The government of Jamaica has asked the United States health sector to cease the poaching of its nurses. “Jamaica Says to Stop Poaching Our Nurses” was a report on National Public Radio earlier this year based on an interview with Mr. James Moss-Solomon, the chairman of the University Hospital of the West Indies in Kingston. He likened the situation to a crisis.
The exodus has forced Jamaican hospitals to reschedule some complex surgeries because of a lack of nursing staff on their floors, according to the report. Moss-Solomon says the United States, Canada, and the United Kingdom are, in his words, “poaching” Jamaica’s most critical nurses. “Specialist nurses is the problem. We have tons of regular nurses,” he told NPR. He was talking about nurses trained to work in such settings as intensive care units, oncology, infectious disease, operating rooms, and emergency rooms. They are the ones being lured away and their English language skills heighten their appeal. “We do very well training our specialist nurses here at a fraction of the cost of what it costs you in the United States or Canada or the UK; so, the issue is an economic one for us,” he explains.
In February, as part of the Jamaica Medical Mission, I discussed this issue with Althea Davis, RN, MHA, as I sat with her in a church hall in the city of Port Maria. For 27 years the mission has served the people of Jamaica under the auspices of the St. James Episcopal Church of Leesburg, Florida. The 55 members of the team represented physicians, dentists, hygienists, optometrists, pharmacists, nurses, physician assistants, and support staff. They came from Los Angeles, Ottawa, New York, San Francisco, Maryland, and Florida.
The team brought state-of-the-art health care to the people of that region for eight days and with tremendous energy and dedication delivered competent care to over 1,700 patients, who for the last 5 years have had their medical records computerized and accessible when the team visits.
Davis, a supervisory public health nurse, serves four health districts. “The nurses are expected to provide service in every aspect of care and are held to a very high standard. In the case of the public health nurse, the Jamaican nurses rank among the best worldwide,” she says.
According to Davis, the training model that Jamaica has followed came out of work done back in the 1970’s and is continuously updated. Over time, specialists have been added in areas such as nutrition, health promotion, information technology, and electronic records management, which is intended to provide a more robust care delivery system and improve patient satisfaction. “Because of training provided, we were well prepared to deal with the Ebola outbreak, and the highly contagious Chikungunya virus,” says Davis.
However, Davis quickly hastened to add that the problem facing the nursing sector is that the profession is “under resourced.”
Davis’ conclusion is an echo of Moss-Solomon’s. The skilled staff are stretched. The referral process for advanced treatment that cannot be handled at the nurses’ level is inadequate at best and unavailable at worst. “It is not just the compensation that influences nurses to leave the island,” Davis says. “It’s also the sense that nurses are not accorded the appreciation for what they do even by health care agencies.”
According to the World Bank, “these shortages have tangible impacts that may compromise the ability of English-speaking [Caribbean] countries to meet their key health care service needs, especially in the areas of disease prevention and care. In addition, the shortage of highly trained nurses reduces the capacity of countries to offer quality health care at a time when Caribbean countries aim to attract businesses, visitors and retirees as an important pillar of growth,” the report states.
In Jamaica, about three out of every four nurses trained have migrated to developed countries. But the Jamaican experience is not unique. In the case of the UK, a recent report by the Royal College of Nursing stated that the nursing workforce has moved from a situation of “net inflow of nurses to a position of net outflow in recent years.” This means that more nurses are moving abroad than are coming to the UK to practice. The main destinations are Australia, Canada, New Zealand, and the United States.
The NPR program stated that Jamaica has been offering free training for nurses to get advanced degrees. The nurses agree to work for three or four years in Jamaica in exchange for the heavily-subsidized education. “But U.S. recruiters,” says Moss-Solomon, “simply pay the fine for contract violation and the nurses fly off to lucrative jobs in the U.S.”
Jamaica’s response to these losses? They are bringing 25 nurses from Cuba to help staff some floors and have plans to recruit nurses from India and the Philippines and have recruited nurses from as far away as Burma/Myanmar.
Increased international recruitment of nurses requires that several policy issues be explicitly addressed. The international debate over the responsibilities of recruiting nations toward countries whose nurses are being recruited, many of which are developing countries, necessitates provision of ethical recruitment guidelines and codes of practice inclusive of possible financial compensation for sending countries in the face of a global nurse shortage.
It is an enviable opportunity to provide healing services to a country in need by combining a fairly large, diverse, multidisciplined medical team. Three nurses on missions did just that, and in the process, they saw that one person can make a difference. They share their experiences in the Dominican Republic (DR), Haiti, Kenya, and Uganda here in the hopes of inspiring others to do the same.
Marie Etienne, PhD, MSN, with Haitian children
The Haitian and Dominican cane cutters and their families in the Dominican Republic are spread over some 350 bateyes (cane-cutting communities). They were in dire need of access to health care—and Marie Etienne, PhD, MSN, a professor of nursing at Miami Dade College, responded.
Etienne, who was born in Haiti, came to the United States at the age of 14. From her youth, she has seen herself as a servant leader and believed a career in nursing would provide opportunities to fulfill her aspirations. She has been a member of the Haitian American Nurses Association of Florida (HANA) and served as president from 2005 to 2007.
Today, she serves as the chairperson of the International Nursing Committee of the Red Cross. In 2005, an attorney and member of the Miami Haitian community visited the bateyes in the DR, and when he returned, he told her that he had seen living conditions of the migrant workers and they were être traités comme des esclaves (being treated as slaves), with no access to health care. He suggested that HANA do something to shine a light on the conditions in the bateyes and devise ways to help the workers and their families. Etienne took the findings of the attorney to the Haitian American Professionals Coalition (HAPC) and obtained support to conduct a needs assessment of the situation. One of the objectives of the HAPC is to examine and address issues affecting Haitians in the United States and abroad.
“We went on the first mission trip to the DR in 2005 to assess the need and take care of the people in the bateyes,” recalls Etienne. The team saw over 1,000 patients in the week they were there and realized the level of need was so great that they decided to do two medical missions each year.
Haitian cane cutters in the DR are not recognized as citizens, and children born in the country do not receive birth certificates. The sugar cane farming sector of the DR depends fundamentally on Haitian migrants, who represent 90% of the labor force in sugar cane cutting and are paid $1 per day.
The team, once assembled, included a diverse blend of medical and health care competencies and others who offered their availability in a supporting role. “But in 2006, I decided that we needed to get nursing students involved because there are certain things you can teach students in the classroom and certain things you can’t,” explains Etienne.
She received the support and participation of the college’s administration and trustees, who quickly approved and funded the project. “As a professor, I inaugurated this project as part of the students’ learning activity to get them engaged and to give back to the community so they may become global citizens and in the process enhance their cultural competence,” she says.
Twelve nursing students from the associate’s degree program were added to the team. The team travelled to the DR to do a one-week mission trip twice each year from 2006 to 2009—each time serving some 1,200 patients ranging from children to the elderly with a wide spread of medical and health conditions.
In 2010, an earthquake struck Haiti, killing over 200,000 people, and the mission’s focus shifted to Haiti. “Our attention turned to the needs in Haiti as relief efforts, and other nurses who were members of the [National Black Nurses Association] came together to share in the relief response treating wounds, stabilizing the injured, triaging patients according to symptoms, and whatever else was necessary,” says Etienne. “I went to Haiti about five times that year going back and forth. I also went to one of the universities to teach the nursing students basic skills and show how they can be empowered to take care of their own country.”
In 2012, the team was asked back to the DR because the health care needs persisted and the living conditions were deplorable. The people in the bateyes were doing their level best by any means necessary to survive, but the team decided not to go back in 2013 because the DR Supreme Court had ruled that the government could proceed to deport all persons who are in the country illegally, and that put a lot of fear into the workers needing health care.
Many Haitians arrive in the DR through open borders without legal documents and stay in the country this way. The living conditions of these communities are extremely poor, and immigrants generally live in impoverished barracks that have no electricity, no basic sewage services, and no potable water. There are no health services, recreational spaces, or schools. The workers work 12 hours per day on average and face the threat of deportation when they attempt to organize to obtain basic rights. “As the impact of the Supreme Court’s decision began to be felt, violence subsequently broke out and, for the sake of the students, I could not take them there that year,” Etienne explains.
On their visits, the U.S. team partnered with the Universidad Central del Este, which assigned 50 medical students for a week. They gave one rotation in the morning and one in the evening to work with Miami Dade College students. “We were assigned a primary school in one of the towns outside Santo Domingo, the capital, where we set up the clinic,” says Etienne. “We had registration in one area, a room for triage, and vital signs in another area. Then we sent the patients to see the primary care doctor, or the PA, and then they went to pharmacy, where all the medications were donated by U.S. Catholic charities and others. We designed a pediatric area, and it had balloons, coloring books, toys, and games just to make the children comfortable where we did play therapy. And for the elderly, we would triage them by themselves, keeping them hydrated so they can see the primary.
“Some have asked us if we feel like we are putting a Band-Aid on the conditions of people’s lives in the bateyes. I would explain that our purpose of going there was so we could save lives. One of the patients had a seizure, and if we were not there he would have died. Another had an asthma attack, and because of the ventilator machine we brought along with the administration of some albuterol and follow-up care, that patient recovered. We feel we are saving lives and making an impact. The people know that someone cares about them and that they are not forgotten,” says Etienne.
“God puts us here to serve other people, and if we can put a smile on someone else’s face—if we can change someone’s life—we should not think twice about it,” she says emphatically.
Sharon Smith, PhD, with Maasai tribesman
At the tender age of eight, Sharon Smith, PhD, believed that one day she would be a missionary. She knew she would go to Africa and serve in some capacity, but she never really knew how that would happen. “I just figured it would somehow come through my interest in health care,” she explains. As a young person, her aspiration was to be an oral surgeon, but she knew she would not like some of the situations she would see, so she chose nursing. She is currently a nurse practitioner at the Family Health Centers of San Diego.
“Nursing offered me more career flexibility. My roles as a nurse just fit my personality, so I am glad I chose nursing instead,” says Smith. “I didn’t know I would go to Kenya, but that is where I landed, and I have really enjoyed the connections and my experience working with the people there. That is what kept me going back.”
Smith’s first trip to Kenya was in 2006 with 12 members of a Pentecostal church group out of Carlsbad, California. A physician friend was unable to go and suggested that she go instead. Since then, she has been back twice on her own. Nairobi served as the primary hub on each visit, but on her first visit she went to the town of North Kinangop, about a two-hour drive from Nairobi, the capital.
She also visited the town of Tumutumu and spent time doing crafts with the children in a home for the deaf and hearing impaired. This was possible because the group from California included a young woman who could sign. The home for the deaf was adjacent to the Tumutumu Hospital, which provides care to approximately 3,000 inpatients and more than 16,000 outpatients each year. Tumutumu Hospital is one of the three mission hospitals in Kenya sponsored by the Presbyterian Church of East Africa (PCEA). Smith and her team came with hospital supplies that they delivered to the staff. The hospital had a large HIV clinic, and while the children waited on their parents, they were provided with school supplies and toys as gifts from Smith and her team.
As the visitors toured the hospital wards (floors), they were exposed to the differences between nursing practices in Kenya and the United States. They saw how much was lacking by way of resources and training. In a ward, there would be a patient with pneumonia next to a surgical patient with an open wound, who may be next to a patient with HIV. There was no segregation based on medical condition. In the pediatric ward, however, three or four rooms were set aside for preemies or small children who were intubated or on ventilators. Smith says that at this hospital there were one or two experienced nurses, but all the work was done by student nurses from the PCEA Tumutumu Nursing School. “They ran the hospital with the number of beds at about almost 200, inclusive of the maternity ward. There was no ICU, however,” she explains.
On her third trip to Kenya in 2010, Smith, who was at that time one of two nurse practitioners in the U.S. team of eight, visited an orphanage of 250 children and did physicals on over 100 of them, from newborns up through teenagers. This provided the orphanage with the children’s first medical records. While on this trip, Smith also had an opportunity to work with some of the nurses of Kenya on a very large, day-long health expo in the Maasai village. They performed health screenings, vaccinations, physicals, oral examinations and extractions, working alongside physicians and dentists from Kenya.
Smith did have an opportunity to see up close the delivery of care inside a hospital in Nairobi after a dog bit a member of the U.S. team and required medical attention. Her assessment is that the hospital provided care comparable to that found in most U.S. hospitals. “My focus and concern was, however, the care delivered by the rural hospitals,” she says.
For Kenyans, Smith is the sister returning home, so they go through the villages and alert the community that “our sister is coming home.” “They plan for my arrival ahead of time,” she says, “and I am planning my return in 2016.”
Angela Allen, PhD, with the head nurse at a Uganda hospital
Raised by her community-minded grandmother, Angela Allen, PhD, took her mission trips to Uganda with concern for both the physical and spiritual well-being of the people of Uganda. The Detroit native received her doctorate from Arizona State University with a focus on geriatric and dementia patients, and now she is the clinical research program director with the Banner Alzheimer’s Institute in Phoenix, Arizona.
Allen visited Uganda in 2010 and 2012 for periods up to three weeks each visit. Her visits allowed her to interact with the elderly who might have some form of cognitive impairment. What she uncovered was that cognitive impairment was less of a concern than physical impairment, which prevented the people in the community from caring for themselves. Even though she had gone with a religious purpose sponsored by the Church of God in Christ, Allen did have an opportunity to do research in an area of interest to her. Virtually all of the team’s time was spent in towns like Jinja, a town of approximately 70,000 people and a two and half hour’s drive from the capital, Kampala.
The team fully identified themselves with the Ugandans they sought to reach by sleeping in their huts and immersing themselves into the life and rhythm of the communities. “The people were hungry for knowledge more so than food, so I taught them, spending time with the women to help them develop a sense of community and even preached to them,” Allen says. “I was well received because, after my first visit to the hospital in Hoima, I was invited back by the hospital. So, I took what I had learned from the qualitative observations I had conducted and returned in 2012 as part of a team of 25 people and a fully developed plan, including a full curriculum for the nursing students.”
Allen’s plan included addressing the needs of adolescents, especially girls, who needed to hear that they were appreciated and acknowledged as persons of value. With the help of town officials, she recruited young girls and, using an interpreter, exposed exposed them to two days of instruction on self-esteem and self-pride.
She also worked on securing hospital supplies through Project C.U.R.E. (Commission on Urgent Relief and Equipment) in Phoenix, as well as surplus supplies from hospitals where she had worked in the past. These filled several crates that were presented to the hospital in Hoima.
Lastly, Allen sought to teach a two-day class to the nurses, but in the process she realized that the level of training the nurses had received was comparable to the training provided to nursing assistants in the United States. Her observations of the accommodations provided to the patients was comparable to those Smith observed in Kenya (e.g., patients were not segregated by medical condition in the wards).
“This was a life-changing experience for me,” says Allen. “I never imagined that this visit to the continent of Africa would affect me so much. It was a very emotional experience because the need is so great. I reaffirmed that my purpose in life is to help others.”
Outside a dining room in the Longworth House Office Building on Capitol Hill, I asked Congresswoman Karen Bass of California how nursing prepared her for service in Congress. Her response was quick: “Good bedside manner.” But she has had only three terms to hone those skills to propose, advocate, or deliver legislation that impacts the field of her choosing. Not so for Congresswoman Eddie Bernice Johnson of Texas. She is an accomplished nurse, administrator, and legislator covering 23 years in Congress and 60 years as a nurse. I recently visited with them both and gained a fresh perspective on their experiences as nurses in Congress, as well as a candid reflection on the issues currently afflicting our country.
Congresswoman Johnson set her mind on becoming a nurse as a teenager, but in 1952 no nursing program in Texas would accept her, so she applied and was admitted to St. Mary’s College in Notre Dame, Indiana, graduating in 1955. She holds the BS degree in nursing from Texas Christian University, and in 1976, she was awarded the MPA degree from Southern Methodist University. Ten years into her nursing career at Veterans Affairs (VA), she was appointed chief psychiatric nurse at the VA Hospital in Dallas. In 1977, she was appointed regional director of the U.S. Department of Health, Education, and Welfare.
Before her election to Congress, Johnson served as a member of the Texas State House of Representatives from 1972-1977 and a member of the Texas State Senate from 1986-1992. She was elected as a Democrat in 1992 to the 103rd Congress and is in her 12th term representing the 30th Congressional District. In December 2010, she was elected as the first African American and first female ranking member of the House Committee on Science, Space, and Technology, a standing committee of the U.S. House of Representatives. Additionally, she was the first African American female to serve as chairwoman of the Subcommittee on Water Resources and Environment during the 110th and 111th sessions of Congress. Her name is attached to several pieces of legislation. Her office in the Rayburn House Office Building impresses visitors who can clearly see what seniority provides.
The author (left) sharing a copy of Minority Nurse with Congresswoman Eddie Bernice Johnson
James Daniels: Mrs. Johnson, your accomplishments are impressive and even astonishing. Your firsts set you apart as a genuine trailblazer. You are the first woman ever elected to represent Dallas in the U.S. Congress. You are the very first chief psychiatric nurse of Dallas; first African American elected to the Texas House of Representatives from Dallas; first woman in Texas history to lead a major committee of the Texas House of Representatives; first African American appointed regional director of U.S. Department of Health, Education, and Welfare; and the first female African American elected from the Dallas area as a Texas senator since Reconstruction. Your crowning accomplishment, however, is as the first nurse elected to the United States House of Representatives.
Congresswoman Johnson: And I hope I won’t be the last!
Daniels: You are clearly regarded as a pioneer because of all the firsts you have accomplished. What does this mean to you? How do you handle that?
Johnson: I never think about it until someone brings it up. I don’t see it as extraordinary. I see it as opportunities that appeared, and I took advantage of them and was fortunate enough to get elected. It has not been easy because I was the first. As a matter of fact, it has probably been more difficult because of that.
Daniels: What motivated you to enter politics coming from a stellar career in nursing?
Johnson: When I was first approached about running for office, I thought it was a joke. All of the women I spent most of my volunteer time working with were mostly white at that time. The judge that gave Lyndon Johnson the oath of office, Sarah T. Hughes, was the one who pushed it, and along with others, encouraged me. It was the white community that persuaded Stanley Marcus [Chairman of Neiman Marcus] to give me a job because I was working for the government at that time. My African American community had to be brought along because they thought what I was doing was a man’s job.
Daniels: So, you were a pioneer.
Johnson: I guess so! My campaign was run out of my garage and my dining room. Not until I went into a run-off against my opponent did my African American women bring their support. After I won, everyone became my friend.
Daniels: You could not get into any university in Texas to obtain your nursing degree.
Johnson: There was no nursing degree program in Texas [in 1952] with national recognition that I could attend. This was before the University of Texas opened [its doors to black students]. It was before Baylor or Texas Christian opened, so that’s why I went out of state. The colleges [in Texas] were not integrated at that time.
Daniels: Growing up, did your parents influence you to achieve? What role did your parents play?
Johnson: My parents played a very key role, because education was number one for them. They thought it was very important. My grandmother was a teacher and went to Prairie View College. My father finished high school but did not want to go to college. He wanted to be a businessman. I watched them as examples.
Daniels: You’ve been here since 1993. What do you isolate as high points during your tenure?
Johnson: My high point was my first two years. Bill Clinton was president and we [Democrats] had a majority, and I had a chance to work very closely with the president in an environment where we were in the majority and with others who thought just the way we did. It lasted two years. This is my 23rd year and I’ve been in the majority six of those years. What I’ve learned during that time is to keep focused on my work and set the goals of what I was trying to achieve and just keep my attention on that. I have been able to get monies for research, and monies for transportation projects of all kinds. I always saw this as an opportunity to make things better at home. When I look back over my achievements, it feels pretty good.
Daniels: There are six members of the House of Representatives who are nurses. Do you ever find common ground on any legislative issue?
Johnson: Well, some. Four of us are Democrats. Unless I look on the roster, it is hard to tell who are nurses from the Republican side, primarily because they are governed from the top. Many things that we try to do—if they do not get permission to do it they will disappear on you.
Daniels: Some of your nursing background includes time with the VA. What do you think of the state of affairs in the VA?
Johnson: Most of my nursing career was at the VA. It needs great improvement. I didn’t blame the secretary [of VA]. It is that layer of management right under the secretary who has gotten their buddies in these hospitals, and it is fueled by retaliation if anyone complains. Until that is broken we will never get to solve the problems of the VA. People are so afraid if they report something because there is going to be retaliation. It’s a very bad situation.
Daniels: Do you think the president is on top of it?
Johnson: The president is trying. We appropriate enough money for every veteran to get first-class care. Care is not being given to the veterans as this point.
Daniels: Do you think Hillary Clinton is going to be the Democratic Party’s standard bearer?
Johnson: I don’t know, but if Hillary runs I will support her and will give it all I’ve got to see that she becomes president. I’ve known Hillary before she married Bill Clinton, so I know her very well.
Daniels: What’s the whisper regarding who is the likely Republican candidate?
Johnson: I have not seen too many Republican candidates that I liked—and I never thought I’d say this—the one that I liked, compared to the rest of them, was [George W. Bush] I never ever thought I’d say this. He was fun to work with, easy to talk with, he was accessible. He was more accessible than Obama is. Listen, when he called me and told me he would run for governor [of Texas], I said, “You what?” I asked him, “What made you decide to run for office?” He loved to have fun. He loved people. He still loves people. When he was in office he was a people person. I remember I called him to tell him I needed his support on the Water Resources Development bill I sponsored [in 2007]. I told him it’s to make sure there is no flooding of the Trinity River. I said, “Are you going to move back to Dallas when you leave the White House?” He said, “If I can find a house I can afford.” I said, “I just need your address because I want a trench from the Trinity to your front door so you’ll be the first to know when it floods.” But that’s the kind of relationship we had. We have the same relationship now.
About this time in our conversation, Johnson’s director of communications, Yinka Robinson, signaled that Johnson had another engagement. I thanked her for her time and invited her to take some photos with me. As she did, she leaned towards me and said, “I wish I had time to tell you what it was like to be the only black student at St. Mary’s. Perhaps we could do that at some later time.”
Congresswoman Karen Bass grew up with three brothers in the Venice/Fairfax area of Los Angeles and is the only daughter of DeWitt and Wilhelmina Bass. In 1990, she graduated from California State University, Dominguez Hills, with a BS in health sciences and certification as a licensed vocational nurse. She completed the University of Southern California’s Keck School of Medicine Physician Assistant Program, and for nearly a decade, worked as a physician assistant (PA). She also served as a clinical instructor.
Prior to serving in Congress, Bass made history when the California Assembly elected her to be its 67th Speaker, the first African American woman in U.S. history to serve in this powerful state legislative role. Bass serves on the House Committee on Foreign Affairs where she is the ranking member of the Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations. As a member of the House Judiciary Committee, she is also working to craft sound criminal justice reforms as well as protect intellectual property right infringements that threaten the economic health of the 37th Congressional District she represents.
Bass’s office is in the Cannon House Office Building, but she is on her way to a luncheon with the Congressional Black Caucus and pauses to chat with me.
The author (left) interviewing Congresswoman Karen Bass
Daniels: You are the first PA ever elected to the Congress, and the first African American and woman elected as Speaker of any legislature in the United States. Does that give you a sense of pioneering?
Congresswoman Bass: No, it gives me a sense of enormous responsibility. I am happy to step up to that responsibility, but it definitely is a big responsibility.
Daniels: You leaped past nursing to obtain credentials as a PA. Why did you do that, and what drew you to the role of the PA?
Bass: When I was a nurse, the pathway to be a nurse practitioner was very, very long. I was a licensed vocational nurse. The pathway to be a PA was much more direct. And in those years I had originally started out to be a PA. But the PA profession was very new, [so] you had to be another profession first.
Daniels: Looking at your nursing and PA careers, how do they inform you to be an effective legislator?
Bass: Well, you know bedside manner can apply in a lot of different places. [Uproarious laughter.] And bedside manner in the political context is called diplomacy. As a PA, I worked in the emergency room, and when I was a nurse, I worked in acute care—both life and death areas—and that type of responsibility and pressure make this pressure seem a lot easier. It gives me a level of calmness in the midst of crisis that other people might not share.
Daniels: Now there are six nurses in Congress. Do you ever collaborate or find common ground with those on the other side of the isle?
Bass: Yes, as a matter of fact, Diane Black [Tennessee Republican Representative] and I are working on child welfare issues. We are both co-chairs of the Child Welfare Caucus. We know each other! It might not be nursing issues per se that we are working on, but it certainly is human service issues.
Daniels: I like what you just said about equipping you with good bedside manner. Does that say you use a lot of touchy, feely ways to persuade support for legislation you are advocating?
Daniels: Tell us about your work on behalf of the foster care issue in the country.
Bass: It’s one of those issues that bring Republicans and Democrats together. The basic premise is that for kids who do not have families, who don’t have parents, it becomes the responsibility of government to take care of those kids. And we should take care of those kids as we would take care of our own. Those are the values that underlie the work that I do on child welfare.
Daniels: Do you run up against Republicans who believe this is just another government overreach?
Bass: No, no, I don’t at all. Diane Black is a Republican and she is the co-chair of the committee. This is an area where members of Congress come together because most of the members of Congress are parents. When it comes to juvenile dependency, kids who are without parents, people are a lot more open.
Daniels: About your work on behalf of Africa, do you see a movement towards democracy and the establishment of democratic institutions?
Bass: Absolutely. The big issue in Africa right now from the perspective of minority nurses is the reason why the Ebola crisis happened. The health infrastructure in those particular countries was so weak that it got out of control. In countries like Nigeria, where they had a few cases, they were able to bring it under control. I think one of the biggest issues for the continent of Africa right now is making sure its health infrastructure is strong enough so that when an epidemic happens it is not catastrophic.
Daniels: And your hot button issue that you are pursuing in this Congress?
Bass: My hot button issue regarding Africa is trade. There is a trade agreement that we need to have happen, the African Growth and Opportunity Act. In terms of health care, it is to ensure that our health care reforms stay strong.
Do you do not attach much significance to the question now asked while visiting your doctor or the hospital? It now becomes one of the questions that has assumed national prominence but also draws attention as to why another question isn’t being asked.
If you are returning from a trip abroad you are asked: Have you visited a farm or come in contact with farm animals while outside the country? Its purpose is to prevent the infestation of harmful pests and disease. If you are applying for credit, you are asked: How long have you lived at your current address? Americans on average move once every five years and the time at an address allows for a meaningful background check. If you are applying for a job, you are asked: Have you ever been convicted of a felony? This information, where permissible, might serve to establish issues of moral character. And if you are visiting a new doctor, you are asked: What drugs are you allergic to? This is helpful in guiding what to prescribe and to avoid complicating any treatment decisions.
Questions are key to establishing understanding and promoting communication with others. Questions also shape discovery and exploration. Many encounters with the justice system prompts the question: Do you see the defendant in the room? An attempt to determine the accuracy of testimony. Is it credible? The interview of a national figure by a reputable journalist often leaves you wondering why isn’t the question that’s on your mind not being asked. Or conversely, why is the question that has just been asked being asked.
Why are we now being asked: In the last 21 days, have you been out of the country? It certainly is not to extract a response that might indicate you have done something wrong. We are a free people. Its purpose is to identify whether steps should be taken to further examine and determine if you are carrying the Ebola virus if your visit had been to any country where the virus is prevalent. It is also to establish whether you might be carrying the Chikungunya virus. Both of these viruses are ravishing different parts of the world and the extent to which we can take protective measures to guard against an infection by either, the goal of the question would have been met.
Unlike the Chikungunya virus, which thrives in areas of environmentally unhealthy settings such as standing water and incorrectly disposed garbage and refuse because it is a water borne disease carried by the mosquito, the Ebola virus (EVD) is spread or challenges containment because of cultural practices. The regions where this virus has been identified and is prevalent, will for a very long time be associated with this disease, and the cultural practices that are never modified or totally abandoned will perpetuate fear of the disease’s continued presence.
What did the medical community do to improve the containment of the disease? They carried out a process of educating the Liberians that the washing of deceased family members’ bodies was a practice that allows the disease to thrive. This practice must be abandoned. A deadly cultural practice must yield to medical science if the lives of Liberians and those in the region are to be spared death and suffering. The washing of the dead now takes its place alongside of Female Genital Cutting (FGC) as a geographically connected practice that is entirely cultural and deadly.
But FGC has been known to the medical community for decades and is a practice that is present not only in Africa, Asia, and the Middle East; it is practiced even in this country. Sara Rashad’s film, Tahara, reminds us that this is a cultural practice that is inhumane, cruel, and the basis of many serious and protracted health problems for its estimated 300 million potential victims.
What would be a reasonable US medical community’s response to these practices considering the number of citizens from these countries who migrate or visit the US where either or both Ebola and FGC are prevalent? You would think that one place to start would be to include at the point of intake of a patient’s medical history this question: Where were you born? Regrettably, you won’t find this on any patient medical history form; probably anywhere in the United States. So much for population health.
It was an intentionally simple question the clinical nurse in the examining room heard. “Lynn,” I said, “Have you ever been bullied?” There came a pause. Then, she responded with a torrent of emotions reflecting anger and disappointment that took her back to the start of her career 23 years ago. I posed the question as she prepped me for the ECG my doctor ordered.
After completing her nursing degree, Lynn went to work as a registered nurse in the emergency department at a suburban hospital in North Carolina. For the next two years, she was abused, intimidated, openly berated, and humiliated by staff nurses with more seniority and the nurse manager.
“What was that like?”
She said it was just how you were treated. “You were made to feel stupid when you sought clarification of a physician’s charted instructions, for example, or asked for input to correctly respond to a patient’s request. Eventually, I left.”
What happened to Lynn is not a rare occurrence among nurses, unfortunately. On July 9, 2008, The Joint Commission, which provides oversight to over 20,000 hospitals and other care facilities, issued a policy directive to its membership called a Sentinel Event Alert. Its instruction was to have procedures in place to deal with “behaviors that undermine a culture of safety” by January 1, 2009. It described “intimidating and disruptive behaviors” in great detail, which is the most widely accepted definition of bullying. Its rationale was clearly embedded within the body of the policy: “There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.”
With mounting evidence that bullying was surprisingly prevalent within the health care sector, the intended purpose of the Sentinel Event Alert was to amend its leadership standards. Accredited health care organizations would be required to create codes of conduct that define disruptive and inappropriate workplace behaviors as well as establish and implement procedures for managing such behaviors. Additionally, the institutions The Joint Commission accredits were expected to make their data available for review, according to Gerard M. Castro, PhD, The Joint Commission’s project director for patient safety initiatives.
Nursing’s Dirty Little Secret
“Nurses eat their young,” wrote Theresa Brown, a registered nurse, in an article in The New York Times in February 2010. “The expression is standard lore among nurses, and it means bullying, harassment, whatever you want to call it. It’s that harsh, sometimes abusive treatment of new nurses that is entrenched on some hospital floors and schools of nursing. It’s the dirty little secret of nursing.”
Her story is not exceptional, and it prompted me to contact Gina, a clinical nurse in Worcester, Massachusetts, with a master of science degree in nursing education and 35 years of experience—15 of which were on a nursing school’s faculty.
“There are nurses that I do not assign a new-to-nursing nurse to because of what I know would be their experience,” Gina tells me. Then, she describes her very recent experience where she accepted a per diem assignment in the operating room (OR) of a local hospital with which she is very familiar: “I almost never survived a month because of the bullying that went on. I had never seen anything like it and never experienced anything like it in my years in nursing.”
It seems that there had not been an assignment of someone new to the OR in 10 years, so Gina was treated as an outsider and not part of the clique. So targeted was the hostility that after three months of enduring the treatment, she says, “I began to feel myself spiraling down, losing my self-confidence. I endured badgering criticism; I couldn’t do anything right; there was an absence of kindness.”
Fortunately, there was a change of supervisor who observed the climate in the OR and stepped in to end the intimidation by referring the preceptor for retraining.
An Occupational Hazard
Scenarios similar to the one Gina describes must have been alarmingly common to have prompted The Joint Commission to issue a specific directive regarding workplace bullying, or lateral violence, as it is technically referenced. Diverse studies identify nursing as a risk group for workplace bullying; further, they confirm that the problem of hostility in the workplace is very common in the health care sector.
Indeed, health systems are aware of this hostility and responding to the Commission’s directive. Duke University and the University of North Carolina, for instance, have policies and procedures to deal with workplace behavior. Duke shies away from describing intimidating and disruptive behaviors as bullying per se—and perhaps may have tacitly not reinforced the implications that bullying is specific and disruptive conduct that impacts the delivery of care.
Carole Akerly, BSN, director of accreditation and regulatory affairs at Duke University Hospital, responded to my inquiry. “Duke,” she says, “has identified behaviors that are appropriate and has not specifically described intimidating and disruptive behaviors, and I don’t know whether we have identified it as that close.” But if bullying is as prevalent as the research and reports indicate—and there are many—it is unlikely that Duke and other health care providers have an incident pattern less than the norm.
The University of North Carolina Health Care System, on the other hand, provides a detailed description of intimidating and disruptive behavior and a very specific description of what constitutes appropriate behavior, so the employee has no room to allege ambiguity. The rationale for its disruptive and inappropriate behavior policy admits that disruptive behavior “intimidates others and affects morale or staff turnover [and] can be harmful to patient care and satisfaction as well as employee satisfaction and safety.” Further, the policy acknowledges the possible presence of such behavior: “While this kind of conduct is not pervasive in our facilities, no hospital or clinic is immune.”
Carol F. Rocker, PhD, RN, the lead investigator of a study of nurse-to-nurse bullying and its impact on retention in Canada, reported in OJIN: The Online Journal of Issues in Nursing in September 2008 that Canadian nurses are not alone when it comes to workplace bullying and emphasized that workplace bullying among nurses is now recognized as a major occupational health problem in the United Kingdom, Europe, and Australia. Why did The Joint Commission go to the trouble of defining bullying if it was not to delineate behaviors that threatened patient safety and care quality? The answer is embedded in what led the Commission to do this in the first place. It’s found in the promulgation of the Universal Protocol (UP).
In addressing the need to create a climate of safety related to wrong site, wrong patient, and wrong procedure within a health care facility, the Commission became aware that one of the contributing factors was the failure to speak up. What stops a clinician from speaking up? Oftentimes, it’s the deference to the physician and other clinicians.
“We have heard of abusive behavior by physicians when clinicians in the operating room, for example, have corrected the physician. Not speaking up is the result of deference to the physician,” says Castro. The UP team became aware at that time that this harmful behavior within care facilities was a safety issue.
A 2003 survey on workplace intimidation conducted by the Institute for Safe Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. Elaborating on this issue, the Commission’s Sentinel Event Alert cites several reasons why disruptive behaviors go unreported, such as fear of retaliation, the stigma associated with “blowing the whistle” on a colleague, and leniency towards physicians who generate high amounts of revenue.
But, so serious is the epidemic of workplace bullying—with particular emphasis on the nursing sector—that 26 state legislatures have proposed legislation to address this concern, beginning with California in 2003. The model, the Healthy Workplace Bill, provides very specific employee and employer remedies, protections, and sanctions. There is clearly a movement to expand safety in the workplace from the purely physical aspect to the equally important emotional and psychological aspects.
When Nurses Hurt Nurses
Kathleen Bartholomew, RN, MN, renowned for nursing consulting and training, cites episodes of nurse bullying that astonishes: a nurse hides a surgeon’s favorite instrument when a substitute fills in as the scrub; a circulator, a nurse who makes preparations for an operation and continually monitors the patient and staff during the surgery, doesn’t tell a new nurse who is scrubbed that she knows the shunt the surgeon selected has fallen on the floor; a newly hired RN who was previously a scrub technician is shunned by both camps. These episodes, Bartholomew says, pose the question whether this is what life is like in the OR.
When the administration at Indiana University Ball Memorial Hospital studied the issue of bullying, it was clear that the problem existed beyond nursing units. “It starts with physician to physician and then trickles down the chain of command,” says Renee Twibell, PhD, the lead investigator and an associate professor of nursing at Ball State University. “If the doctor kicks the nurse, that nurse turns around and kicks the new nurse or the CNA.”
The consequences of adult bullying have led investigators to name it as a significant occupational stressor in the workplace. Moreover, the Center for American Nurses labels workplace bullying a serious issue affecting the nursing profession in particular, and defines it as any type of repetitive abuse in which the victim suffers verbal abuse, threats, humiliating or intimidating behaviors, or behaviors that interfere with the victim’s job performance and are meant to place the health and safety of the victim at risk.
Are all nursing sectors equally at risk? Specifically, I was curious to know whether military nurses have a similar experience. Having spoken with Lieutenant Colonel Angelo D. Moore, PhD, the deputy chief for the Center for Nursing Science and Clinical Inquiry at Fort Bragg Womack Army Medical Center for a previous story, I remembered what he had said. Moore turned my inquiry around and wondered whether gender issues might be at work in some bullying episodes. The ratio of male to female nurses in the military is thrice that of the nonmilitary nursing sector and, according to Moore, the combination of having been to war and the culture of the military contributes to very few incidents where bullying was alleged.
Still, bullying is a complex phenomenon. Although bullies are responsible for their behaviors, investigators have analyzed several potential factors that prime the workplace for bully behaviors, which include organizational leadership and culture, the social system, character traits of the victim, and character traits of the bully. Bullying clearly qualifies as hostile workplace behavior, and if the target can claim protected class status, it becomes a major legal issue for hospitals and care centers. A 2011 study of student nurses by the American Nursing Association reported that 53% of study participants had been “put down” by a staff nurse, and 52% had been threatened or experienced verbal violence at work.
Cheryl Dellasega, PhD, faculty member at the Penn State University College of Medicine and author of When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of Bullying, provides significant research that led her to state that there are cases where the nurse manager or charge nurse—often a highly competent, valuable nurse that the administration does not want to lose—may act as a bully, playing favorites when it comes to assignments or time off. “If they are role modeling this stuff, it will be worse among the staff,” Dellasega told NurseZone.com. “If they get the message that it’s OK to treat people like this, everybody will.”
So, what’s the remedy? Bullying in the workplace is both an awareness and a leadership issue. Moreover, as is so often the case in workplace practices, the leadership should be careful not to be caught being party to making case law by a complainant seeking to link hostile workplace to bullying as a protected class member. Hospital management might address the presence or prevalence of bullying behavior by examining how it is factored into their training in root-cause analysis, as well as what their whistleblowing protection policy provides.
Nurse leaders must establish clear guidelines about what behaviors will not be tolerated and what is unacceptable, Dellasega believes. She also recommends creating a suggestion system so nurses can anonymously report things that happen on the unit, and asking for feedback about what would make the work environment better.
Gabriela Cora, MD, takes a harder stand, saying hospital administrators should have zero tolerance for bullying behavior. “Lay a plan for improvement,” Cora adds. “Reward them when they improve their behavior and be ready to fire them if they continue the bullying behavior. Second, avoid praising or rewarding nurses for their work performance if they are bullies. Instead, respectful treatment of patients and positive interactions with colleagues should be rewarded.”
Ultimately, it’s all about modeling positive behaviors and holding employees accountable. If the policy is zero tolerance for bullying, it should mean just that—zero tolerance.