In May 2015, I joined the faculty at the University of Florida College of Nursing (UF CON) as an associate professor. Fourteen months later, I became a single adoptive mother to a newborn. My successful journey through single motherhood while balancing my academic responsibilities was due, in large part, to the overwhelming support I received from the entire body of the CON including the dean, department chair, faculty, staff, and students.
Working From Home
When I think about the reaction of my senior colleagues when I shared the news that I adopted a newborn, I am in awe. My department chair was elated, and after congratulating me, the first words she uttered were,“Miriam, you have my support. I am here to provide you with whatever resources you need to succeed at motherhood and your academic career. You can take maternity leave, work from home to direct your research, teach online, and teleconference as needed.” Before I could respond, my department chair excitedly went next door to inform the dean, who glowed with joy about my news, grabbed my hands, and stated emphatically, “You are taking maternity leave.” I was stunned.
I was surprised about the reactions I received from the administrators because I was not sure what to expect. I was a newly hired associate professor trying to build my research program following relocation from another institution. Because I was a relatively new hire, I was afraid they would express misgivings about my status as a single mother with no family support, which might affect my productivity as an employee; however, these fears were not realized. Although the administrators strongly encouraged me to take maternity leave, I opted to work primarily from home and hire a babysitter to assist me, who cared for my son when I travelled to campus to teach and to attend research team meetings. Incredibly, senior colleagues encouraged me to bring my son to our hour-long meetings and to classes after students requested it. As a result of their kind support, I brought my son to research team meetings, where my colleagues enjoyed meeting him, and to class, where my students happily posed for photos with my son and me.
Was it Unprofessional to Bring a Baby to Work?
Despite the tremendous support I received to bring my son to the CON, at times, I felt that it was unprofessional. Realizing that I was projecting upon myself the negative stereotypes about motherhood and child-rearing, I asked myself several key questions: What is unprofessional about being a mother? What is unprofessional about role modeling to my son the importance of strong work ethics? What is unprofessional about exposing a baby to intellectuals who are positive role models? I surmised that exposing my son to an environment replete with kind, smart, and diligent professionals could only help him learn the behaviors he needs to become successful in life.
It has been nineteen months since I started my motherhood journey, and I am still breathless about the kindness and support I received and continue to receive from my colleagues. Knowing that I had the option of taking maternity leave as well as the full support of the administrators who were not concerned about my productivity was reassuring.
His Majesty, Kasi, Among Nurses
By Miriam O. Ezenwa, PhD, RN
Nurses, my Angels
They gather to do what they do best
Fix the ills around the world
Care for those needing their healing presence
Enters, His Majesty, Kasi, drawing attention
Heads turn left and back, eyes twinkle starry-like
Smiles everywhere, hearts blooming light
Love! Love in the air for His Majesty
Calm nurses, my Angels, research retreat in progress
Work in teams, way of the future
Stand strong, hands locked in place
Embrace people from far and wide
Including those who don’t look alike
We are stronger in the spirit of the rainbow
Need to rest from the trip to here
Nurse Karen holding tight, heart pumping peace
The future is smart for His Majesty, nurses’ wisdom grows in strength
His Majesty needs a diaper change
Nurse Jeanne-Marie and nurse mommy to the rescue
Now, where were we?
Back to fixing the world
How about fixing how we secure our existence?
Many ways of teaching, the more the merrier, the merrier the better
Sleepy-sleepy, growth in rapid measure
Uncle Yingwei got this one, his manly touch is much needed
Once! Twice! Hunger and starvation
Hurry Mommy! Tummy thunders, feels like no end in sight
Mommy doting, needs now met
Sorry for my interruptions, I am just a baby
To resume business, let’s take stock
Goals are important, set now, assess in time
We are nurses, born to fix ills, from birth to death
Yes, nurses fix ills all the time
His Majesty needs a break, nap is golden
Nurse Versie won the prize, His Majesty is a treasure
Mommy close by inspecting every touch
New mommy, but instincts never fail
Back to research retreat, His Majesty is listening
Teams assembled, lead authors identified. Here! Here!
Oh no! Nature calls again, can’t ignore
Nurse Cindi in charge this time
Mommy always in tow, my bag in hand
Back again to wrap up, day went well
We must tell our story, stir the soul
His Majesty must depart now
The throne at home beckons, Queen Mommy in charge
Car must be readied, His Majesty commands comfort
Uncle Yingwei again to help, he has been there from day one
Goodbye, nurses. His Majesty must retreat
Till we meet again, a year from now
Assess your outcomes, inform His Majesty
Did I say that nurses are great?
Lest I forget, nurses are magnificent
You are my tribe, away from home
His Majesty, Kasi, enjoyed your company
Spread the word, it takes a tribe
A tribe of nurses, best any time
It helped me focus on enjoying motherhood and have the peace of mind related to a secure livelihood. I remind myself of how blessed I am for the inherent flexibility of my academic position. This feeling of gratitude propels me to work harder so that I do not disappoint myself or the trust the administrators bestowed upon me, to find an appropriate work-life balance required for success in academia.
My Tribe Away From Home
When my son was six weeks old, the CON had a faculty research retreat, and although I did not have a babysitter, I did not want to miss the retreat. I talked to my department chair about this problem, and she suggested that I bring my son to the retreat. The entire faculty in attendance surprised me with their support. At that moment, I knew that I had found my tribe at the UF CON even though I was 6,000 miles away from my home country, Nigeria. I captured the interactions between my son and my newly found tribe in the poem, His Majesty, Kasi, Among Nurses.
Take Home Message
Current knowledge suggests that many mothers in academia struggle to succeed as they balance motherhood and academic responsibilities. These challenges could be quadrupled for single mothers in academia who are immigrants and who may not have family support. I experienced many challenges being a single adoptive mother, particularly on the days that my son was sick; however, I always had the help of my colleagues, who personally assisted me in caring for him. Their support enabled me to excel at motherhood and my faculty role, and I am immensely grateful for this support. Based on my positive experiences, I encourage other universities around the United States to emulate the actions of the UF CON administrators and support mothers in academia as they balance two important aspects of their lives: motherhood and an academic career.
As increasing numbers of patients don’t speak English as their first language—or at all—the health care field is taking action. Here’s what’s happening and how you can become involved.
Imagine if you were in a hospital in a country where no one spoke English. Being in a strange hospital or other health care facility can be scary enough, but if you had no idea what was going on, it would make you more stressed—possibly making your health worse. You would feel incredibly vulnerable, as not knowing what was happening to you or if the workers could help you would be terrifying.
There was a time in the United States when that could happen. Although it shouldn’t happen, legally, anymore, as Allison Squires, PhD, RN, FAAN, explains, there is still a need for more bilingual nurses. “All health care facilities are required by law—including the Civil Rights Act and updated regulations in the Affordable Care Act—to provide patients who do not speak English with an interpreter,” says Squires, an associate professor at the New York University Rory Meyers College of Nursing. “The interpreter can be an in-person interpreter or a telephone or video interpreter to meet the requirements of the law.”
According to Squires, the increase in patients who haven’t developed English skills comes from two situations: the post-WWII legacy in which U.S. citizens came here as immigrants, and the most recent wave of immigration, which has matched or surpassed the immigration numbers of the early 20th century. “According to the Pew Research Center, one in five households in the U.S. speaks a language other than English at home. More communities are also becoming refugee resettlement cities across the U.S., which means increasing linguistic diversity in places that have historically only had English speakers,” says Squires. “The demand for nurses who speak another language is at an all-time high.”
Location, Location, Location
While all the sources whom we interviewed agree that Spanish is the most prevalent second language needed for patients, they also say that other languages are vital as well, depending on your region of the country. “Spanish is the priority language nationally. Other languages depend on where you live and who is migrating there,” says Squires. “For example, in the New York City and New England regions, there are now large numbers of Russian speakers. These individuals often come from former Soviet Union states where Russian was the official language. Other parts of the country, like Texas and Louisiana, have large numbers of Vietnamese speakers who came to the U.S. as refugees or immigrants. Other than Spanish, language demand is often specific to a local health care service area.”
“Spanish is the language in highest demand, particularly in Texas, California, Florida, and Illinois. In California, bilingual skills are needed for Spanish, Chinese, Vietnamese, and Russian,” says Terry Mort, who is manager of talent acquisition for VITAS Healthcare, the nation’s leading provider of end-of-life care. In the 14 states and the District of Columbia in which they provide care, VITAS Healthcare has also found the need for Mandarin, Cantonese, Tagalog, Hmong, Korean, and Creole.
“We constantly have to look at demographics of the communities we serve and pay attention to how they’re changing over time,” explains Mort. “Take California as an example. At one time, South Central Los Angeles was primarily an African American community, whereas today it’s predominately Hispanic. And as our services move into outlying areas of Los Angeles County, our needs change again because we encounter more families that are Filipino, Asian American, or Hispanic American.”
Currently, in South Florida, several VITAS hospice teams are solely Spanish speaking to appropriately serve their patients’ and community’s needs. “In California, a trilingual nurse—someone who speaks English, Spanish, and other language—would be in high demand,” says Mort.
Although particular languages may be needed to serve certain populations, there are also instances in which unexpected languages may also be required. For example, when there was a recent influx of patients from Puerto Rico at the University of Maryland Baltimore Washington Medical Center who needed health care after Hurricane Maria, there were more Spanish-speaking patients, says Edith Lopez Dobbins, RN. Dobbins is a JET Nurse, which stands for Just Excellent Timing and means that she is a full-time nurse who serves as supplemental staff for different nursing units throughout the hospital. As a result, she has noticed an overall increase in patients who speak Hindi and Korean as their first language.
“In the hospice profession particularly, we also have the challenge of end-stage dementia patients, who may revert to their language of origin as their disease progresses. We had a Russian patient who reverted to speaking Russian, but the family indicated he had not conversed in that language for more than 20 years. If that happens, it requires us to update our care plan so that our nurses and staff members can communicate effectively with these patients in a language they understand,” explains Karen Peterson, senior vice president and chief nursing officer for VITAS Healthcare. “The more languages our staff members can speak, the easier our job is.”
Benefits to Being Bilingual
Bilingual nurses on staff help open everyone up to another world as well as another set of patients to care for, says Vivian Carta Sanchez, DNP, ARNP, from Tenet Florida Physician Services. “Nurses who are bilingual can also serve as translators to communicate very important information from physicians who do not speak the language,” says Sanchez.
Squires says that if you work in a hospital, home care, long-term care, or rehabilitation, there are four key times when interpreters are needed—admission, patient education, consent, and discharge. “Using an interpreter during these times can help reduce your patient’s risk for readmission and complications,” explains Squires.
Having a nurse who is bilingual, rather than using a family member to translate, can be crucial. “Let’s say that I take five minutes to explain something in detail to a patient, and the family member who translates what I said to the patient takes about 30 seconds. I can tell that my patient isn’t hearing the same thing that I said—and that’s a risk to the patient, because they’re not getting complete information,” says Peterson. “It’s one of the reasons we prefer not to use family members as translators because they are part of the unit of care and also dealing with psychosocial issues associated with end of life.”
Another advantage to staffing or being a bilingual nurse is that when you are speaking the same language as a patient, the work you are doing will take the same amount of time that it does as when you are talking with an English-speaking patient, says Squires. There’s no need to be concerned about waiting for an interpreter to arrive or to have to deal with any issues that can occur when using an interpreter by phone. In addition, communicating with family members may also be easier. “That being said, as a bilingual nurse, if you are the first language nurse to work with the patient when they access health services—be they in the hospital, home care, or primary care—sometimes you spend more time with them initially because the patient is so happy to have someone who speaks their own language,” states Squires. “You find out all this other stuff that the patient held back because of the language barrier or issues with interpreter services. Another advantage of being a bilingual nurse is that you can quality check video or phone interpretation.”
Speaking to patients in their native language isn’t only about the words; it’s also about their culture. Dobbins says that while they use “language phone-lines” to keep at patients’ bedsides so that they, their families, and the health care workers can communicate—which is certainly helpful—the phones can also make talking more impersonal. “It makes patients and their families uncomfortable—possibly because it’s not just about language, it’s about culture. Most of the time, we use peers in the health care team who speak the same language as the patient for better communication and overall quality of care,” says Dobbins.
“Bilingualism is even more imperative in the hospice profession because there’s a lot of emotion and psychosocial aspects of language surrounding the dying process. Each person might have a different opinion or thought process around the issues related to dying. It’s unique in that people may have difficulty conveying their thoughts and feelings, even in the same language, simply because it’s about death,” explains Peterson. “Some patients or family members can’t even say the word ‘hospice,’ so they find a way not to say it. But when our nurses, families and patients understand each other’s language and cultural nuances, we’re more confident that patients are making the right decisions and receiving the best possible care because everyone understands each other.”
Knowing about patients’ culture has become so important that the Chamberlain University College of Nursing began offering a Hispanic concentration on its Phoenix, AZ campus in May 2016. Pam Fuller, EdD, MN, RN, the Phoenix campus president, states that this concentration doesn’t aim to attract Hispanic nurses, but rather to appeal to nurses who want to care specifically for this culturally diverse group. This concentration is offered to anyone who is enrolled in the university’s pre-licensure BSN program. Because of its ability to logistically provide clinical experiences for students who are enrolled in the Hispanic concentration, the Phoenix campus volunteered to pilot it. “The local hospitals and health care centers currently serve Hispanic patients and families every day, and Chamberlain helps provide nurses and care to these local communities,” says Fuller.
“Providing nursing care requires not just an appropriate educational degree and a license, but also crosses boundaries of human dignity and respect. Many, if not all, hospitals and care centers are challenged to communicate more effectively with their patients, regardless of cultural background. Chamberlain specifically launched the Hispanic concentration based on information from hospitals in our local markets,” explains Fuller. “When a patient is in pain or in need of health care, they tend to revert to what is comfortable to them, culturally. If you are culturally more comfortable with your own language and traditions, if there is someone who can speak—at least a little bit—the language you speak, it makes the care that much more effective and personal.”
“Chamberlain’s Hispanic concentration is not a language program. This concentration exposes students to the Hispanic language and culture and allows for 25% of their clinical experience to be placed with a Hispanic patient. This gives them real-time experience in serving the Hispanic population,” says Fuller. “Any student—regardless of their personal cultural background—may enter this concentration…The goal of the Hispanic concentration is to educate students and expose them to the culture and language of the Hispanic community to provide an improved level of care to this population.”
Attracting Appropriate Personnel
How can facilities go about recruiting bilingual nurses? Squires believes that a combination of actions could help. Nursing schools need to recognize local demand for bilingual services and restructure curricula to help ensure the success of English as a Foreign Language (EFL) students, says Squires. “Even now, EFL students have lower pass rates on the NCLEX-RN exam, and that’s not helping to meet our need for more bilingual nurses. Schools need to change how they teach and support EFL students so they have the same success rates as English speakers,” Squires says.
“Organizations should give bonuses to people who are bilingual to encourage better communication,” says Sanchez.
As for becoming bilingual, Squires says that to achieve the level of fluency to be able to effectively and safely communicate with patients about health issues, nurses would be required to undergo years of study or at least a six-month immersion in a country where the language that they want to learn is spoken. “Having just a few words or phrases can be helpful for recognizing when a patient is in pain or [has] toileting needs, but when it comes to the complex communication needs that go with admission for services, patient education, consent, and discharge, you really need to have what’s called sociolinguistic competence in a language. That’s something that your employer should help you certify or do it on your own to make yourself more marketable,” says Squires.
At the end of the day, being bilingual or having bilingual nurses on staff is all about patients’ safety and comfort. “As a nurse, many of my most rewarding moments have to do with going the extra mile to help a Spanish-speaking family during their hospital stay,” says Dobbins.
Kyana Brathwaite, founder and CEO of KB CALS- Caring Advocacy & Liaison Services, worked as a critical care nurse when she hurt her shoulder during a patient transfer.
“Our patient population is getting heavier [and] it is not always realistic to pull colleagues from different areas/departments to help. My true issue was not with the injury—although unfortunate, they do happen—my issue was with how my particular situation was handled after the injury by both management and the entity I worked for,” she explains.
For these reasons, the pain of her injury and the lack of support by management, Brathwaite chose not to stay at the bedside. Would she have stayed had circumstances been different?“Prior to the injury, I was considering staying at the bedside for at least five more years to give me time to plan the direction in which I wanted to take my nursing career.”Although she did plan to continue her career eventually, she would have given solid years to suffering bedside nursing specialties.
In fact, many nurses run from the bedside as soon as possible because conditions are so deplorable. They look for jobs in advanced practice, teaching, and other non-bedside related areas of nursing, while the number of nurses taking care of the most critical patients continues to dwindle.
Here are four reasons nurses leave the bedside and some ideas as to how to make them stay.
1. New Grad Education
New grads can go into a bedside job and not know exactly what they are in for. In nursing school, clinicals usually don’t go beyond two to three patients per student so they are not exactly exposed to the real-life rigors and stresses that come with the life of a bedside life—and cultural shock is a very real phenomenon.
“Nursing students are constantly told by faculty, peers, mentors, and experienced nurses what bedside nursing is ‘really like,’ says Greg Eagerton, DNP, RN, an associate professor at the University of Alabama at Birmingham School of Nursing. “However, it is like the first time we ride the bike by ourselves…The same is true for new nurses; their hands are held throughout their training and then the day comes when they are ‘alone’ and it’s a little frightening. They now have the sole responsibility for their patient’s care, their patient’s life—and that can be daunting. It’s also the reason we always encourage team support from their mentors, their more experienced peers, and from all members of the health care team, including physicians, therapists, support staff, etc.”
Although this is true, new grads often express intense dislike of their new role as a bedside nurse, and they immediately want to move to another branch of the profession. Is it that the nurse is not prepared or that the job is simply too difficult? It certainly sounds like management is trying to accommodate new nurses, but a quick search of internet nurse boards will reveal new nurses in despair. Perhaps more intensive job shadowing will allow new grads to see what bedside nurses do. Perhaps more realistic teaching would also go a long way toward helping them. Whatever the answer, new grads are a special population that needs attention—though it already gets quite a bit—to keep them safe and happy at the bedside.
2. Staffing Ratios
Another issue that chases nurses from the bedside is poor staffing ratios. It can be overwhelming for one nurse to have eight to ten patients to themselves. Not only is it unsafe, it is also stressful, and many nurses would rather find a new job than to put their licenses and their mental health on the line like that. For this reason, staffing ratios are important to consider when examining the loss of bedside nurses.
“I do not feel staffing ratios is the main driving factor,” argues Ken Shanahan, MSN, RN, CCRN-K, clinical nursing director at Tufts Medical Center. “One of the main reasons I feel this way is because the only state with staffing ratios is California and yet they have the most nurse strikes. These strikes are actually increasing dramatically and are something we will need to address as a profession. The work environment is the most important factor and number of nurses or ratios is only a component of the working environment. There are many other components that we are not hitting the mark on that would help create a healthy work environment.”
Although a large portion of nurses would disagree with Shanahan’s opinion on the importance of staffing ratios, he does have a point: they are not all that is involved here. Getting the floors better staffed is only one part of the puzzle, but addressing pressing issues such as horizontal violence is needed, too. Everyone knows about staffing ratios, but few realize they are only one prop to hold up a very large house meant to keep nurses at the bedside.
3. Compassion Fatigue and Burnout
Compassion fatigue and burnout are the psychological components that keep nurses from staying at the bedside. The two are closely related but are not the same. Burnout, in short, is frustration with the situation and is typified by anger. Compassion fatigue is an exhaustion of the ability to extend oneself emotionally anymore and is typified by depression. Please note, these are very simple definitions and they are not exhaustive. Both of these conditions can occur together, and neither is pleasant. Nurses have had their lives broken over these issues, and no one wants to go through that. How, then, do we solve this problem?
“Burnout and compassion fatigue are concerns for direct care providers in all professions,” explains Eagerton. He suggests the following measures to help support staff:
- Leaders should be visible and approachable.
- Work schedules should allow adequate time off between shifts.
- Adequate breaks should be provided during the work shift so that staff have down time.
- Schedule time for staff to have discussions about what stressors they are experiencing that may lead to burnout and fatigue.
- Create opportunities for staff to be involved in activities that allow them to do things that are not direct patient care but have meaning to them, such as committee membership, attending professional conferences, and so on.
- Have resources available for nursing staff in addition to their managers to discuss their stressors, such as chaplains, mental health professionals, and counselors.
- Have dedicated space(s) on or near the units where they work where they can have some quiet time or time to eat their meal or have their break without interruption.
With these ideas in place, nurses can have a better shot at overcoming compassion fatigue and burnout. When these are not a factor or are a mitigated factor, the more a nurse can feel happier staying at the bedside.
Nursing is definitely a contact sport, as stories like Brathwaite’s prove. Transferring patients is getting more and more difficult with increased body weights. In addition, various specialties are more susceptible to transfer related injury. For instance, operating room nurses are at great risk because they must move patients who are unconscious and essentially dead weight. However, that doesn’t make your typical bedside nurse any less at risk. Moving and lifting are just as much a part of the job, and mechanical equipment is usually not available to help.
“There is only one of you, [and] there will always be more patients,” says Nick Angelis, CRNA, MSN, author of How to Succeed in Anesthesia School (And RN, PA, or Med School) and cofounder of BEHAVE Wellness.“If no one is available to perform a task safely with you, don’t do it. Hospitals always push putting the patients first, but you’re a danger to patients if you give and give until your weekly schedule must also include time for massage and chiropractor appointments. Flu vaccines, unsafe equipment, dangerous staff ratios, risk of physical harm from unruly patients because hospital security resembles nursing home patients—these all require putting yourself first.”
It really does come down to this: Nurses need to learn how to put themselves first. If you can’t lift that 300-pound patient, then don’t even try, no matter how much it needs to be done. Similarly, hospitals need to make allowances for nurse injuries. Providing mechanical lifts, better security, and education about safety could go a long way towards protecting nurses and keeping them at the bedside.
In the end, the question of keeping nurses at the bedside is definitely multifactorial—and controversial. Patients have been cared for all this time with the methods we’ve been using, so why change? The reason to change is that the nursing shortage is real, and it isn’t what you think. It isn’t a lack of trained nurses. It is a lack of trained nurses willing to work. If we can make the bedside more appealing to these nurses who have run for cover, perhaps the nursing shortage wouldn’t really exist at all.
One of the American Nurses Association’s seven Bill of Rights for Registered Nurses is to “freely and openly advocate for themselves and their patients.” Yet, women and minorities may not be as effective advocating because they’re less likely to negotiate. There is a “win-win” negotiating style, developed at Harvard’s famed Negotiation Project, which may be more appealing. Practice them in small ways until they become second nature. Then when it’s necessary to advocate about safety, staffing, workplace violence, etc., you will be ready with a collaborative, problem-solving approach.
But if you don’t negotiate? Nurses who accept poor compensation or working conditions can end up feeling victimized, devalued, and unmotivated. With that attitude, they are less likely to provide excellent patient care and to get promotions. Don’t let that happen to you. Elevating your negotiation skills will lead to better communication, collaboration, and results for you and every other party.
Reframe the Concept of Negotiations
Given the overwhelming percentage of female nurses, it’s important to consider how gender plays into negotiation. Research shows that women are two and a half times more apprehensive about negotiating, while men are four times more likely to initiate a negotiation. In fact, 20% of women say they don’t ever negotiate, even when the situation necessitates it, according to Linda Babcock and Sara Laschever, authors of Women Don’t Ask: Negotiation and the Gender Divide.
That apprehension keeps many nurses from learning and practicing this important communication competency. “Negotiation is in the top five life skills that everyone should have,” insists Donna Cardillo, RN, author of The Ultimate Career Guide for Nurses.
“We negotiate all the time—with our kids, partners, patients, and coworkers, often without even realizing it. The word can have a negative connotation but only because most people don’t understand what it really is,” explains Cardillo. In health care, there is an additional connotation, and that’s terms of negotiation and union contracts, she adds.
According to Webster’s Dictionary, “negotiation” is defined as “to meet and discuss with another in order to reach an agreement.” But many of us suspect that in order to do that, one party must dominate, trick, or pressure the other into submission.
Sometimes, we have to reframe an uncomfortable concept, like negotiation, and perceive it in a new way, to make it more palatable, notes Cardillo.
“For example, say a nurse wants to attend a national nursing conference, and get paid time off, and expenses covered and so on. I’ll advise explaining the benefit to the hospital and the nurse manager. ‘By going, I’ll be able to bring back information from national speakers and experts to share. I will do an in-service session, or write a paper on it, and I’ll bring back printed materials,’” she explains. Nurses needn’t let a “No” response discourage them, either, adds Cardillo, because it may take repeated requests to get what you want. But if you don’t ask, the answer is always “No.”
Another way to reframe it, Cardillo says, is that by asking you’re planting seeds of change for the future, so you’re advocating for yourself and for your profession.
“Many of us were raised not to ask for what we want and to feel satisfied with whatever we got. I just saw a tweet from a nurse: ‘People say I need this job. I say this job needs me.’ That’s so true. Everyone is entitled to feel valued in the workplace,” she says.
Steven P. Cohen, author of The Practical Negotiator, has trained health care professionals in negotiation skills globally and agrees that nurses must self-advocate. “Your number one job is to look out for your own interests. Self-interest means maximizing circumstances to help you get what you need: good pay and benefits, rewards and resources that let you serve the patient. You must be well served.” He notes that if a nurse is treated badly, then he or she can’t function well, and patients suffer.
There are three kinds of interests to consider and prioritize in a negotiation—in conflict, complementary, or in common, according to Cohen. “If you’re going on vacation with a multigenerational family, how likely is it that you have common interests and all want to do the same things? Not likely. But you may have complementary interests. Your goal could be that everyone in the family will have a good time on the vacation.” He advises nurses to look for where there are complementary interests and no conflict, and to build step-by-step to a win-win solution. “Most anyone in a hospital, from aide to CEO, has similar objectives,” he adds “and is asking the same questions: How can I make the most of my job? How can I take care of the people I need to take care of?”
Negotiate in Your Off-Hours
One of the best ways for nurses to become empowered is for them to learn and practice good negotiation skills, asserts Michelle Podlesni, RN, president of the National Nurses in Business Association. “Why are we having nurses that don’t last two years in a hospital setting? Because they aren’t empowered and negotiation starts with assuming your power. I help nurses to understand their power,” she explains.
Podlesni believes that negotiation skills can be learned, like other important nursing skills. Earlier in her career she read The Power of Nice by Ronald Shapiro and Mark Jankowski, and it made a big impression on her. The book defines negotiation as using knowledge to get what you want, using the “three P’s” of preparing, probing, and proposing.
“Say a new nurse is getting scheduled in a certain way. How do they know it’s fair? You ask: ‘How is the schedule made?’ Nurses don’t always assess their own situation and propose what works better for them. We need to make a paradigm shift—your license is a license to start practicing in your business as a nurse,” Podlesni says.
Think of your negotiation skills as a muscle and flex it often in everyday situations. “Practice everywhere you go, even at the Macy’s makeup counter,” she says. “When you go to put lipstick on the counter, say ‘By the way, is this the best you can do?’ And then wait. And talk through a smile,” she advises. As long as you’re pleasant, salespeople will try to accommodate bargain-hunters, often pulling a percentage-off coupon from under the counter.
Even if they can’t give you a discount, clerks may have the power to sweeten the deal in some other way. “Another time at Macy’s I bought furniture and had to wait for an extended period during my workday, so I said to the clerk, ‘I know it’s not your fault but what can you do to help me out?’ She took away the delivery fee and saved me $150,” she adds.
For examples of opportunities in which to practice your negotiation skills and ideas about effective strategies, check out the blog The Daily Asker. A graduate student, Roxana Popescu, set herself the goal of negotiating a request everyday. So, at the farmer’s market, she might ask, “How about an end of the day discount?” She would often get it, or a free sample, or a bonus bag of produce. Over the course of one year, she asked for a discount 411. Analyzing her success rate, she discovered that she did better when she was nice (80%) versus when she was meek (58%). Perhaps unsurprisingly, she enjoyed the greatest success (85%) when she was very nice, or even flirtatious.
Negotiate with Coworkers
Whether delivering direct patient care as a manager, researcher, or as an entrepreneur, nurses need effective negotiation skills. Not every nurse is in a role that requires negotiating with patients, students, vendors, clients, or external agencies. But almost universally, nurses must negotiate with colleagues and coworkers.
“I’m a double minority, a male nurse and an ethnic minority,” says Usama Saleh, RN, BSN, MSN, PhD, a nurse educator. “Nurses are about 90% female today, but when I started it was only 3 to 5% male. I always felt like a minority in terms of gender, so I had to learn to negotiate with female nurses. Naturally there are differences in terms of negotiation styles. But I need to be able to work effectively within a female dominate profession.”
Usama was working as an RN in oncology and often negotiated with colleagues about the assignment of patients, for instance, and to resolve conflict so all parties are satisfied. In addition to ensuring an equitable workload, “it’s important to negotiate with your nurse mates on the team in order to deliver effective care. I always look at it in terms of quality of care,” he explains.
Usama came to the U.S. from the Gaza Strip and also had to become accustomed to the negotiation style of Americans who were born and raised here. “Culture and religion influence the etiquette of negotiation,” he says. “I wasn’t able to be aggressive; I was a soft negotiator. I admired it when negotiators were more assertive, but because of cultural factors I couldn’t do it.”
Usama also taught in China for short while and saw how negotiation is different there, as it is throughout the Middle East. Though he can adjust his individual style to the culture, overall, he’s happy with it. “I believe using a softer negotiating style has given me good results. It’s softer than usual in the U.S., but it is still effective and I’m very satisfied with the outcomes,” he adds.
Now You’re Ready for Salary Negotiations
“When I speak to groups of nurses I have a joke: Everything in life is negotiable except for the salary of a staff nurse,” says Cardillo. Most hospitals have set salary ranges for nurses, sometimes negotiated by unions, until you go on to be a case manager, supervisor, or manager.
If you’re not sure if salary negotiation is appropriate in your role or organization, Cardillo suggests you probe with these phrases:
- Is there any way to … ? (Boost salary, add benefits, etc.)
- Are any adjustments available?
- Is there any room for negotiation?
Where to get salary survey info: professional associations, National Association of Colleges and Employers (NACE), Salary.com, jobstar.org, bls.gov, medzilla.com, career fairs, career development centers, and coworkers.
Even if you can’t negotiate your initial salary, you may be able to negotiate during a wage and performance review or an improvement plan meeting. “Most of the time, nurses are nervous going in to that type of meeting,” says Podlesni. “Take ownership of the discussion and go in prepared with information and knowing your desired outcome.”
For example, in a performance evaluation where a nurse is judged poorly, he or she doesn’t have to accept an unfair assessment. In one such situation, “an emergency room nurse was told she did not have timely emergency room skills such as inserting NG tubes,” Podlesni recounts. “I advised her that evaluations need to be conducted fairly and use consistent criteria across that board…I recommended that she request a video or documentation of someone doing the skill in the timeframe suggested. They were unable to provide this, and as a result, she received her $10,000 annual salary increase.”
During a wage evaluation, you can always negotiate for a higher salary or better benefits package. “Say your salary is $60,000 a year,” Podlesni says. “What stops you from saying ‘I love my job and want to keep working here, but I need to get to $65,000 a year to spend that much time out of my home and to pay childcare expenses’?” You may not get that raise but at least it starts a conversation and then you can decide if you want to stay in the job or if it’s time to find a better paying employer.
Believe in Your Value
Minority nurses bring an extra dimension to their work that they may not recognize and value highly enough. “Being Latina and bilingual, bicultural, we’re typically in a culture that doesn’t boast,” says Adriana Perez, PhD, ANP-BC, FAAN, assistant professor of nursing at the University of Pennsylvania School of Nursing. “We’re taught that you have to be modest, don’t call attention to yourself. It’s about building relationships and taking care of others. We have to balance humility with self-confidence.”
At the National Hartford Centers of Gerontological Nursing Excellence leadership development program, Perez learned the essentials of career success, including salary negotiation.
“AACN publishes mid-to-average salaries for professors that might not factor in additional skills or expertise,” she explains. “I’m bilingual, board-certified adult nurse practitioner, and researcher addressing health equity issues that are national research priorities. There aren’t that many Latina nurse scientists so it puts me in a great bargaining position. I can help the school meet its inclusion and diversity mission. But that’s not enough. I have to produce results and demonstrate a measurable impact.”
Polish Your Negotiating Skills
Many organizations offer professional development workshops that focus on cultural diversity, communication skills, negotiation, and conflict resolution. The leadership program that Perez benefited from included a career-enhancing mentorship relationship.
“We grew from mentor and mentee to now colleagues and friends. I attribute a lot of my growth to that program,” she says. “I recommend finding mentors. Study the leaders in your organization whose style you like and who are well-respected. Ask them for coffee: ‘Can we schedule some time?’ Nurses are giving and want to help. They’ll share lessons learned and will tell you about programs, scholarships, training, and other resources out there.”
It’s true that some nurses will never enjoy advocating for themselves. But it doesn’t have to be that way, with a little practice they can increase their confidence and ability. The end result: Better outcomes for everyone.
Obesity rates are alarmingly high in the United States. Altogether, overweight and obesity rates exceed 70% of the U.S. adult population according to the Centers for Disease Control and Prevention. This figure comes with staggering health care costs, as obesity is known to heighten the risk of several chronic diseases including hypertension, type 2 diabetes, and certain forms of cancer. Obese individuals also experience a decreased quality of life and a higher mortality rate. These negative health consequences are pronounced among minority populations who often have less access to health care along with a higher rate of obesity-related comorbidities.
African Americans are disproportionately affected by obesity. According to the American Heart Association, 77% of African American women and 63% of African American men are overweight or obese. Within African American faith-based communities, health education programs remain limited despite substantial evidence from the literature indicating its advantages. Significant barriers contribute to a low utilization of health promotion programs in African American faith-based communities. According to a systematic review in Obesity Reviews, some of these barriers include scheduling conflicts with church activities and keeping the interest of participants. Nonetheless, the same study concludes that health programs focused on weight management and weight-related behavior in African American churches can effectively help address the obesity issue.
The NWEP Project
The Nutrition and Wellness Education Program (NWEP) was a pilot study led by a team of two student nurses and one faculty to provide health education in the All Nations Church of God in Christ, which is a predominately African American congregation located in North Richmond, California. The program was conducted during the fall of 2016 and consisted of a series of six workshops of about two hours each facilitated by the team of student nurses. The workshops consisted of teaching using PowerPoints and handouts; group activities, such as modifying recipes and building shopping planners; and recipes/cooking demonstrations. The NWEP aimed to provide the participants with the knowledge, resources, and tools to access and select healthier food options in order to sustain positive nutritional outcomes. This program provided nutrition education regarding the basic food groups, the properties of food items, the benefits of eating certain foods, and hands-on demonstrations of healthier meal preparations. Furthermore, participants learned how to select healthier foods in groceries and restaurants within a limited budget.
The Significance of Nutrition Education
Education plays a crucial role in providing disadvantaged communities with the essential resources needed to make better lifestyle choices. Although obesity originates from a complex interplay of genetic, environmental, and behavioral factors, poor dietary habits remain an important contributor to this health issue.
Nutrition education is an integral part of reducing excessive body weight since it can increase knowledge about food and cost-effective approaches to eating healthy. In this regard, NWEP aimed to bridge the knowledge gap and stimulate the adoption of healthier dietary habits among the program’s participants. The NEWP was an eye-opening experience for the women who participated in the program. They lacked basic nutrition literacy, such as the five food groups, or the information contained on nutrition facts labels. They expressed reactions that ranged from surprise and disbelief to apprehension as they grasped the notion of added salt and sugar in food items.
For example, when the workshop facilitators showed the amount of sugar in an eight-ounce soft drink, one participant exclaimed: “Oh, that is a lot of sugar! I would have never imagined this is the amount of sugar I get from one can of Coke.” Similarly, when the facilitators demonstrated that in certain brands of chips, a single bag could contain more than the recommended daily intake of sodium, their reactions were indicative of the fact that they lacked the basic knowledge to make informed dietary choices. Other fundamental nutrition concepts covered in the program were calories and nutrients in foods. This allowed the participants to differentiate between high-calorie, nutrient-poor foods versus low-calorie, nutrient-rich foods and the benefits of incorporating more of the latter into one’s diet.
Moreover, participants had to practice the lessons learned during the workshops. Each participant was invited to explore strategies that fit their individual needs and circumstances. Most of them agreed that cooking at home allowed for a better control over their food’s quality because fast food contains a higher amount of salt, sugar, and fat. Throughout the workshops, the facilitators presented ideas for improving the nutritional qualities of their foods. These included swapping ingredients, lightening the seasoning, and improving the flavors with alternatives such as herbs and spices instead of butter or cheese. Other suggestions included using weekly meal planning, consuming in-season, fresh fruits and vegetables instead of canned foods, and baking in place of deep frying.
Nonetheless, one cannot ignore that increased knowledge alone is insufficient in achieving behavior and dietary change. In the Annals of Global Health, Himmelfarb and colleagues argued that knowledge is not everything as far as behavior modification is concerned. It is necessary to reinforce the skills of these participants and to provide them with support resources (e.g.,regular dietary counseling) to reach the goal of adopting and sustaining healthier dietary habits.
Observations and Feedback
The participants of the NWEP demonstrated a strong interest in the topics covered during the workshops. They could relate to the content of the lessons since it provided relevant information to improve their diets. These women acknowledged the importance of eating a healthy diet and the potential of this pilot program to help them make a positive impact on their health and that of their families since they were generally the primary grocery shoppers and cooks in the household. During the workshop sessions, they actively engaged in the activities, participated in the discussions, asked questions, and shared their challenges in adopting a healthier diet. This enthusiasm was indicative of the need and importance of health promotion program in this faith-based community. The women gave positive feedback overall and reported that they would be interested in staying in the program if it was extended. It was also a good opportunity to address some of their misconceptions about food properties, such as the characteristics of whole-grain foods. Beyond the learning experience of the NWEP, the participants developed a fellowship and camaraderie. They often stayed on the premises of the church and engaged in long, lively conversations at the end of the sessions. This act of bonding could be used as a support system to sustain the desired lifestyles change.
Lessons Learned and Recommendations for Future Projects
The NWEP underscores the challenges and opportunities for implementing health education programs in a faith-based environment. This study highlights the importance of nutrition education because a limited understanding of nutrition and diet also accounts for poor food choices and dietary habits. Improving nutritional literacy is a critical component of health education because it can initiate a behavior modification. The interest the participants displayed during the workshops is a clear indication of the need for health literacy and health promotion programs. Such programs should be implemented over a longer period and should be expanded to provide substantial support and sustain healthy lifestyles such as physical activity, dietary counseling, or health monitoring. Training lay-health educators among church members offers an efficient and inexpensive means to reach a wider audience within the community for a longer duration of time.
Despite its success, there were several challenges encountered while running this pilot program. Ongoing communication between facilitators and faith-based organizations will help ensure efficient workshop sessions. Also, providing the participants with monetary incentives, such as paying for their transportation or offering grocery gift certificates, may increase participants’ attendance. Using innovative technology such as text message reminders could also boost the attendance rate. Substantial financial support is equally critical for the success of such programs because the host community may lack basic equipment including a kitchen, a projector, and internet access, to facilitate the program.
The NWEP helped identify strategies to improve health outcomes in underserved communities. Health education in African American faith-based communities holds the potential to improve access to preventive care services. Despite its promise to reach a large number of individuals in underserved populations, health education programs in faith-based communities are limited. The NWEP attempts to address this gap by focusing on nutrition, which is a crucial component of health. Nutrition is a major part of health care and dietary modification is an essential, primary intervention in improving the overall health of disadvantaged populations.
A clinician sees a Somali patient with a primary complaint of back pain and, following an exam, prescribes a traditional course of western medical action. The patient, however, is reluctant to act on the medical advice because he thinks his back pain is caused by a bad relationship with his parents or guilt over something he did. “It is always good (for clinicians) to have some knowledge about their patient’s culture, to know who they are dealing with,” says Fozia Abrar, MD, of Minneapolis. “It might cost time and money, but you save more money by not getting a misdiagnosis, by improving quality of care.”
Suffering from bacterial gastritis, a Somali woman in Minnesota visits several providers but does not take the medication they prescribe. When met with a smile and a greeting in her native language by Dr. Abrar, the patient complies with the same treatment recommended by the previous providers—Dr. Abrar successfully persuaded the patient to fill a prescription and take the medication because of her knowledge of the patient’s culture. This situation is not new or unique—medical anthropologist and psychiatrist Arthur Kleinman, MD, has spent 30 years championing cultural issues in medicine. He says a great body of evidence shows culture does matter in clinical care.
Every cultural group has traditional health beliefs that shape members’ perspectives about wellness. The increasingly diverse, twenty-first-century patient population requires clear communication and practitioner awareness of patient health perspectives in order to significantly impact patient satisfaction, safety, compliance, and outcomes.
Organizational Culture, Patient Satisfaction, and Safety
Organizational culture informs every worker whether patient satisfaction is a key value. By influencing employee behavior and how employees are treated, culture drives employee effectiveness, safety, and whether employees take advantage of opportunities as they arise. Organizations that dedicate additional employee resources to patient safety signal to employees that both employee effectiveness and patient safety are high priority. In other words, organizational values and beliefs guide employee commitment to patient and worker satisfaction. According to the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report, patient safety improved more at hospitals where they increased employment of staff who reported incidents, compared to hospitals that did not expand the number of employees who reported incidents.
At Atrius Health, a Massachusetts ambulatory care provider with 36 locations, staff can report safety events while updating existing electronic health records (EHRs). This reporting mechanism has increased the number of reported events, and as many as 30% of events reported monthly come in through the EHR tool, according to Ailish Wilkie, patient safety and risk management director for Atrius Health.
In other words, employee accountability shapes workplace and organizational culture.
Patient Culture, Provider Culture
In addition to the effect workplace culture has on patient satisfaction and employee competency, two additional areas of culture impact health care effectiveness. Both a patient’s cultural background and the provider’s scientific/medical culture inform patient and provider wellness perspectives. If patient compliance with the treatment plan is the goal, providers need to understand the patient’s cultural identity.
By the same token, patients need to know that their perspectives are respected. Few health care observational studies have reported sufficient information to support the claim of provider bias, but a 2006 study published in the Journal of General Internal Medicine reported that most internal medicine residents gain cross-cultural skills through informal training, and most stated that delivery of high-quality, cross-cultural care was important but were skeptical about the expectation of learning every little detail about all cultures. Barriers to cross-cultural care included lack of time, not knowing enough about the religion or ethnic group of the patient they were caring for, and/or dealing with belief systems which are different than their own.
A 2000 study in Social Science and Medicine found that physicians rated minority patients more negatively than White patients; the study also reported that physicians viewed minorities as non-compliant and more likely to engage in risky health behaviors. Clearly, providers need reliable resources to add to their understanding of the patient’s perspective.
A 2017 survey of 111 health care providers revealed where providers currently turn to access cultural training and information, and what types of information providers need when they are unsure/unaware of the patient’s cultural profile and its implications for treatment decisions, patient compliance, and safety outcomes. The survey found that providers want more data on their patients’ use of nontraditional medicine; their faith beliefs; and who the health care decision-makers are.
Diversity and Disparities
An increase in racial and ethnic minority health professionals provides greater opportunity for minority patients to see a practitioner who speaks their primary language or is from their own racial or ethnic background. This can improve the quality of communication, patient safety, satisfaction, compliance, and outcomes. In addition to increasing the diversity of practitioners, hospitals are working to improve hiring diversity, employee cultural awareness, and organizational culture.
In 2015, The Health Research & Educational Trust (HRET) commissioned a national survey of hospitals and health systems to quantify the actions they are taking to promote diversity in leadership and governance, and reduce health care disparities. Data for this project were collected through a national survey mailed to the CEOs of 6,338 U.S. registered hospitals. The response rate was 17.1%, with the sample generally representative of all hospitals.
Minorities represent a reported 32% of patients in hospitals that responded to the survey, and 37% of the U.S. population, according to other national surveys. In contrast, the HRET survey data show that minorities represent only 14% of hospital board membership, 14% of executive leadership positions, and 15% of first- and mid-level positions.
As a sign of progress, though, nearly half of hospitals surveyed had a plan to recruit and retain a diverse workforce matching their patient population. Further, 42% said they implemented a program to find diverse employees in the organization worthy of promotion.
Cultural Data Collection
The HRET data show that 98% of hospitals are collecting patient data on race. Additionally, other areas of data collection included ethnicity (95%) and first language (94%). But, the percentage of hospitals that correlated the impact these factors have to the delivery of care was a mere 18%. Remarkably, in 2011 only 20% of hospitals analyzed clinical quality indicators by race and ethnicity to identify patterns, whereas 14% looked at hospital readmissions, and 8% analyzed medical errors.
A serious flaw in the HRET survey was zero data collected on hospital patient national origin. The report listed myriad reasons why hospitals might be failing to meaningfully use the data, such as fearing potential liability issues after publicly acknowledging disparities in care, concerns about the public relations backlash, and a lack of knowledge in developing clinical programs that would reduce or eliminate inequalities. Plus, some hospitals noted the lack of a “diversity champion” on their staff to help lead the effort.
Hospitals seem to be making progress in educating staff on diversity, with 80% providing cultural competence training during orientation and 79% offering continuing education opportunities on cultural competency, according to the survey.
Hospitals have begun to include leadership goals designed to reduce care disparities by implementing diversity initiatives such as: allocating adequate resources to ensure cultural competency/diversity initiatives are sustainable; incorporating diversity management into budget planning and implementation process; increasing hospital board diversity to reflect that of its patient population; board members demonstrating completion of diversity training; developing plans specifically to increase ethnic, racial, and cultural diversity of executive and mid-level management teams; and executive compensation tied to diversity goals.
Beyond the C-suite, hospitals are developing diversity plans with initiatives that include diversity goals in hiring manager performance expectations; implementation of programs to identify diverse, talented employees within the organization for promotion; documented plans to recruit and retain a diverse workforce that reflects the organization’s patient population; required employee attendance at diversity training; hospital collaboration with other health care organizations to improve health care workforce training and educational programs in the communities served; and education of all clinical staff during orientation about how to address unique cultural and linguistic factors affecting the care of diverse patients and communities.
This increased implementation of appropriate health care and adherence to effective diversity and cultural education programs at every level of health care will ultimately result in improved patient satisfaction, compliance, hospital safety, and patient health outcomes.