse staffing and education levels. The team analyzed the data and surveys to assess the effects of nursing factors on the likelihood of patients dying within 30 days of hospital admission.
Based on their analysis, the researchers estimated that patients in hospitals where 60% of nurses had bachelor’s degrees and cared for an average of six patients had a nearly one-third lower risk of dying in the hospital after surgery than patients in hospitals where only one-third of nurses had a bachelor’s level education and cared for an average of eight patients each.
“Our study is the first to examine nursing workforce data across multiple European nations and analyze them in relation to objective clinical outcomes, rather than patient or nurse reports,” said Aiken. “Our findings complement studies in the US linking improved hospital nurse staffing and higher education levels with decreased mortality.”
In the US, analysis of patient outcomes associated with nurse staffing practices has informed proposed or actual legislation in nearly 25 states. These types of analyses also informed the recommendation of the Institute of Medicine that 80% of nurses in the US have a bachelor’s degree by 2020. Hospitals have responded to this recommendation with preferential hiring of bachelor’s degree-trained nurses.
The RN4CAST study was designed to provide scientific evidence for decision makers in Europe to guide planning for the nurse workforce for the future. The study’s findings provide evidence to guide important decisions about improving hospital care in the context of scarce resources and health care reforms.
“This study is another example of how nursing science can help inform policies that promote positive patient outcomes not only in the US, but around the world,” added Grady.
There’s a movement that’s spreading across the nation, and it’s called “Muevete USA.” It’s a project that brings together nurses and nursing student volunteers, low-income Hispanic children, and community organizations to learn about the importance of healthy eating.
Muevete (Move) USA, a program designed and executed by the National Association of Hispanic Nurses (NAHN) community, is possible thanks to a $150,000 grant from The Coca-Cola Foundation. It draws inspiration from First Lady Michelle Obama’s “Let’s Move” campaign. Muevete USA seeks to equip nurses with the skills and passion to short-circuit the pervasive cycle of childhood and adolescent obesity in the Hispanic community.
Since its implementation in 2011, the five-lesson educational program—teaching the basics of healthy eating, through preparing healthy snacks and exercise activities—has gathered momentum nationwide, having doubled in both participation and enthusiasm in 2013.
“The 2013 NAHN Muevete USA obesity prevention program was exceptional,” says Project Director Angie Millan, RN, MSN, NP, CNS, FAAN. “First, we doubled the number of instructors trained and the number of children who participated. Secondly, the program was implemented in 20 NAHN chapters throughout the United States, an increase of five chapters from the previous year.
“The most popular part of the program continues to be the five lessons, where the children get to interact with the instructors and participate in hands-on activities,” Millan added.
In 2012, the program expanded its reach to not only children, but also to their parents, custodians, and relatives, and saw increased community partnerships, which emphasized the grassroots focus of the project.
In Chicago, nursing student volunteers taught children a specialized dance routine to the beat of Latin music at the Boys & Girls Club in the Little Village neighborhood. In Phoenix, children gathered at the Friendly House where they learned techniques in self-defense and got their hearts pumping in relay races and obstacle courses. In Washington, DC, children and their families learned callisthenic and aerobic exercises at the Latin American Youth Center & Little Stars Camp.
The NAHN chapters developed YouTube videos as part of the project. Visit www.nahnnet.org/2012MueveteUSAChaptersVideos.html to watch the videos.
“We are delighted to once again partner with NAHN and this important health lifestyle training program,” says Frank Ros, Vice President, Hispanic Strategies for Coca-Cola North America. “This program is another step towards helping to create healthy, sustainable communities.”
“We are so proud of our student members, as well as the experienced NAHN nurses who came together with children and their families in low-income Hispanic communities to make this project a huge success,” remarked NAHN President Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE. “NAHN wants to thank The Coca-Cola Foundation for making this project possible.”
From New York City to Rio Grande Valley to Los Angeles, NAHN chapters, Hispanic nurses and nursing students, along with children and their families, continue to move to the beat of a healthier life.
In the largest, most comprehensive, nationwide study to examine the prevalence of allergies from early childhood to old age, scientists from the National Institutes of Health (NIH) report that allergy prevalence is the same across different regions of the United States, except in children 5 years old and younger.
“Before this study, if you would have asked 10 allergy specialists if allergy prevalence varied depending on where people live, all 10 of them would have said yes, because allergen exposures tend to be more common in certain regions of the US,” said Darryl Zeldin, MD, scientific director of the National Institute of Environmental Health Sciences (NIEHS), part of NIH. “This study suggests that people prone to developing allergies are going to develop an allergy to whatever is in their environment. It’s what people become allergic to that differs.”
The research appeared online in February in the Journal of Allergy and Clinical Immunology and is the result of analyses performed on blood serum data compiled from approximately 10,000 Americans in the National Health and Nutrition Examination Survey (NHANES) 2005-2006.
Although the study found that the overall prevalence of allergies did not differ between regions, researchers discovered that one group of participants did exhibit a regional response to allergens. Among children aged 1 to 5 years old, those from the southern US displayed a higher prevalence of allergies than their peers living in other US regions. These southern states included Texas, Oklahoma, Louisiana, Arkansas, Tennessee, Kentucky, Mississippi, Alabama, Georgia, West Virginia, Virginia, North Carolina, South Carolina, and Florida.
“The higher allergy prevalence among the youngest children in southern states seemed to be attributable to dust mites and cockroaches,” explained Paivi Salo, PhD, an epidemiologist in Zeldin’s research group and lead author on the paper. “As children get older, both indoor and outdoor allergies become more common, and the difference in the overall prevalence of allergies fades away.”
The NHANES 2005-2006 not only tested a greater number of allergens across a wider age range than prior NHANES studies, but also provided quantitative information on the extent of allergic sensitization. The survey analyzed serum for nine different antibodies in children aged 1 to 5 years, and nineteen different antibodies in subjects 6 years and older. Previous NHANES studies used skin prick tests to test for allergies.
The scientists determined risk factors that made a person more likely to be allergic. The study found that in the 6 years and older group, males, non-Hispanic blacks, and those who avoided pets had an increased chance of having allergen-specific IgE antibodies, the common hallmark of allergies.
Socioeconomic status (SES) did not predict allergies, but people in higher SES groups were more commonly allergic to dogs and cats, whereas those in lower SES groups were more commonly allergic to shrimp and cockroaches.
By generating a more complete picture of US allergen sensitivity, the team uncovered regional differences in the prevalence of specific types of allergies. Sensitization to indoor allergens was more prevalent in the South, while sensitivity to outdoor allergens was more common in the West. Food allergies among those 6 years and older were also highest in the South.
The researchers anticipate using more NHANES 2005-2006 data to examine questions allergists have been asking for decades. For example, using dust samples obtained from subjects’ homes, the group plans to examine the link between allergen exposure and disease outcomes in a large representative sample of the US population.
NIEHS supports research to understand the effects of the environment on human health. For more information on environmental health topics, visit www.niehs.nih.gov.
As a young girl in New Dehli, India, Harpreet Gujral, MSN, FNP-BC, INC, grew up knowing medical practitioners of all stripes. Depending on the illness, her parents took her to a conventional medicine physician, a homeopathic doctor, and even an ayurvedic (ah-yur-ve-dic) practitioner. By blending those approaches, they not only exposed her to her future profession—she loved the nurse’s white cap and uniform—but also to a mix of holistic health practices.
So when an e-mail about a nurse coaching program crossed her computer screen in 2011, Gujral took a close look. After two decades as a nurse and nurse practitioner, primarily with Inova Health System in Fairfax, Virginia, she was intrigued by the idea of returning to the holistic concepts she had set aside years ago to fit into this country’s Western health culture. As a nurse coach, she’d no longer be the “expert” voice telling individuals what to do. Instead, she’d be guiding them to their own conclusions, on their own timetables, with their unique stories front and center. In short, this would be about treating the whole person.
“I realized that my roots were calling me,” Gujral says. “I’ve always taken pride in how I treat my patients and their families, but I also know that there’s room for improvement. There’s always a little bit more I can do in the way I practice. This holistic approach offered me that opportunity. It also took me back to my Eastern roots.”
Perhaps you hear the same call. After years of dispensing care the traditional nursing way, you’re open to a practice approach that moves patients toward optimal wellness and even lifesaving self-care without suggesting a “fix.” Nurse coaching offers those opportunities. As detailed in a recently published American Nursing Association (ANA) textbook, The Art and Science of Nurse Coaching: The Provider’s Guide to Coaching Scope and Competencies, this approach puts patients (or clients, as they are often referred to) in charge of their own care by letting them direct the activity and pace.
“As nurses, we’re great at telling people what to do,” says Barbara Dossey, PhD, RN, AHN-BC, FAAN, co-director of the International Nurse Coach Association (INCA), and a coauthor of the book. “But the beauty of nurse coaching is that we’re no longer fixing things. Instead, we’re helping clients really look at their situation, tap into their own resilience, and be able to say, ‘I can try that. I can do that.’”
Patient First Is Fundamental
But with a relationship-centered focus as the goal, what do nurse coaches specifically do to change the dynamic? And what constitutes the art versus the science? The short answer is that coaching actually expands the role of nurses and nurse practitioners by integrating the scientific, scholarly based skills they learned in nursing school with a bevy of new aptitudes and theories to help them guide individuals holistically on the road to wellness.
To be successful, nurse coaches accept two fundamental beliefs: First, people are unique persons in their capacity to learn, develop, and change. When invited to direct their own health, they’re very capable of positively impacting their progress. Second, nurses can play a primary role in mobilizing someone’s innate capacity for such growth and self-healing. By establishing a deep connection and true collaborative relationship—one in which they’re willing to be led rather than always leading—nurses are uniquely positioned to guide any individual in realizing his or her wellness potential. That means any specialty, any setting, and any condition—acute or chronic—that might benefit from behavioral change.
But how does one navigate the relationship with clients so they’re inspired to take even preliminary steps toward renewed health? For starters, rather than offering your educated opinion and advice, you should:
• Encourage people to be experts in their own care. That means accepting them unconditionally where they are in terms of their lives and health issues while giving them wide berth to identify their own priorities and areas for change. You may not share someone’s values or decisions, but by honoring this person’s uniqueness, you encourage a course that truly reflects his or her belief system and way of doing things. In short, you recognize that change is best achieved when it comes from within and fits someone’s readiness, desires, and goals.
• Emphasize human caring in each encounter. Although this concept is a moral ideal in all of nursing, it’s particularly important when the goal is to assist someone in his or her wellness journey. Human caring requires that you’re fully present and nonjudgmental. It means creating a safe environment in which people can freely express their hopes, dreams, fears, and pain, knowing that such information will be met with empathy and respect. In short, regardless of their current vulnerabilities or choices, your clients can be confident that you’ll be supportive as they evolve toward healthier goals.
“Before I was trained in holistic nursing, I approached patients as dependent persons in need of services, guidance, and resources,” says Margarita Ruiz Severinghaus, RN, MA, AHN-BC, HWNC-BC, clinical resource coordinator at the Office of Care Management for Dartmouth-Hitchcock Medical Center, based in Lebanon, New Hampshire. “It was a one-dimensional approach to care. But as a holistic nurse coach, I have a much broader perspective of the whole person. I’m much more aware of the multiple dimensions involved in this individual’s entire experience.”
Where Art and Science Merge
Eliciting your client’s health story and goals entails a level of inquiry that goes deeper than a traditional patient-provider interaction. Some of the skills you’ll weave throughout each encounter come from the counseling and psychology worlds. Others may even touch on behavioral and other principles you learned first in training.
In nurse coaching, your objective isn’t to analyze a current problem, judge a previous failure, or even dig archaeologically for old issues. You’re also not there to “fix” the clinical diagnosis at hand. Since this approach is about raising a client’s health consciousness and general awareness, you’re focused on where that person is right now in generating achievable goals. That may include, for instance, helping a midnight-shift worker realize better options to quality health than hitting the all-night deli because it’s an easy stop between the subway and home.
“One of the strongest principles in my approach to nurse coaching is cultivating awareness because that allows you to make choices,” says Bonney Schaub, RN, MS, PMHCNS-BC, cofounder of the Huntington (NY) Meditation and Imagery Center, and coauthor of the ANA book. “People often don’t realize that something is a habit until you say, ‘Let’s look at the steps that go into this.’ Once they become aware, however, they can create a plan to choose differently.”
Whatever you do, you want to create positive energy—or ch’i—by listening attentively, engaging skillfully, and most importantly, following your client’s lead as he or she determines the direction of each session. It’s in these exchanges that the art and science of nurse coaching converge. Of course, you’re still going to utilize the scholarly-based, critical thinking and systematic processes you learned in nursing school. The same can be said for the competencies, professional standards, and core values. They’re as fundamental to the science of nurse coaching, as are the communication skills you’ll need to break through barriers and keep people on track.
The art of nurse coaching refers to how skillfully you maneuver those tasks along with additional aptitudes and tools you’ll use to address the body-mind-emotion-and-spirit connection of an integrative or holistic health experience. It also suggests the nuanced adjustments you may have to make during each encounter. In that way, the art of coaching is much like the art of dance. Both require that you know when to lead in one direction, when to follow in another direction, and when to change directions, depending on any shifts in energy. So how does that occur? As Darlene Hess, PhD, RN, AHN-BC, PMHNP-BC, ACC, HWNC-BC, founder of Brown Mountain Visions, a coaching firm based in Los Ranchos, New Mexico, and coauthor of the ANA book, observes: “You develop an inner ability to trust yourself to be in that quiet place where you may not have a clue as to where to go next or what to do next. Yet you remain still and present, allowing that knowing to emerge. Then, as it does, you and your client dance together with it. That’s the art.”
In practical terms, you’re relying not only on that intuition, but also on a bevy of other modalities—guided imagery, meditation, and art therapy on the list—to help clients discover and win their goals. But for starters, you’re just mindfully present with the person. That simply means that you’re focused entirely in the moment on what this individual is saying with no preconceived notions as to what that conversation might yield. To do so, you’re engaging in:
• Deep listening plus the power of the pause and not knowing. By concentrating intently, you’re not only creating a safe space where your client can deepen his or her own awareness, but you’re also allowing yourself to hear this person’s story. Perhaps it’s the woman whose spirit is broken after losing everyone she loves. By cultivating your deep listening skills, along with additional tools such as the power of the pause and not knowing everything, you’re able to explore territories with her that might otherwise remain unknown or untouched. Deep listening also permits you to pay attention to body language, which sometimes speaks louder than words. “If somebody is ready to cry, I’m not going to interrupt where he or she is at that moment,” says Dossey. “I’m going to hold that space and just allow this person to go with it.”
• Motivational interviewing and appreciative inquiry. Used in tandem, these techniques are foundational in your efforts to draw out individuals, accept what they’re saying, and encourage them to reach their own conclusions. Motivational interviewing, for instance, is about valuing change. It’s about getting a middle-aged man to understand that taking his blood pressure medication every day is important, even if it didn’t seem so in the past. You’re not trying to scare this person with the arithmetic of unchecked hypertension and silent strokes. Instead, you’re searching—through the co-technique of appreciative inquiry—for clues as to your client’s best strategies and strengths. Perhaps in the end that means simply suggesting, “Is it possible to set the pills at your bedside with water and make them part of your morning routine?”
• Open-ended questions. The tools that drive every encounter, open-ended questions allow you not only to engage people in decision-making, but also to gather important intelligence. The beauty of this technique is that you can use it no matter where your client sits on the willingness spectrum. For instance, if he or she is just contemplating the possibility of eating healthier, sleeping better, or even getting off drugs, you open the conversation by asking, “Is this something you might do in the future?” or “What might be some of the barriers to starting now?” Or, if your client is edging toward action, you might nudge things along with: “Can you imagine what change might look like?,” “Can you think of how you might accomplish it?,” or “Are you willing to do it in the next six months?” You know your client is finally ready for real action when he or she mentions an immediate goal, eager to strategize steps for meeting it.
How long might that transition take? It’s hard to say what triggers someone from merely thinking this could be a good idea to saying, “I’m ready to take action.” Perhaps a wake-up call—a family member getting sick or a news story generating a scare—suggests that the time is right. It’s also difficult to assess what obstacles or new issues may emerge and intrude along the way. Daily habits, cultural practices, or even a worldview suggesting that the course of health events can’t change because that’s what God or nature intended can be overwhelming. Likewise, your client may experience a more immediate issue that forces a course correction from the long-term plan to the problem at hand. Perhaps she’s afraid to go home, for instance, because an abusive husband is waiting.
Whatever attitudes, ingrained beliefs, socio-economic circumstances, or life challenges are creating roadblocks, probing questions and deep listening allow you to guide someone in overcoming them. Whether you’re asking your abused client for permission to offer resources that might keep her safe or you just want to know what’s the “worst” and “best” case scenarios for taking off excess weight, you’re continually gauging this person’s readiness.
“As nurse coaches, we sometimes feel responsible for the timing,” says Dossey. “But if we’re truly going to have a patient-centered focus, we’ve got to acknowledge that it’s someone else’s life and someone else’s choice. We can create the opportunity for change, but we can’t force people to take it. Anyone who has raised children will confirm that.”
Building Success on Strengths
Whatever the timeline, when the opportunity presents itself, nurse coaches pivot to options that build on someone’s strengths rather than emphasize his or her weaknesses. Since the very premise of this approach is to praise or encourage people to success, you’ll likely be helping your client enlarge his or her strength vocabulary by identifying all of the traits that he or she has relied on in the past. Keep in mind, however, that people often don’t recognize the true virtues in their own story or what they’ve accomplished previously. The efforts seemed so small. The tasks were so large. Or the relapses have been too many in number to appreciate that just being open to a new attempt is evidence of progress.
Whatever the challenges, the big goals for your client may be incremental at best:
“I’ll walk to the mailbox.”
“I’ll add vegetables to my dinner.”
“I’ll reduce my salt intake.”
“I’ll give up half a pack of cigarettes each day.”
Even a heroin addict’s willingness to stop sharing needles can be a lifesaving behavioral change. This person may not be ready to give up drugs, but he or she is at least willing to consider the transmittal risks of infection. “It’s not necessarily going to be everything that you want for them,” says Gujral. “But just making strides in the right direction and seeing the value of those strides, even quantifying them, will keep them moving forward.”
After overhearing a pre-op nurse practitioner scold one woman for having horribly high blood sugar levels for someone facing immediate cardiac surgery, Gujral decided to draw attention to the positive news during her subsequent diabetes consult. She parlayed her motivational interviewing techniques by focusing on how her teacher-client had accomplished a 2% decrease in her hemoglobin A1C test from results over the past two years. With a double take and a smile, the woman related that she just had made a concerted effort to eat healthier, despite the difficulty of living alone with no support system.
Knowing that the levels should improve even further, Gujral followed with: “What do you think would allow you to get an even better result?” The woman offered that she’d examine her after-school schedule to see how she could incorporate more activity and a healthier eating plan. Then came the negotiation. Gujral thought her suggestion of walking 10 minutes around the house after dinner was a perfect pitch idea. But as to the TV dinners her client promised to eat each night, Gujral wondered aloud if there wasn’t another easy option with less salt. Perhaps heating mixed frozen vegetables, seasoned with olive oil, might be a doable alternative. “Would that be something that might work for you?” By securing a “Yes, I can do that,” Gujral gave her client options after surgery. “It’s really important for our clients to feel that they’re coming up with a plan that can work,” she says. “I’m available to embellish it, but not just as an expert. I’m using my coaching techniques.”
Whatever the strategy, you’re always mindful of the final leg—sustainability—of your coaching efforts. You’re not only guiding folks in realizing what they need to do to get unstuck, but you’re also helping them break down their objectives into small tasks that can be used over time. What else must be present for this person to keep things going long-term? Besides ready responses to that inner critic and habits that can thwart their efforts, they need to recognize the tactics that have worked for them in navigating other life issues.
Likewise, your client will decide how to measure success, based on the goals the two of you set up-front. Perhaps it’s to walk down the stairs without pain every morning or maybe dance at a granddaughter’s wedding next year. Whether true progress takes place within the context of your coaching relationship or much later, your role is to encourage the possibility and acknowledge every feat. More importantly, you want your clients to recognize and accept what they have accomplished, too! Since momentum builds on momentum, improvement on one goal can encourage targeting the next one. And even if the two of you can’t celebrate winning the initial objective, you can mark any strides that might lead to fruitful results later. “Nurse coaching doesn’t necessarily guarantee that your clients will be habit-changers,” says Severinghaus. “But hopefully this process of discovery will allow them to appreciate the effect of choice on their happiness and well-being.”
Final Thoughts
A nurse coaching relationship isn’t built to last forever, even if you really enjoy the interaction. Although the length of any commitment is based on someone’s needs and goals, there’s both a starting point and an ending point. Whatever the timeline, your goal is for your client to tap into his or her innate abilities to be empowered for a lifetime. Other medical practitioners likely have explained the stakes, and may even have referred this person to you. But you’re there to right the ship so it can sail.
In the meantime, you may find a deeply satisfying way to practice that connects you to your profession and patients in an exciting new way. For instance, when she answered that e-mail in 2011, Gujral found more than just INCA’s Integrative Nurse Coach Certificate Program. She was up close and personal once again with the holistic health concepts she had first learned in her native India—only now they’re an integral part of her day. As assistant director of certifications services at the American Nurses Credentialing Center (ANCC) as well as a private hospitalist practice nurse practitioner, Gujral has found ample ways to use her nurse coaching skills. Whether she’s collaborating with ANCC staffers or guiding patients to better medical results, she delights in coaxing people to do their best. So inspired by nurse coaching as a path to wellness, she’s even pursuing a doctoral degree in nursing practice, focused on integrated health and healing.
“I’ve always taken pride in being a nurse,” Gujral says. “But my satisfaction with my profession has gone up many notches since I became a nurse coach. Making the connection with people at such deep levels is amazingly fulfilling. It gives me great joy.”
Romeatrius Moss, RN, MSN, APHN-BC, DNP, doesn’t mince words when she advises other nurses about advancing their careers. “If you aren’t geared and ready and have everything in your toolbox, you are going to be left behind,” says Moss, the executive director of the Mississippi Gulf Coast Black Nurse Association. “Getting an advanced degree is extremely important. It pushes our profession forward.”
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.
Moss’s 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.
“It’s 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,” says Jane Kirschling, PhD, RN, FAAN, president of the American Association of Colleges of Nursing (AACN). “The bottom line is about patient safety and providing health care that is high quality, efficient, and cost effective.”
In light of the study and others like it, nurses—who build careers on change—are 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. “Whether it is an associate’s, bachelor’s, or master’s-prepared nurse, the reality is that nursing requires lifelong learning,” says Kirschling.
Nurses have choices about how to advance, but a degree appeals to many organizations. “A minimum of a bachelor’s in nursing will open doors when you are competing for a job, and it shows a level of commitment,” says Marie-Elena Barry, a senior practice and policy analyst at the American Nurses Association. And even Kirschling says that an associate’s 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 Administration’s (HRSA) “2008 National Sample Survey of Registered Nurses” showed that half of registered nurses hold a bachelor’s degree or higher, and just over a third hold an associate’s. The rest have a diploma in nursing. Most nurses initially receive an associate’s 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 master’s 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 master’s 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 bachelor’s 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 don’t 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. “Lots of nurses get a degree and go to work and don’t think about career development and learning how to grow your career,” 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 isn’t easy, and adding other obligations, like family, often makes the task overwhelming. But as the demand for nurses with a bachelor’s 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. “This is a train,” she says. “Jump in when you can.”
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. “Provide evidence of how you made a difference,” advises Phillips.
Kirschling suggests talking with your employer about wanting to build on your skill set or your desire to continue your education. “Employers want to retain nurses and create career mobility within the organization,” she adds.
Keep Your Options Open
“People believe the continuing mantra that nurses need to work in traditional venues like hospitals and doctors’ offices,” 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 doesn’t 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. “It’s not all about the money,” says Kosicek, “but they all have bills.”
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. “It’s not always about your base pay of dollars,” she says. “You can negotiate other ways of compensation.” For example, you can ask for more vacation days, a higher match of your 401(k) plan, or tuition reimbursement for classes.
“No one is teaching that,” 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. “It is a totally different language,” she adds.
Act Like a Leader
Even if you haven’t reached your ultimate career goal, you can act like you have. “You can’t do a BSN [program] and expect to be a manager,” says Barry. “There are lots of little steps.”
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. Don’t 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. “It increases your ability to network and puts your face out there.”
Don’t 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.
“Nurses are not going to get in with traditional nursing resumes or traditional interviewing skills,” says Kosicek. “They have to show they are business wise.”
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 doesn’t work for everyone. You have to consider the financial return on your investment, so you aren’t trading more education for insurmountable debt.
Chart the financial impact of furthering your education. If you want a degree but can’t imagine how you will pay for it, become a sleuth for scholarships or take an alternative path. If your company doesn’t 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. “It gets you excited and keeps you informed and learning outside your unit,” says Barry. “Certification is important. It shows your commitment to your profession. It also shows your professional role modeling.” When you are learning and advancing by taking classes, even if it’s 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. “Sometimes you just have to do it,” she says. “I didn’t want to sit around and not take some risk. Most people who have a well-rounded professional life have taken some risk.”
Have a Plan
Your career will stagnate if you don’t 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. “Part of the learning process is going through and collecting along the way,” says Barry. “As you are getting a degree, you are exposed to all those other areas.”
Even if you are not looking for a job, keep accurate records of your career successes, advises Phillips. “We don’t document our outcomes,” she says, so when the time comes to tell potential employees about them, it’s hard to remember the details. Keep a file—“call it a happy file,” suggests Phillips—where 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. “Nurses have to be prepared,” she says. “You never know when an opportunity will present itself.”
Does an Advanced Degree Equal Respect?
Like it or not, an advanced degree is the first step toward a leadership position. “It’s very important for nurses to get a nursing degree,” says Barry. For nursing as a profession to advance with respect, getting a degree—particularly a BSN—will also bring more nurses into position to take over as future leaders. “Nursing education has a lot to do with where you go,” 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.
“The risk is that we have to be open and willing to leave our comfort zone to experience all nursing has to offer,” says Phillips. “And it’s scary. But I don’t believe anyone should be burned out. You need to find a new perspective.”
Just as each nurse is unique, so is each successful career path, says Phillips. “I’ve been a nurse for 37 years, and I am just as excited today as the day I graduated because I see the possibilities,” she says. “At 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?”
Julia Quinn-Szcesuil is a freelance writer based in Bolton, Massachusetts.
