Some rules on physical appearance in hospitals and other institutions can be off-putting to nurses, especially students entering the profession. “Why can’t I wear nail polish?” they might ask, or “Why do I have to cover up a tiny butterfly tattoo on the back of my neck?” Sometimes, these rules are based on concerns about infections, backed by rigorous scientific studies. But in many cases, the rules are based on less definable concerns, such as concepts of nursing professionalism or what is thought to bother patients.
The rules vary widely by institution, and they are evolving as social norms change. For example, a growing number of young nurses wear tattoos and piercings, pressuring hospitals to relax rules. Also, the Civil Rights Act of 1964 protects discrimination against racially based hairstyles such as afros and dreadlocks.
The following is an analysis of some of the most controversial rules, based on dress codes posted on institutions’ websites and nurses’ comments on message boards.
Banning Nail Polish and Gel Some hospitals and nursing schools ban all form of nail polish, which can upset some nurses. For example, a nurse on the allnurses.com discussion forum wrote that a ban on all nail polish would make her seriously consider finding a new job. “I think that ‘no nail polish’ is a pretty ridiculous requirement,” she wrote. “Seeing a cheerful color on my nails brings a smile to my face.”
Such bans are based on studies showing that when the polish chips, infections can lodge inside the crevices. That’s enough reason to ban all nail polish, according to Beverly Malone, PhD, RN, CEO of the National League for Nursing. “Patient safety should be the paramount concern,” she says.
However, many institutions only ban long fingernails and artificial nails, which have been shown to have higher risks of infection than ordinary nail polish. And other hospitals, focusing on the problem of chipping, simply ban chipped nails or require new polish on nails every four days, to reduce the risks of chipping. But this requires strict enforcement.
The problem is that rules that are nuanced may be difficult to carry out, and enforcement relies on frontline managers who may be less than enthusiastic about them. “A policy that says ‘NO…but!’ is no policy at all,” another nurse wrote about nail standards on allnurses.com. “If they make allowances (4 day changes, etc.), they might as well just shut up about the issue and everyone can wear what they want.”
The introduction of gel and shellac nails over the past few years has only complicated matters. These polishes last longer than traditional products and are touted as chip-free. Although they are still too new to be well-studied for infection risks, some hospitals have included them in bans of artificial nails, and this has caused uproar among some nurses.
Tess Walters, a manicurist in Logansport, Indiana, says a ban on gel nails at a nearby hospital brought in six nurses who needed emergency redoes. “Hospital policies lump gel polish together with artificial nails,” Walters says, adding that “sweeping policies make for disgruntled employees.”
Excluding Unusual Hairstyles Many hospitals and nursing schools ban hair in bright, unnatural colors, and some specifically ban unusual styles. “Extreme trends such as dreadlocks, Mohawks, and long spiked hair is not acceptable,” according to the University of Utah Health Care’s dress code. Other institutions are more easy-going: “There are 3 nurses on my unit that have locks and I never heard a problem about it,” according to a comment on an allnurses.com forum discussing nurses with dreadlocks. “Personally, I think if the unit and region is culturally diverse then it won’t be a problem.”
Hairstyles that can be pulled up or tied back don’t appear to present problems with infection control. But, Malone says unusual looks may offend some patients and staff. When hospitals formulate rules, “patients’ views and the professionalism of nurses ought to be major considerations,” she says.
However, Malone doesn’t think the rules should impinge on natural hairstyles, such as dreadlocks, worn by African Americans who choose not to straighten their hair. According to the Equal Employment Opportunity Commission (EEOC), Title VII of the Civil Rights Act makes a distinction between racially based hairstyles and ones that could be worn by anyone, such as Mohawks or green hair.
The EEOC compliance manual, which carries out Title VII, prohibits employers from restricting hairstyles that involve “racial differences in hair textures.” However, a federal judge in Alabama recently denied an EEOC lawsuit against an insurance company that terminated a dreadlocked employee, arguing that African Americans have a choice to wear other hairstyles besides dreadlocks. The case, EEOC v. Catastrophe Management Solutions, is being appealed.
But even hairstyles not protected by Title VII are flourishing in some places—perhaps because employers have no interest in being strict, or because they prize the nurse’s skills and patients don’t seem to mind. Another nurse on allnurses.com says she has worn spiked hair and a rattail in a wide variety of health care settings for about 20 years, and she now works in a rural Appalachian community. “The little old country Baptist preachers’ wives often comment on how much they like my hairstyle,” she asserts.
Curbing Tattoos Hospital rule-makers have had to contend with a surge of young employees with tattoos. A 2012 Harris survey found that 38% of Americans in their 30s had at least one tattoo. Minorities in particular seem to have them. A 2006 study published in the Journal of the American Academy of Dermatology found that 38% of Hispanics and 28% of blacks had tattoos, compared with 22% of whites.
“Tats” were traditionally for males, but the Harris survey found that as of 2012, more women than men wore them. However, most female tattoos aren’t visible. According to a 2010 Pew Research Center survey, only 13% of tattooed women had art that could be seen outside their clothing.
Unlike nail polish, tattoos don’t present safety issues like harboring germs, but they can upset patients and other staff. According to a 2012 study in The Journal of Nursing Administration, patients tend to have negative attitudes toward health care workers—especially women—who have tattoos. Moreover, certain tattoos, such as depictions of demons, may strongly offend some patients.
Hospitals typically prohibit visible tattoos but often allow employees to cover them up under long sleeves, Band-Aids, or larger bandages. “I’m not saying get rid of your tattoos,” Malone says. “Just cover them up when you’re at work. You’re in a professional setting.”
Some hospitals soften the rules on covering up. The radiography school at Akron Children’s Hospital calls for covering up “to the extent possible,” and Rochester General Hospital calls for covering “inappropriate” tattoos.
A few, though, have stricter rules. For instance, the nursing school of Missouri Southern State University not only bans visible tattoos but won’t allow students to cover them up, either. In 2009, the policy drew many protests from applicants, according to The Joplin Globe. A spokesman for the school told the Globe that a bandage put over the tattoo “could become wet or soiled, and there is the potential for cross-contamination.” The school’s 2014-2015 student handbook shows the tattoo rule is still in place.
Like employees with green hair or a Mohawk, people with tattoos basically don’t have any Title VII protections either, according to Robert G. Brody, an employment attorney in Westport, Connecticut. In a 2010 analysis, he wrote that the law “does not include ‘tattooed’ as a protected classification.”
Rules on Body Piercings and Earlobe Gauges Body piercings are now common among younger women in particular. According to the 2010 Pew Research Center survey, 35% of women and 11% of men under age 30 have a piercing somewhere other than in an earlobe.
The eyebrows, nose, top of the ear, lips, and tongue may be pierced. In addition, holes in the earlobes can be stretched and fitted with round ornaments, or “gauges,” which are as much as 1½ inches in diameter. Piercings don’t seem to present much of an infection hazard for patients, but items like large nose rings could be grabbed by patients, and the sight of these adornments can be off-putting to some people.
Basically, piercings don’t have Title VII protections from employers’ actions. Hospital rules typically state that “visible” piercings are prohibited, but it’s not clear what that means exactly. Does it mean that piercings will be allowed if the jewelry is removed and replaced with clear or skin-color pieces—the equivalent of a Band-Aid over a tattoo? Or, does it mean that only piercings under the clothing will be allowed?
Children’s of Alabama, a hospital in Birmingham, meant the second interpretation, according to Deborah Wesley, RN, MSN, the hospital’s chief nursing officer and coauthor of its rules. But some institutions specifically allow some camouflaging. “Ear gauges must be covered/non-conspicuous,” according to the nursing student guidelines at Tarrant County College. Alternatively, Lancaster General Health in Pennsylvania allows gauges that are solid, don’t exceed ¼ inch in diameter, and don’t have jewelry connectors.
Rulemaking and Enforcement When making rules on appearance, hospitals have to balance the conflicting demands of patient safety, patient satisfaction, and employee satisfaction, says Wesley. To make sure employee satisfaction has a role, staff nurses at Children’s of Alabama develop the first draft of the dress code, which is then sent to leadership for approval, she adds.
This process produced a rule on tattoos that is unusually tolerant. “Tattoos that consist of nudity, profanity, or are racial in nature are not allowed,” the Children’s of Alabama rules state. As a result, tattoos “have not been an issue for us,” Wesley says. “We understand that newer generations have evolving views on this.”
For rules to be respected by staff, they have to be enforced in an equitable way, she argues. Management has to understand the rules and believe in them. At Children’s, “the rules are managed at the unit level,” Wesley said. “Our frontline leaders know these policies and procedures.”
“We have really tried to find a balance,” she says.
Leigh Page is a Chicago-based freelance writer specializing in health care topics.
Are you stuck in a rut at work? If so, it might be time to consider a promotion. You may not have the authority to make that happen exactly, but you shouldn’t wait around expecting to be noticed either. You can—and should be—your strongest supporter. If you’re ready to take charge, here are 10 proactive ways to help you take that next step in your career.
1. Don’t Wait to Get Started
Don’t put off getting your career going, advises Beverly Malone, PhD, RN, CEO of the National League for Nursing (NLN) in New York City. “A lot of young people in particular will say, ‘I don’t know exactly what I want to do, so I’m going to wait before I make a move,’” she explains. “My advice is get started, even if you have to change directions later.”
For Malone, starting her career moves early made it possible to have a highly varied and distinguished career. The eldest of seven siblings, she was raised by her great-grandmother in rural Kentucky. As a young nurse, she worked in a psychiatric unit. Later, she served as dean and vice-chancellor of a historically black college. Then she became president of the American Nurses Association (ANA). And before taking the helm of the NLN, she lived in London, serving as general secretary of the Royal College of Nursing.
One of the hardest decisions for young nurses is choosing a field of study for a degree. “Don’t be too concerned about what kind of degree you get,” Malone advises. “There will always be something you can do with it later.” For example, she no longer works as a psychiatric nurse, but she says her experiences in the field still serve her well.
2. Be a Team Player
You can’t rise through the ranks without being a team player, argues Kanoe Allen, RN, MSN-CNS, PHN, ONC, executive director of nursing at Hoag Orthopedic Institute in Irvine, California. “Understand the staff you are working with,” she suggests. “The team can make or break you.” She also recommends volunteering for extra duties. “It allows other people to see you,” she says.
Raised in a family of Chinese, Japanese, and Hawaiian descent, Allen rose rapidly as a young nurse. Taking a job at a critical care ED, she was named charge nurse within a year and became interim administrator a year after that. A rapidly rising young nurse might have ruffled a lot of feathers among older nurses, but Allen thinks she “garnered some good will from the staff.”
Allen puts a lot of emphasis on social skills. “You need to understand the interplay between personalities and departments and work in a collaborative manner,” she advises. She still finds these skills invaluable as an administrator. “You have to really listen to your team,” she adds.
3. Find a Mentor
Finding a mentor is important to your career, because mentors know about “the back stairs,” Malone says, referring to the secrets of getting ahead in a large organization like a hospital. As a floor nurse, “you know there’s a door to go up, but you don’t know where the door is until a mentor shows you it.”
Sasha DuBois, RN, MSN, a 29-year-old floor nurse at Brigham and Women’s Hospital in Boston, relies on several mentors to show her the way. She acquired her first mentor in nursing school, when she heard her making a speech. “I walked up to her afterwards and struck up a friendship,” DuBois recalls. “She’s invested in seeing me grow.” They get together at least once a year.
Allen advises young nurses to cultivate people who are very accessible to them and can serve as career coaches. “A coach is someone who can be honest and tactful,” she says. “She can provide supportive feedback and help you with your own critical thinking.”
4. Follow Your Passion
You can’t have a successful career unless you are passionate about your work, argues Maria S. Gomez, RN, MPH, founder of Mary’s Center for Maternal & Child Care in Washington, DC. “If you want to achieve anything, you have to have a passion,” she says. “If you only care about your own job, it’s easy to get burnt out. You just go to work and come home.”
As an immigrant from Colombia at age 13, Gomez did not know any English except “thank you.” When she went to work in a large organization as a young nurse, she was unable to find a mentor. ‘The older nurses I worked with didn’t like their work,” she says. “I couldn’t wait to move on.”
She found her calling working at a public health department. “I saw a lot of injustices, and I wanted to make a difference,” she explains. In 1988, she founded Mary’s Center as a shelter for women immigrants from Latin America. Today, the organization has a budget of $39 million and provides care at six locations for low-income women, children, and men in the DC area.
5. Go Back to School
Going back to school to get a higher degree or certification is really about “creating opportunities for yourself,” says Kerry A. Major, MSN, RN, NE-BC, chief nursing officer for Cleveland Clinic Florida. “A degree can open multiple doors and help you find out what your passion is,” she says. “A lot of young nurses don’t realize all the choices that are out there.”
A degree makes you more competitive, Major says. At many hospitals, a master’s degree is a requirement for entry into management. But apart from spiffing up your resume, a degree is an opportunity to learn new skills. “The literature shows that a degree produces a more rounded nurse,” she explains.
Major notes that school is a great opportunity to mix with nurses from other walks of life who you might never have met within your own institution. “You can get an idea of all the opportunities that are out there,” she says. “You’ll meet someone who works in public health, and someone else is an operative nurse.”
6. Nurture Your Communications Skills
Speaking and communications skills become more important the further you move up the career ladder, says Glenda Totten, RN, MSN, CNS, PHN, director of nursing service at Kaiser Permanente Los Angeles Medical Center.
Totten is constantly honing her skills. She identified a senior manager with a great communication style and started paying attention to what he says and how he says it. “I listen intently,” she says. “He’s very precise. He doesn’t beat around the bush when answering questions. He’s able to give bad news in a realistic way, without sugarcoating it or kowtowing. And he’s open to feedback.”
Totten can practice her communication skills in many ways, including serving on a nursing quality improvement committee. She is also responsible for coming up with tools to quickly inform frontline nurses about changes in the hospital policies.
7. Read Voraciously
Don’t forget to read. It can help you improve your communications skills, find new role models, and get on-the-job training. “Reading increases your written and verbal comprehension, improves your vocabulary, and widens the topics you can talk about,” says Totten.
Through reading, Malone says she discovered a new mentor named Mary Seacole, a Jamaican-born nurse who worked in 19th century Britain. In a parallel career to that of Florence Nightingale, Seacole tended to troops in the Crimean War. “Sometimes having a mentor just means having that person in mind when you’re trying to accomplish something,” Malone explains.
Reading is also a good way to pick up new skills. Consider checking out The Nurse Manager’s Survival Guide: Practical Answers to Everyday Problems by Tina M. Marrelli, which is now in its third edition.
You can also take webinars. The “Nurse Manager Development Series” was designed by Lippincott’s Nursing Management journal and ANA to help new nurse managers develop their skills. Topics include retaining talent, managing disruptive behavior, conflict resolution, budgeting, and finance.
8. Volunteer for Assignments
Volunteering for assignments outside of your department helps broaden your skills and makes you a better candidate for promotion, says Juanita Hall, BSN, RN, a nurse manager for cardiology, outpatient treatment center, and dialysis at Providence Hospital in Washington, DC. “Get experience in different departments,” she advises. “Volunteer to be the float nurse.” For example, Hall volunteered to work in dialysis, where she didn’t have much background.
As a young nurse, Hall didn’t initially seek promotion, but she was always willing to learn new things. “I wanted to know what was going on,” she says, and because she was involved in many activities, “my name would come up to the nurse manager.” Even though Hall didn’t have a master’s degree, she got a job as an assistant nurse manager.
“It’s important for nurses to be willing to absorb,” Hall says. “Take in all you can from others. Ask questions [and] show yourself as very interested in what others have to say, so that people feed the information to you.”
9. Don’t Let Ambition Get Out of Control
Hard work and dedication are always welcome, but sometimes a person’s ambition ends up alienating others. “My position is that good things will come to you,” says Hall. “You don’t have to beat anyone up to get to them.” An associate minister in her church, Hall relies on her spirituality to center herself.
Nurses can also be susceptible to burnout if they take on too many assignments. The prime time for burnout comes when studying for an advanced degree while still holding down a full-time job. When DuBois was studying for her master’s degree, she was working 36 hours a week and taking three classes each semester. “I didn’t get burnt out, but I can see how it could happen,” she says. “Everyone has to figure out how much you can handle. It’s about balance.”
Even with her studies completed, DuBois still maintains a busy schedule, including a morning workout in the gym on off-days. “A lot of my friends look at my calendar and think I’m crazy,” she says. But she also reserves time for fun. “I like going out to a party or birthday. I feed off of that. That’s my time to let my hair down.”
10. Use Your Organization’s Career Ladder
Many organizations offer career-ladder programs, which offer higher pay or more responsibilities to nurses who demonstrate their skills, according to Shawana Burnette, OB-RNC, MSN, CLNC, a nurse manager on High Risk Post Partum and High Risk OB at Carolinas Medical Center in Charlotte, North Carolina.
Burnette’s hospital’s ladder process rates bedside nurses on engagement and certification and rewards them with a higher pay level. Nurses who achieve the next rung of the ladder, RN II, get a 10% raise. At higher levels, nurses may be asked to be a preceptor and orient new hires or a nursing student. “The focus is to encourage professional growth and to reward highly engaged nurses in your facility,” she explains.
The ladder process encourages earning certificates in various fields. Burnette is currently studying for a nurse leadership certificate. She says her hospital strongly encourages certification and even provides tuition reimbursement to take review classes to prepare for the certificate exam.
Enjoy the Journey
Nurses who continuously nurture their careers will reap great benefits as they advance up the ladder, argues Allen. “Your nursing career is a journey,” she says. “It’s an incredible journey. It will involve hard work and reaching something meaningful to you.”
Leigh Page is a Chicago-based freelance writer specializing in health care topics.
Nursing is entering an era of great transformation that is driven by three major changes: an aging baby boomer population; the ongoing impact of the Affordable Care Act (ACA); and rising educational goals for the profession, including greater emphasis on the bachelor’s of science in nursing (BSN) and advanced practice nursing (APN) degrees.
For minority nurses, these changes bring a variety of benefits, as well as some possible drawbacks.
The aging of the baby boomers is expected to produce a plethora of new nursing jobs, which could lead to higher wages, greater job security, and greater variety in types of work. By the same token, this deluge of new patients could put new strains on the nursing workforce, possibly leading to higher patient-to-nurse ratios.
The health care law is changing the way nurses deliver care—emphasizing more outreach into the community and closer collaboration with patients. These changes could boost the need for nurses from the same cultural background as patients, at a time when African Americans and Hispanics are underrepresented in nursing. But the changes also mean less work for nurses in the traditional hospital setting.
Finally, nurses will have greater opportunities to advance their careers by going back to school for more training; APNs, and especially nurse practitioners (NPs), are already in great demand to cope with a growing physician shortage. However, having to spend more time in school may be challenging for nurses with limited finances.
Nursing is embracing these fundamental changes to keep pace with a rapidly evolving health care system, says Jo Ann Webb, RN, MHA, senior director of federal relations and policy at the American Organization of Nurse Executives. “Health care is changing, and nursing has to change with it.”
Baby Boom Changes Postponed, But Not Cancelled
For several years now, the profession has been bracing for a massive shortage of nurses, but it’s been slow to materialize.
The massive baby boomer generation, making up almost one-third of the population, began to turn age 65 in 2011. As they continue to get older, both supply and demand of nurses will be affected in a big way. On the supply side, retiring baby boomer nurses will empty the ranks of the profession. On the demand side, aging baby boomer patients will need more nursing to manage their declining health.
Yet, these massive changes were postponed by the 2008-2009 recession and the weak economy that followed, argues Marcia Faller, RN, PhD, chief clinical officer for AMN Healthcare, a health care staffing company based in San Diego.
Aging nurses, short on household funds, held off retiring and even came out of retirement to work again. Meanwhile, the aging patients have put off care, flattening the demand for health services. “Everybody is trying to figure how these changes will play out,” says Faller, who led a major AMN Healthcare survey on registered nurses in 2013.
But as a result of this delay, new nurses who had expected a strong jobs market have struggled to find openings. For example, a Denver TV station reported in 2013 that, of 752 openings for RNs in Colorado at that time, only four were for new graduates.
Lack of jobs has been especially hard on minority nurses, many of whom lack savings to fall back on. With their careers sidetracked, they’ve had to take non-RN jobs in health care or in completely unrelated fields.
In a new graduate hiring survey, the California Institute for Nursing & Health Care reported that in 2012–2013, the latest year available, a little over 40% of new RN graduates in the state hadn’t found an RN job—only a slight improvement over the previous three years. Of those who didn’t find RN jobs, 20% were working in non-RN roles in health care and 23% took jobs outside health care. The rest went back to school or volunteered in health care at no pay.
Many new graduates are angry and mistrustful. In a 2013 survey by two nursing professors at Molloy College, which was published by the National Student Nurses’ Association, many new RN grads thought the nursing shortage was just a “myth,” created by nursing schools to attract more students.
The impending nurse shortage, however, is not going away, says Mary H. Hill, PhD, RN, nursing professor and assistant provost of Howard University in Washington, DC. Aging patients can’t continue to delay treatment and aging nurses can’t continue to put off retirement. Indeed, states like Texas and many rural areas are already encountering shortages. “Nursing has experienced some challenges, but even greater challenges lie ahead as the baby boomers retire and leave the nursing workforce,” says Hill.
The need for more nurses will be overwhelming, according to the US Bureau of Labor Statistics (BLS). In a recent occupational outlook report, the BLS said there will need to be about 500,000 more nursing positions by 2022. In addition, about 500,000 baby boomer nurses are expected to retire over that same time period, meaning that over 1 million new nurses will be needed over the next decade, according to the BLS.
That means that the hospitals and other employers who are now rejecting young applicants will end up begging for them to apply, which could push up nurses’ wages. Hospitals could also simply pile more work onto existing nurses, but doing so would be unworkable in the long run.
Nursing schools have been pushing hard to expand class size so there will be enough nurses for this tsunami of demand. But they’ve had to turn applicants away, due to a lack of nurse educators. Nursing schools in New York, for example, rejected 2,900 qualified applicants in 2012, more than in any year since 2005, according to the Healthcare Association of New York State (HANYS). Many of these spurned applicants have probably moved on to other careers, which is a great loss for nursing.
Repercussions of the Affordable Care Act
Like the baby boom, the health care law represents another great sea change for nursing and is also still in its early stages. The full impact of the ACA “hasn’t shaken out yet,” according to Webb.
Beginning in January 2014, millions of Americans gained coverage under Medicaid and in subsidized policies sold on the new health insurance exchanges. But it’s still unclear how much these people will boost demand for health care and thus nurse hiring. Exchange policies tend to have very high deductibles, discouraging people from getting care. Additionally, millions of Americans still haven’t signed up, despite a federal requirement to do so. The penalties in the first year were fairly minor but will rise in succeeding years, which may boost coverage.
The elephant in the room, of course, is Republican opposition to the law. Republicans continue to promise repeal, and it could happen since they’ve gained control of the Senate and the House. In the meantime, however, this sweeping law is fundamentally changing the face of health care in this country—not just in terms of sheer numbers of patients, but also in the way it is delivered. And in another few years, it would be very hard to turn these changes back.
“I’m not saying it’s a perfect law,” says Webb, “but it has, in my view, put nursing on the map. Nurses have a bigger role now.” Accountable care organizations and patient-centered medical homes are new models of care that are encouraged by the ACA. Both models reward hospitals and other providers that coordinate care and provide more patient education—two areas where nurses excel.
“The ACA emphasizes primary and secondary prevention and education of patients,” says Shawona Daniel, MSN, CRNP, assistant professor of nursing at Tuskegee University, a historically black institution in Alabama. “Education is one of the most important nursing roles. I’d say 90% of what nurses do involves teaching patients and working on preventive issues, which helps keep patients out of the hospital.”
Webb added that working in medical homes requires computer skills in order to deal with electronic health records and telehealth services, such as e-mailing and Skyping patients, as well as using remote monitoring devices. “These patients need monitoring, and this is where nursing is really critical,” she argues.
The Shift Away From Hospitals
Daniel reported that virtually all of her students still expect to work in a hospital—at least initially. But the ACA favors new models of care outside the hospital. For example, Medicare is reducing hospital reimbursements, and hospitals are being penalized for readmissions within 30 days.
“There is an ongoing shift from inpatient to more community-based outpatient care,” says Hill.
Faller agreed with this assessment. “Only the sickest of the sick will be in the hospital, and care will flow out into the community,” she explains. As health care moves out of the hospital, home health is already a growing field, and it has become a magnet for telehealth and other high-tech services, she adds.
In addition, Hill says nurses will be able to find ample jobs at dialysis centers, community health centers, physicians’ offices, outpatient surgery centers, and pain management clinics, to name a few settings. “There are just so many opportunities,” she argues.
As part of the de-emphasis on hospital care, many patients are being discharged earlier and placed in long-term acute care (LTAC) facilities, where they spend many weeks often still on ventilators and IVs. Care in the LTACs is “complex and challenging,” says Joseph Morris, CNS, GNP, PhD, director of nursing and allied health at Victor Valley College in Victorville, California. “Nurses who work in these facilities require advanced skills, such as advanced cardiac life support and telemetry training.”
Morris, who is trained in gerontology, welcomes the influx of aging baby boomers. Many nurses seem to feel that a geriatrics career—which can mean working in a nursing home—means “lowering your sights,” he says, but he disagrees. “It’s clinically challenging because you’re more likely to see multiple health problems.”
Dealing with older patients is also personally rewarding. Morris, who is African American, has fond memories of taking care of elderly black men in Detroit. In contrast to the stereotype of geriatric patients sitting in their wheelchairs muttering to themselves, “most geriatric patients are still active,” he says.
Nurses Get More Training
The job market is beginning to favor nurses who have a BSN degree, and advanced practice nurses such as NPs are in great demand.
Both trends earned key endorsements from the Institute of Medicine (IOM) in its 2010 report, The Future of Nursing. The report set a goal that 80% of nurses should have a BSN degree by 2020 and urged states to drop barriers against NPs working “to the full extent of their education and training.”
Hospitals are quickly shifting to BSNs. In New York, 70% of hospitals in 2013 preferred hiring BSNs, compared with 46% in 2011, according to HANYS. Many younger nurses are heeding the call. Faller pointed to the 2013 AMN Healthcare survey showing that almost one-quarter of nurses ages 19–39 said they would pursue a BSN, and more than one-third said they would pursue a master’s degree in nursing.
Hill says it’s fairly easy for someone with an associate degree in nursing to transition to a BSN degree. They can enroll in a “RN-to-BSN” transition program, which lasts 12–18 months and is available in many locations across the country.
Meanwhile, NPs have been proliferating. According to a 2013 report by the Health Resources and Services Administration (HRSA), the number of NP graduates grew by 69% from 2001 to 2011, fueled by the growing shortage of physicians in primary care and easing of state restrictions on NP practice.
“Nursing students are more ambitious than they used to be,” argues Daniel. “A lot of them want to go back to graduate school and become nurse practitioners.” She says she hopes some of them will choose a career in academia so that more nurses can be trained. This was another goal of the IOM report.
Morris says the new doctor of nursing practice credential, which will be required for all NP students starting in 2015, expands the amount of study, making NPs even more desirable as primary care providers as well as specialty caregivers.
Of course, the extra time and money needed for a BSN, and especially an NP, can be a barrier for minority students. Rather than pile up loans, Morris urged students to thoroughly research available scholarships. “Nursing students have not always been proactive in seeking out the opportunities.”
Push for Diversity
The new models of care fostered by the ACA require closer relationships between providers and patients, which means hiring nurses from the same ethnic background as their patients. Hospitals and other employers “want their nurses to be compatible with the culture or their patients,” says Faller. “But this will be a challenge, particularly for the Hispanic population.”
While Hispanics make up 17.1% of the population, they account for only 4.8% of RNs, according to the HRSA. There is also a gap for African Americans, who account for 13.2% of the population but just 9.9% of RNs.
As a black male nurse, Morris says it’s easier for him than for white caregivers to connect with black patients. He says many of them are still painfully aware of the infamous Tuskegee experiment. In a project that lasted until 1972, white doctors didn’t inform black male patients that they had syphilis, so that they could follow the natural progression of the disease. As a result, older black patients in particular are still wary of “being used as guinea pigs,” he says.
Morris has worked hard to boost African American representation in nursing, visiting schools to spread the word about a nursing career. He is also interested in boosting the number of black men in nursing. While men make up almost 10% of all nurses, very few black males enter the field, he says.
Nurses Have a Central Role to Play
There are many opportunities for minority nurses in this era of great change in the health care system. According to the IOM report, nurses will take center stage in this process.
“We believe nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system,” the report maintained. “How well nurses are trained and do their jobs is inextricably tied to every health care quality measure that has been targeted for improvement over the past few years.”
Leigh Page is a Chicago-based freelance writer specializing in health care topics.
As millions of uninsured people get coverage under the Affordable Care Act (ACA), job opportunities for registered nurses could open up in the nation’s community health centers because many of the newly insured are expected to go there for care. These facilities, also known as federally qualified health centers (FQHCs), provide primary care in medically underserved areas, regardless of patients’ ability to pay. Teams of physicians, nurse practitioners, registered nurses, and other health care workers treat mostly Medicaid patients and the uninsured.
FQHCs, the mainstay of the nation’s health care safety net, have been growing by leaps and bounds in the past decade, posting an 80% increase in new jobs. Now a new wave of patients is expected, fueled by the Medicaid expansion and the new health insurance exchanges, where premiums for low-income people are subsidized.
Planners of the expansion predicted that since many physician practices have limited capacity for new patients, many of these patients would go to FQHCs. Therefore, the ACA set aside billions of dollars in construction funding to help FQHCs expand their facilities so they could handle an onrush of patients.
No one knows, however, how many new patients will come, and the centers, operating under tight budgets, have been holding off on hiring until they get a better idea.
Also, while FQHCs employ a significant number of RNs, these facilities may not appeal to everyone. Salary levels vary widely, with some facilities paying less than hospitals, and many FQHCs are more interested in health care workers with less training, like licensed practical nurses.
What FQHCs Want
Community health centers are looking for nurses who are committed to serving low-income people, usually minorities, says Gary Wiltz, MD, chair of the National Association of Community Health Centers.
“The work should be viewed as a calling,” he says. When Wiltz interviews job applicants for his own FQHC, the Teche Action Clinic in southern Louisiana, he says he wants to see compassion. “The patients are disenfranchised, but many of them have jobs and are working very hard,” he notes. “As a provider, you have to be aware of what they are going through.”
Jennifer Fabre, RN, a nurse practitioner at Teche Action, says nurses are paid less than those who work in hospitals or nursing homes. But Community Health Services, an FQHC in Hartford, Connecticut, pays them comparable rates, according to Valerie Tyson, RN, a nurse at the Connecticut facility.
Tyson says working in a FQHC is very different from the hospital med-surg unit where she used to work. “The hospital has people who are very sick, but here the patients have an acute illness or need follow-up care for a chronic illness,” she says. “This is their primary care stop.”
A big part of the job, she explains, is teaching patients to manage chronic conditions. The RNs also take patients’ calls, routing some of them to doctors or nurse practitioners but taking care of most of them, she adds.
The Connecticut FQHC serves inner-city patients who are mostly Hispanic and black, some sharing Tyson’s roots in Jamaica. Unlike in the hospital, “you get to know these patients over time,” she says. “You develop a relationship with them.”
Fabre added that nurses have to understand their patients’ needs. “You do whatever you need to do to help the patient,” she says. “It doesn’t do patients any good if you prescribe a medication for them and they can’t pay for it.”
Roots in the Civil Rights Era
FQHCs have a rich history of community service, going back to the Civil Rights era. The oldest rural FQHC, the Delta Health Center, was founded in 1967 in Mound Bayou, Mississippi—the oldest predominantly black settlement in America.
This little village is in the heart of the Mississippi Delta, a land of cotton fields that gave birth to the blues. The health center sits on land once owned by the brother of Confederate president Jefferson Davis, Joseph E. Davis, who encouraged “self-leadership” among his slaves, letting them build a “model community.”
After emancipation, Joseph E. Davis’ former slaves spent two decades earning enough money to purchase the land, founding the village in 1887. Today, Mound Bayou has 687 households and is still almost entirely black. The town came into prominence again in the Civil Rights era of the 1960s, when it caught the eye of H. Jack Geiger, MD, an idealistic Massachusetts physician who wanted to create a new type of health care facility for the poor.
In the 1964 Economic Opportunity Act, the cornerstone of President Lyndon Johnson’s “War on Poverty,” Geiger persuaded President Johnson to include $1.2 million for test sites at Mound Bayou and Boston. Envisioning a self-sustaining community, Geiger and his followers not only built a clinic in Mound Bayou but also dug wells and helped residents improve farming methods.
FQHCs have enjoyed a renaissance in the new century, starting with a wave of new federal funding under President George W. Bush. Patient volume grew by 50%, reaching the 15 million mark in 2006. Under President Obama, the Recovery Act set aside $2 billion in extra funding for FQHCs in 2009, and patient volume then reached 20 million.
The ACA set aside $11 billion for the centers, mostly for construction, to help them build capacity to meet the coverage expansion. The Delta Health Center received $5 million of this funding, allowing for its first significant expansion since it opened 47 years ago.
The new building will open in February. “We’re going to have brand-new rooms and new equipment,” says Neuaviska Stidhum, RN, the chief operating officer at Delta. “It means we’ll be able to see more patients.”
Centers Holding off on Hiring
But even as Delta and many other FQHCs expand, they are holding off on hiring more staff and even, in some cases, opening some of their new projects. Facilities have to be careful about hiring because the new federal funding does not cover operational expenses. Teche Action Clinic, Wiltz’s FQHC in Louisiana, renovated two new sites using federal money, but it doesn’t have the funds to open them.
Moreover, there are signs that the anticipated onrush of new patients may not be as large as expected. Half of the states, including Mississippi and Louisiana, aren’t participating in the Medicaid expansion. Technical problems with exchange websites are dissuading some people from signing up, and the fine for not obtaining coverage may initially be too low to force some people to buy insurance.
Stidhum adds that many doctors’ offices in the Delta region still have a lot of capacity, so there would be less reason for the newly insured patients to use her FQHC. “We don’t know what we’ll do yet, “said Stidhum when asked about hiring. “Maybe we’ll need more staff, or maybe we’ll just need to shift their duties around.”
The story is different in Connecticut, which has joined the Medicaid expansion and has a very active insurance exchange. Tyson says her Hartford FQHC has put off hiring, but she is optimistic about hiring in the future. “The center is really busy,” she says. “If there are more patients, we would have to hire more nurses.”
Two years ago, Evelyn Javier was working in a research lab in Maryland and was unhappy with her career. “I liked the job, but it did not fulfill my purpose,” she says. “I felt like there was more I could do.”
What she really wanted to do, she decided, was to help people. In 2011, she quit her lab job and entered nursing school in New Jersey. Javier, now age 29, just received her RN degree and is about to launch her new career.
Many young minorities, after making false starts in other fields, discover that a career in nursing is actually the best fit for them. These career-changers—usually in their mid-20s—are attracted by the opportunity to help others, get out of an office setting, and interact with many different people. They also like the wide variety of nursing jobs they can choose from.
Nurse educators say these more seasoned students are generally more intense, get higher grades, and have a clearer idea of their career goals than their younger counterparts. After trying out something else, “they know what they want,” says Deborah A. Raines, PhD, RN, ANEF, a professor of nursing at the University at Buffalo School of Nursing. Though Javier had good grades, Raines says some latecomers to nursing were initially poor students who worked for a few years in low-paying jobs and then became more serious about their careers.
Raines, who authored the 2011 study “What Attracts Second Degree Students to a Career in Nursing?” in OJIN: The Online Journal of Issues in Nursing, says nursing tends to be something these second-careerists always wanted to do, but they were sidetracked into careers like teaching, business, or marketing for a few years. These students often bring skills from the previous jobs. Javier, for instance, says she brought a knowledge of aseptic techniques and teamwork skills from her lab job.
A Career Change From the Heart
While traditional nursing students often cite salary and job security as key reasons for going into nursing, Raines says career-changers tend to have “intrinsic” motivations—reasons that come from the heart. “They really want to help other people,” she adds.
Javier switched to nursing after she took a career aptitude test, showing the field was her real calling. “I realized I wanted to go back into the community,” she says. “I wanted to be the person providing the extra care for those in need.”
As with many second-career nurses, Javier already had a college degree and could shorten her nursing education. Since she had already taken all the science courses she’d need for a bachelor’s in nursing degree, she was able to jump right into clinical training at the Muhlenberg School of Nursing in Plainfield, New Jersey. To help support herself as well as decide whether she wanted to be in clinical care, she took a job as a patient care technician at the same hospital where she was training. “I wanted to see if the hospital environment was right for me,” Javier says. It turned out to be a good fit.
Having just earned her degree, Javier now plans to work for about a year and start a bridge program for a master’s in nursing degree next spring. Ultimately, she wants to be a nurse practitioner specializing in family health with an emphasis on women’s health. And as a member of the New Jersey Chapter of the National Association of Hispanic Nurses (NAHN), she wants to focus on helping Hispanic patients. “I’m concerned about the cultural and language barriers that Hispanics face,” she explains.
Overcoming Family Expectations
Raines says second-career nurses often have to overcome family expectations about another line of work. “They were directed a certain way by their parents, and then they found out that nursing was what they really wanted to do,” she says.
She recalls a second-career student from Haiti whose parents insisted that she should work at a law firm. The student did so for a while, but “she always wanted to be a nurse,” says Raines. She earned her nursing degree, worked for a year as an emergency medical technician, and then went back to graduate school. She is now in a doctoral program.
Jade Curry, an African American nurse, also had to overcome the expectations of some family members who thought she should be a doctor. To see if she’d like it, she even worked in a dermatology office for a year and attended a mini-medical school at the University of Michigan, where she majored in biology. But she didn’t like it and instead considered a career as a science teacher or in public health.
Her career path took another turn when, as an undergraduate, she began working for a program to help boost minority participation in certain health care professions, including nursing.
She became a strong proponent of the profession. “There are so many things you can do with a nursing degree,” says Curry. “You can go into teaching or practicing. You can work in multiple settings, like the ER or the ICU. You can get into a specialty like pediatrics or oncology. Or you can do research. Every discipline needs a nurse because we are the gatekeepers.”
After graduating college in 2003, Curry briefly considered taking another minority recruitment job at the University of California in Los Angeles, but instead she enrolled in the University of Michigan’s School of Nursing. “Basically, I recruited myself,” she says.
After earning a nursing degree in 2006, Curry received a master’s of science in nursing degree from the University of Pennsylvania in 2009. Now married with a one-year-old son, she is a nursing PhD candidate and is working at a teen health center. Her research interest revolves around how parents with teenagers communicate about sex.
Raines says many second careerists are “very focused about where they want to go.” She recalls a nursing student who came from a human resources job. “She wanted a nursing job in a certain unit, with a certain number of beds,” she recalls.
Vaneta Condon, PhD, RN, served as director of the Pipeline to Registered Nursing program at Loma Linda University in California, which recruits underrepresented minorities into nursing. She says about 30% of the students already had a college degree in areas such as science, business, and teaching, and some already held jobs before they switched to nursing.
“The biggest reason they give for going into nursing is wanting to spend more time helping people,” she says. Since they already had some life experiences, “they start off as better nurses. They can adapt more readily to a nursing program and working with other people.”
Helping people has been the life work of Suleima Rosario-Diaz, RN, who has been a minister in the American Baptist Church in New Jersey for many years. A few years ago, she decided to get a nursing degree with the goal of performing health care missionary work in other countries.
Rosario-Diaz entered an accelerated nursing program at the University of Medicine and Dentistry of New Jersey. Now age 30 and married, she works as an admissions and discharge nurse at Palisades Hospital in Edgewater, New Jersey, and is working on a master’s degree.
She is still a minister as well as vice president of the New Jersey Chapter of NAHN. “Being a minister helps me to be a better nurse, to show love to people,” she says. “I want to be a calming presence.”
Rosario-Diaz wants to combine her therapeutic education with pastoral counseling. “A lot of religious folks do chaplaincy work in the hospital, but that does not interest me,” she explains. “I want to be hands-on, to be a presence when you are in pain. I am task-oriented, so it’s a great fit.”
Minorities have entered nursing from all kinds of walks of life. From the loss of a loved one to an unfulfilling job, inspiration can strike just about anywhere—and the smallest trigger can ignite that spark to become a nurse. Here are four examples to encourage you to make the leap:
Losing a Loved One. Chrispina Chitemerere was a schoolteacher in Zimbabwe before immigrating to the United States.1 She got a teaching job but didn’t like the work, she said in the May 2013 issue of the Elms News. Chitemerere said she found a new calling while taking care of her mother, who was dying of cancer. She became a licensed practical nurse and then enrolled in the Accelerated Second Degree in Nursing Program at the Elms College School of Nursing.
Combining Passions. For nine years, Randi Simpkins taught fifth and sixth grades in elementary school.2 “While I absolutely love the field of education, I knew that there was more for me to learn,” she wrote in an essay that won a Robert Wood Johnson Foundation New Careers in Nursing scholarship last year. “Daily I encouraged my students to pursue excellence and reach beyond their limits. Upon reflection, I was forced to acknowledge that I, myself, had not attained my own goals of academic accomplishment.” She “stumbled upon the opportunities in nursing” and enrolled in the Duke University School of Nursing in January 2012.
Encouraged by Others. When Christine Hernandez’s mother was dying of cancer, a hospice nurse came into their home to care for her and sparked Hernandez’s interest in nursing.3 “She was amazing,” Hernandez told RN Builder.com. “It wasn’t just my mother she was helping but all of us. She was a strength that we just couldn’t have done without.” A few years later, Hernandez worked as a nanny for a dual-physician couple. They encouraged her to get an RN degree, so she enrolled in an RN program at Salt Lake Community College in Utah. Her goal is to work in pediatrics, oncology, or hospice.
Divine Intervention. In India, Binny Varghese earned a bachelor’s degree in human genetics and worked as a researcher in the biosciences.4 But as a child, “I gained a passion to serve others,” he told the Kansas City Nursing News in 2012. After immigrating to the United States for an arranged marriage with an Indian American woman, he decided that nursing was his real calling and entered an accelerated nursing program at MidAmerica Nazarene University in Olathe, Kansas. “When God wants you to do something better, he shows you the way,” he told the paper.
1. Elms College. From Africa to Chicopee, Two Students Earn Second Degree in Nursing. Elms News. May 15, 2013. www.elms.edu/elms-news/from-africa-to-chicopee-two-students-earn-second-….
2. Randi Simpkins. “I believe this about nursing…” essay. Robert Wood Johnson Foundation New Careers in Nursing. August 2012. www.newcareersinnursing.org/scholars/essay-contest/winners/randi-simpkin…
3. G. Jones. Nursing Student Interview with Christine Hernandez. RN Builder. April 11, 2013. www.rnbuilder.com/blog/education/nursing-student-interview-with-christin…
4. Nursing is second career for MNU student. Kansas City Nursing News. 2012. prewww.kccommunitynews.com/kc-nursing-news/30992401/detail.html.
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