I received a call from Dr. Gloria Rose, my former professor at Prairie View A&M University College of Nursing, asking me to be the keynote speaker at the Pinning and Hooding Ceremony on May 9, 2018. After taking a breath, I accepted the offer and stated, “Yes, I am honored to do it.” As soon as I got off the phone with Dr. Rose, I called my mother and she was so proud of me.
As a nurse practitioner (NP), my work experience includes opening a clinic and managing house calls, as well as serving in homeless shelters, skilled nursing facilities, pediatrics, family practice, community, personal care homes, private homes, weight management, pain management, and the Redi-Clinic. Throughout my sixteen years of practice, I have developed four rules which have assisted me to accomplish success. The following rules have supported my differential diagnoses and plan of care for clients.
Rule 1. Get a Good History
One of my favorite jobs was working at the homeless shelter. I recall a case that continues to stay with me to this day. The medical assistant presented: “He is here to have his string cut from his chest. The NP before you just cuts it and then he returns again when it gets too long.” I was thinking what is going on with string cutting from the chest.
As the man is sitting on the examination table, I asked how he is doing and right away he states, “I just need you to clip this string and then I will be okay. That’s what they do, clip it.” He removes his shirt and right away I see the healed surgical incision down the middle of his chest, but in the center is dark blue string protruding from a very small hole.
“When did you have the open-heart surgery, sir?”
“I think it has been about three years,” he replied.
“Have you been getting the string cut for the past three years?”
“Yes, ma’am,” he replies.
“I am not going to cut the string today. This is suture string that is hanging out of your chest from the open-heart surgery. We do not have radiology services here. I want to get all of the string out for good.”
Then, I secured the string with gauze and taped it to his chest. I arranged for him to go to a special procedures clinic. I provided cab vouchers and informed him to leave now. A couple of days later, the man returned. He was smiling. He stated that he had a gift for me. He gave me an envelope. I opened it. It was filled with suture string. Then he said, “Thank you! You solved the problem!”
Rule 2. Take Your Time
I learned this in graduate school. I saw a young female who presented with missed periods, vomiting, and fatigue. I was focused on her vomiting, and I was in a hurry. I left the room. I failed! Turned out she was pregnant. They say that you learn from your mistakes. I learned that day to always “take my time.”
Rule 3. Be Professional At All Times
At the homeless shelter, I saw a man and asked him how he was doing. “I am not doing well. The doctor gave me this medication for my blood pressure. Oh man! I keep peeing from left to right. As a matter of fact, I got to pee right now.” I reviewed the chart. The medication was hydrochlorothiazide. It is a diuretic which causes frequent urination. I changed the medication to lisinopril to treat his blood pressure and instructed the man to keep a log of his BP readings by going to the CVS around the corner. I gave him pens and a pad and instructed him to return in two weeks for follow-up. When he returned, I was off. My collaborating physician followed up with the patient. He called my supervisor upset that I changed the medication he prescribed. Upon my return to work my colleagues stated, “Robbie, you are in trouble.” I held my tongue. I remained calm and quiet. As I reviewed the chart there was a copy of his blood pressure log, which showed improvement in his blood pressure since taking the lisinopril. This man is homeless and does not have the comfort of a home with a restroom. He has to locate a public restroom to relieve himself. In my professional opinion, changing the medication was the best treatment for him and improved his quality of life.
Rule 4. Go With Your Gut Feeling
During a house call visit the client stated she had a sore and cannot understand how it got there. She reported, “at first I had pain at that same area.” (gut feeling) “Then this sore appeared. Went to the emergency room (ER) and was told that it was an insect bite.”
“Okay, let me see the sore; lift up your shirt.” I saw a fluid filled lesion on an erythematous base. “You have shingles.”
She looked at me, “are you sure?”
“Yes, I am.”
“But the doctor at the ER said it was an insect bite. You are a nurse.”
“I am a nurse practitioner. I can contact your primary care provider (PCP) to prescribe the medication to decrease the severity of the shingles.” She was still not convinced. “Okay, let’s take a picture with your cell phone and then you can send it to your PCP.” As I was leaving, the doctor’s office called and verified the diagnosis. Pain is a symptom that occurs before the lesion appears.
My four rules of practice have provided me with a solid foundation and are the framework of my practice. Every day, I use my four rules of practice and the outcomes are immeasurable. It’s great to know when you have improved the client’s quality of life. This is the greatest satisfaction of all to achieve as a NP.
As we usher in the 116th Congressional Session beginning January 4, 2019, lawmakers (newcomers and incumbents) will have the opportunity to address a number of legislative and regulatory issues. Immigration reform, access to affordable health care, climate change, and national and global security are among a long list of issues that will be discussed and debated during this new congressional session. And while there are numerous competing demands as with all other legislative sessions, nurses are encouraged to remain abreast of issues that impact health care and the nursing profession.
This year promises to be another great year to continue improving our policy acumen and advocating for those issues that are most important to us and the communities we serve.
Moving forward in 2019, newly elected Lauren Underwood, MSN/MPH, RN, of Naperville, Illinois will represent the 14th Congressional District of Illinois beginning January 3, 2019. Rep. Underwood is committed to ensuring that everyone has access to affordable health care. She is currently one of two nurses serving in the U.S. Congress. Other nurses across the country hold elected positions in their state legislatures and government appointed positions or serve on a number of advisory committees or boards.
This session, lawmakers committed to eliminating health disparities will work to enact legislation that will propel us toward achieving health equity, particularly for underserved populations who suffer disproportionality from a number of illnesses and poor social conditions. No doubt the issue of health care reform will remain front and center, especially in light of the recent ruling from a federal Texas judge deciding that the Affordable Care Act is unconstitutional. Because this debate is far from being over, we must remain vigilant in monitoring what is happening with this historic legislation. And just as 2018 was deemed the Year of Advocacy by the American Nurses Association, we must be mindful that advocacy is always in season calling us to lend our voices on behalf of those we serve. Regardless of position or setting, every nurse can seize the opportunity to weigh in on policy issues that are of importance to them.
So, consider how will you stay engaged and informed of federal and local policies or regulations that may influence your practice or even the degree to which health care is available to those you serve. Remaining updated on policy issues is becoming even more essential for today’s health care professional. Our professional and specialty nursing organizations provide key resources and often have a specific policy agenda. Have you explored what your professional organization’s position is on a number of policy issues important to nursing?
Consider attending an actual or virtual lobby day this year. Each year nursing organizations such as the American Association of Colleges of Nursing (AACN), the American Organization of Nurse Executives (AONE), and the American Nurses Association (ANA) convene lobby days in DC but also provide opportunities to participate virtually for those who cannot attend in person. Visit their web sites for more details. Numerous state nursing organizations and other health related organizations across the United States also convene lobby days providing yet another venue to lend your voice to a number of health-related causes. And remember to touch base with the Office of Government Relations within your health care system, university, or college.
Be resolved to visit a legislative official this year to learn more about their health policy agenda and promote the profession as well. Commit to reading the local news for policy hooks as they say, “all politics is local.” Subscribe to the Federal Register to stay informed about opportunities to offer comments on proposed regulations, policies or key reports. The Register also highlights opportunities to apply to serve on national advisory committees. Volunteer to give testimony at hearings and town hall meetings as lawmakers can benefit from hearing directly from nurses on health care matters. Well that should keep us all pretty busy. In the meantime, check out some of the resources listed on the right to help with advancing your engagement in policy advocacy.
Key Resources to Stay Abreast of Health Policy and Legislative Issues
Nursing and Health Care Related Issues
Health Care Access and Other Health Care Related Issues
Health Equity and Disparities Reduction
State Specific Data
Check with your local and state Departments of Health to locate recent and local statistics.
Tracking Legislative Bills
More and more health care organizations are using big data, predictive analysis, and data metrics to streamline the process of recruiting nursing talent. Over one-third of human resources departments rely on analytics to manage staffing, according to the 2017 Deloitte Global Human Capital Trends report. That trend has exploded over the last few years, as organizations lean on technology in earnest. For example, approximately 95% of hospitals use an applicant tracking system (ATS), which is like a gigantic digital filing cabinet full of resumes, according to industry experts.
Big data (or people data) may sound intimidating to nurses who aren’t tech savvy, but the information that they refer to is often quite simple. “Facebook, Google, the U.S. government—even my own tiny website has its own big data,” says Brittney Wilson, BSN, RN, an informatics expert based in Nashville, Tennessee who owns the popular blog The Nerdy Nurse.
Big data usually means extremely large data sets, which help reveal patterns and associations, especially relating to human behavior or that look at trends and systems and help make a determination, explains Wilson.
“Data is everywhere and almost all of it is discoverable. I always tell nurses to not post anything online that they wouldn’t put in front of a recruiter when they’re applying for a job. You have to assume that someone is scraping that data and applying it to an algorithm,” she adds.
How Organizations Collect People Data—and What That May Mean for You
In a recruiting context, a nurse’s personal information can be culled from social media profiles, consumer data, and public records, in addition to a hospital’s personnel data or those of a third-party recruiting program vendor. That nurse’s individual data points can then be merged into bigger data sets, so analysts can create algorithms or statistical models that aim to predict which candidates are equipped to succeed in a given role.
For example, automated systems can spit out resumes from applicants in a certain zip code, based on an algorithm set to predict turnover. Perhaps previous employees with that zip code may have been short-timers, due to a grueling driving commute or unreliable mass transit.
Then even if nurses knew why they were getting the cold shoulder from a piece of software, there’s not much they can do about it. Their home address data is out there and available to hospitals, even if they attempted to hide it by using another street address, through a UPS or other office forwarding service, say.
But what if that undesirable zip code is for an area with a large minority population? Recruiters and IT folks are starting to realize how digital “gates,” based on zip code and such, may adversely impact underrepresented populations. The U.S. Equal Employment Opportunity Commission frowns on practices which essentially “profile” applicants and employees.
“We need to attract more racial and ethnic minorities to nursing,” says David Wilkins, chief strategy officer of Woburn, Massachusetts-based HealthcareSource, a provider of talent management systems for hospitals. “We’re thin in labor supply and there’s a high labor demand.” The unemployment rate in health care is so low—RNs at 1.4%, and NPs at 1.1%, according to recent Bureau of Labor Statistics reports. “With such an acute shortage, it’s hard to believe that people are consciously turning away any candidates.” Wilkins wonders if unconscious bias, such as when an applicant has an ethnic sounding name, may be at play.
Crowdsourcing, One Surprising Cyber Trend in Recruiting
Relode is an innovative crowdsource referral platform for health care recruiting. “In 2014, we saw there were lots of inefficiencies in the hiring process and wanted to use software to solve this problem,” says Joe Christopher, chief technology officer at the Brentwood, Tennessee-based firm. “The platform allows our small team to work on thousands of jobs. Health care is profession-centric, so staffing agencies are ultimately working with the company. We’re trying to help you, as a nurse, to take your next step.”
A nurse can sign up on the Relode portal, then work with a talent adviser who will set up a profile and then make a match with an appropriate job opportunity based on the nurse’s experience, skill set, goals, and other desires. “As a new grad, you may have to take what’s available, but if we know you ultimately want to go back to California, we can help. What if we can connect you to this great employer [in another state] who can train you? And then after a year or two, you can go back home to California or wherever. Or you might like it and want to stay longer.”
Relode offers nurses a way to earn side income through its crowdsourcing platform. “Nurses are used to thinking, ‘if I need extra money, I need to work an extra shift.’ But we believe the best nurse knows another best nurse. So as a travel nurse, for instance, you may know nurses in Dallas and Phoenix, and if you connect us and that person gets hired, we pay $3,500 directly into your account,” says Christopher. In fact, one nurse signed up with Relode and referred seven other nurses, earning money for connecting people she already knew to new opportunities, he adds.
Make Sure Your Online Application is Optimized for Search Engines
Human resource experts claim that very little recruiting happens without technology anymore. “Your first point of entry is very likely going to be a piece of software, an applicant tracking system. It has to determine the degree of fit between you and the job. So, make sure your resume is well-structured, clean, and easy to parse for an applicant tracking system,” says Wilkins. “Focus less on making it look pretty, and instead, make it very scannable and readable. The average time someone is going to look at it is six seconds.”
A big part of what applicant tracking systems search for is keywords and phrases. Recruiters may be carrying 100 plus openings at one time so they can’t look at all the resumes for each position. “In order to be seen, yours must be in the top 10 or top 20 ranking,” he says. “You should have multiple resumes to make sure the keywords match. Most of the time organizations tailor job titles and descriptions to a particular opening.”
A Travel Nurse Weighs in on High-Tech, Low-Touch Recruiting
Jake Schubert, RN, BSN, travel nurse and owner of Nursity.com, an online NCLEX prep course, is no stranger to the recruiting process and shares a few key insights.
1. The nurse-recruiter relationship is becoming less and less personal.
I get hundreds of emails from travel nurse recruiters all saying basically the same thing: “would love to work with you… would love to work with you… would love to work with you…” Don’t spam nurses with phone calls and emails. You don’t like it when people do that to you, so why would you do it to them? But if you really want to be effective, stop with the spam and make your message personal. For example, you can go to my Instagram and you’ll see that I love to scuba dive. Then reach out to me there with something personal like, “Hey I noticed you like to dive. We have contracts with three hospitals in Florida that are close to some great dive sites.” But no, they don’t do that. Instead they fall back on the same line: “Let me know when you you’re ready to start traveling with the best recruiting company!” I feel like responding: “Let me know when I’m relevant to you.”
2. Many nurses are naïve about a recruiter’s role and motives.
New graduates and some other nurses may think: “This recruiter is really on my side.” But they’re not—they’re being paid by their company so that’s where their loyalty lies. They know when you’re not asking for enough money, for instance, but they won’t tell you where you’re leaving money on the table. It’s not like other industries where people are required to disclose a conflict of interest—when real estate brokers represent both sides in a transaction, they’re legally required to disclose their dual agency.
3. Nurses have the power to create better relationships with recruiters.
I’m one of the thousands of nurses working with Kaiser Permanente right now. You go online and create a profile on their portal, and they email you when an appropriate job pops up. But that’s not how all jobs get filled in a hospital. It’s all about relationships. Managers are always asking me “Jake, do you know anyone who’s looking for a job?” Every hospital is looking for good nurses, and nurses who have good communication skills are hard to find. If I had one piece of advice for new graduates, it’s “Don’t text a recruiter, and don’t think of email as a long text. Email is an online version of a letter, so don’t leave out the niceties.” When you communicate fully, you show that you’re different and that you have professional communication skills.
So, for instance, if you were applying for a job as a dialysis nurse, Wilkins would advise the use of a preponderance of keywords related to that specialty. “Of course, use the word ‘dialysis,’ but also all the words alongside it and related terms and synonyms.
Dialysis in an elder-care, or long-term care setting, is different than working with general patients at an outpatient dialysis care clinic. Use senior care words, long-term care versus outpatient care words. The care job is probably the same but the stuff on the edges is different.”
Wilkins offers a final caveat regarding online application systems, which sounds basic, but could torpedo your candidacy if ignored. “The average completion for an online application is around 15%, which means 85% of online applications are never completed. While in some cases, this is because a candidate changes their mind mid-process, most of the time it’s just because the process is long and complex,” he explains. “But the really scary data is that 15% of people think they’ve actually fully submitted their application when they really haven’t. Sometimes they just miss the ‘submit’ button at the end. Go back and make sure you completed all the steps.”
Nurses shouldn’t forget to update their own employer’s human resource portal—it makes it easier for the department (or a hiring manager) to identify internal candidates. When there’s a job requisition for an assistant nurse manager with a master’s degree and a set of relevant experience, for instance, a recruiter can look through the hospital’s internal database of qualified nurses before posting the job publicly.
How to Protect Your Online Privacy When Job Searching
“We need to educate nurses that when you put your resume out there on any career site—upload it to CareerBuilder, Monster, Indeed—you’re selling access to that resume,” warns Christopher. An applicant may upload a resume and forget about it, but when they get an email or call from a recruiter, wonder: “How did they get my number?!” When you trace it back, almost always it was that uploaded resume and the terms of service that allow recruiters to contact you.
There are workarounds though, that will protect your privacy without hampering your job search. “Lots of people are able to set up an email address specifically for this use—you’d check it once a day if you’re in the job market, or once a week if you’re not,” says Christopher. “Sometimes the systems also require a phone number. You may be able to set up a Google voice number or use another solution like that.”
When using online job engines and portals, be aware that there are games that some unscrupulous recruiters play, says Christopher. For instance, “a staffing agency that does lots of work with nurses may put up a job listing for an opening that doesn’t exist” at the moment. That gives them a running start for handling hard-to-fill roles, “so that when an employer asks for an ICU nurse, say, they already have 10 nurses that have applied for that. Indeed will no longer host agency jobs, the listing has to be from the employer,” because of recruiter abuses. “Even now Indeed offers applicants a way to filter jobs—there’s an employer of record option.”
Present Your Best Cyber Self to Snag a Job
Nurses and talent recruiters are both figuring out the new communications etiquette, with some stumbles along the way. “I get text messages from recruiters pretty frequently. I was shocked the first time because they contacted me on a very non-professional manner, in my opinion,” says Regina Callion, RN, MSN, travel nurse and owner of ReMar Review, an NCLEX review program.
“Greetings will be skipped, and it will pretty much say ‘Make 10,000 dollars in a month! Sign up today for xyz.’ The lack of formality and information provided is a turnoff.”
That anti-text sentiment is common, even among some Millennial, digital native nurses. “My cell number is the last bastion of privacy for me,” Wilson says. “I don’t want to get a text from a recruiter without my consent. It feels like you entered my living room and sat on the couch and don’t even know who I am.”
But recruiters say that reaching out to nurses in the traditional way isn’t efficient, so they have to employ new channels. “Our team has found that texting is a really great way to communicate for nurses. They’re busy and so instead of leaving a message and waiting for a call back, a text is a brief but direct conversation,” says Christopher. “Obviously, you have to know who the person is and agree to it, but texting is a really efficient way for us to say: ‘Here’s a great opportunity that meets three out of four of your criteria. Do you want to talk about it?’ Or if there’s a simple question from an employer, we can get a quick answer: ‘Are you licensed in California? I know you graduated from school there but …’”
The nurse-recruiter dance requires sensitivity and cooperation from each partner. Recruiters do a service for nurses, exposing them to opportunities they might not otherwise discover and fast-tracking their applications through the hiring process. Nurses can help recruiters by making themselves easier to find and by being open to approach. “It takes a lot of energy to look for a job, and it’s a lot like dating—when you’re not looking, that’s when you’re most desirable,” explains Wilson. “My job before this one was with a startup who found me because I’d SEO’d [search engine optimization, or the process of affecting the visibility of a web page] my profile online so well… I always tell people—take a phone call. You never know.”
Especially since the #MeToo Movement began, sexual harassment has been in the spotlight. We spoke with nurses who have been harassed, legal experts, and nursing professionals to determine what you should and can do if this happens to you.
Celia,* RN, a longtime hospice nurse, remembers it like it was yesterday. A younger man, at least younger for hospice, had been admitted with terminal cancer. While Celia says she recalls other nurses talking about the patient having made “inappropriate comments,” she had never experienced it herself.
Until she did.
The patient had been angry and struggling with what he deemed the unfairness of dying young and leaving his wife and child—and knowing that he wouldn’t be able to take fun trips or do things with his daughter. Because he had a trach, which requires frequent suctioning and medication, he felt like the staff was treating him like a leper—when actually, they were simply following all safety precautions.
“Once trach care was completed, I sat down, took my gloves off, and offered him a hand to hold—this is standard practice between hospice staff and patients, and it’s not frowned upon,” says Celia. At the time, the patient held her hand, cried, and expressed gratitude for the time to talk. “I felt we had a nice, professional, and therapeutic rapport.”
A few weeks later, a couple of days after Christmas, Celia was caring for the patient, and he asked if she was married. When she responded that she was in a long-distance relationship, he asked how she took care of her sexual needs—and asked using inappropriate, graphic sexual language.
Celia replied, “One—that is none of your business. And two—It’s not appropriate conversation between a patient and a nurse!” Then, Celia calmly informed him that this was harassment and abuse. With one word to her managers, she told him, she would never have to be his nurse again. She says that the patient was contrite and apologized. Celia passed it off as a one-time thing and let it go.
Unfortunately, that wasn’t the end of the harassment. After a couple of weeks, Celia was the patient’s nurse again. While taking care of his trach, she talked with him. When he could speak, they discussed their favorite kinds of music. She recalls, “It was a nice interaction, as I grew up in a musical home, and discussing this was special to me.”
Near the end of the treatment, though, everything changed. The patient told her lots of things that he would like to do with her sexually, in graphic detail.
Celia recalls, “I was horrified. I was angry. I felt nauseated. I felt ashamed about my body, and I wanted to cry. I was shaking, inside and out.”
She told the patient that he was so far out of line. He was shocked that she was so rattled and tried to justify it by saying that it was a compliment. Celia left his room immediately.
The first thing she did was post on the staff’s white board that she would no longer care for this patient. When she calmed down, she emailed her managers and then communicated with them in person the next day.
Celia’s managers were supportive. She never saw the patient again, and he left the facility a few days later.
Harassment is Prevalent
A Medscape.com survey published last year revealed that the majority of nurses—71%—say that they had been sexually harassed by a patient. Of those responding, 90% were female nurses, 10% male.
But male nurses get harassed as well. They may, however, be even less inclined to report it. In the same survey results, it states, “By gender, female nurses…were much more likely to say they had been sexually harassed than their male counterparts (73% for female nurses vs 46% for male nurses).”
No matter the gender of the nurse who experiences it, sexual harassment is wrong. That said, how do you decide if what a patient is doing or saying is sexual harassment?
If it Looks Like a Duck and Quacks Like a Duck
According to Trista Long, RN, DNP, MBA, ON-C, a nurse manager for an inpatient med/surg unit with Blessing Health System, it is easy, most times, for nurses to differentiate between behavior that is appropriate or inappropriate. “The first sign of inappropriate behavior is when patient’s actions or conversation makes the nurse uncomfortable. Patients who are making inappropriate comments will first ‘test the waters’ by making inappropriate jokes or mild comments to gauge the nurse’s response. If the nurse dismisses the comment, the patient will likely continue with the inappropriate conversation or actions.”
If a patient exhibits inappropriate verbal behavior, it’s often easy to recognize, says Long. “Nurses know what crosses a line and what doesn’t,” she says. Because of the physical nature of nursing, however, Long says that inappropriate physical behavior can sometimes be more difficult to recognize.
“I often tell my staff that—again—inappropriate touch is anything that makes them uncomfortable…it’s no different than being in public and having someone touch you inappropriately. Just because you are in a hospital does not give another person the right to touch you,” explains Long. “Most patients will want to hold your hand or touch your arm, but they will not go any further than that. An action or remark could be considered harassment if the nurse directs the patients to stop, but that direction is ignored.”
“A ‘reasonable person standard’ is generally used to determine if conduct is motivated by prurient interests or for a person’s sexual gratification,” says Debra W. Levin, counsel in the health law group at Brach Eichler. She previously served as counsel to the New Jersey State Board of Medical Examiners and was the Assistant Section Chief responsible for legal services provided to more than 50 licensure boards, including the New Jersey Board of Nursing. “If a reasonable person would be offended, then it can be determined to be sexual harassment. Because the standard is subjective, it is often hard to determine.”
“Sexual harassment is generally any unwanted sexual direct or indirect physical contact or comments. Of course, some physical contact may be more overtly ‘sexual’ than other contact, but much of the time, the intent will be evident,” says Jessica T. Ornsby, LL.M., Esq, managing attorney with A+O Law Group. “A good rule of thumb is whether the contact is objectively appropriate under the circumstances. For example, if a nurse is taking a patient’s blood pressure, is it necessary for the patient to place his or her hand on the nurse’s thigh? Probably not. But if a nurse is helping a patient into bed, that patient may need assistance stabilizing himself/herself and may rest his or her hand on the nurse in a way that would otherwise not be necessary.”
She adds, “Sexual harassment is basically a step down from sexual assault. If the action/contact involves force or any kind of penetration, that is most likely assault and should be addressed accordingly.”
What to Do if It Happens to You
Suppose a patient sexually harasses you. What do you do?
“Experts believe that sexual harassment is significantly underreported in health care. For that reason, I believe the best defense for nurses starts with reporting these types of incidents,” says Jennifer Flynn, CPHRM, risk manager at Nurses Service Organization. “No matter who the harasser—whether it be a supervisor, coworker, or a patient—nurses can take steps to address harassment in their workplace.”
“While working in a hospital, the first step is for the nurse to address the behavior. The nurse should tell—not ask—the patient to refrain from the inappropriate comments or actions and to stop immediately. The nurse should then report the behavior to his/her manager so that the leader can be aware. If the behavior stops, it typically will not need to go further,” says Long. “It is imperative that the nurse set boundaries with the patient immediately once s/he recognizes the behavior. If the action is severe or violent, the nurse should report it immediately, and the leader should address it. If the nurse is uncomfortable caring for the patient, the patient can be reassigned to another nurse. There have been times when I have assigned only male nurses to a patient who was harassing the female nurses.”
There may be times in which a patient won’t stop. In this case, Long says that the leader should talk with the patient and stress that the behavior won’t be tolerated and must cease. “If the behavior continues or if the nurse is uncomfortable caring for the patient, the patient should be reassigned to another nurse, and the leader should engage the Risk Management Department and/or the Security Department to assist. Many times, a Security Officer will be asked to speak with the patient and direct them to stop the behavior. Since they are often in uniform, it can be a show of added authority and the behavior will stop. If it does not, the Risk Management Department can speak to the patient and explain any legal consequences to their continued inappropriate behavior,” says Long.
Ornsby says that each work environment, ideally, should have some kind of policy with regard to sexual harassment. “Nurses should make note of these policies and earmark them for future reference,” she says. “If the policy does not specify to whom to report the incidents—ask. If a patient’s behavior…is making you uncomfortable or causing you to feel unsafe, leave the situation immediately. Your personal safety and well-being are the most important. Federal laws on sexual harassment apply regardless of whether the harassment is taking place at a hospital or a doctor’s office.”
Levin agrees that health care organizations should have policies in place. “Larger or licensed facilities may have staff to counsel the patient regarding harassing behavior. Additionally, in regard to patients, the patient can be transferred to another’s care, a chaperone can be provided, and the patient can be counseled. In dramatic situations, the patient can be discharged/terminated from the practice or facility. State-specific laws apply that govern termination of the doctor/patient relationship/discharge so that the patient is not abandoned, and there is a transition of care,” she says.
The American Nurses Association has challenged nursing professionals to end sexual harassment in the workplace by adopting a zero-tolerance policy. “Much has been written lately about the importance of nurses engaging in self-care. Not tolerating sexual harassment is an integral component not only for self-care, but also for self-respect, vital for professional effectiveness. Speak up when sexual harassment occurs and facilitate a civil work environment,” Flynn says.
The Bottom Line
“If the organization is not responsive to the nurse’s claims, s/he should consult legal counsel or their union. No one should be subjected to sexual harassment in the work place,” says Levin.
Long says that harassment, whether physical or verbal, has been perceived in health care as “part of the job.” But it’s not and never should be seen as such. “It is never acceptable to be harassed by anyone at any time. Nurses are an integral part of the health care team and should command the same respect as every other profession,” says Long. “Unfortunately, nurses have been depicted in a sexual manner for ages and that has demeaned the profession. Being a nurse does not negate my rights as a human being to not be verbally or physically assaulted.”
“I took an oath to care for others, but that does not mean that I have to sacrifice my physical or mental well-being,” Long adds.
* not her real name
Let’s rewind back to the summer of 2014. I
was in the midst of my senior year of nursing school taking classes, working,
and doing my best to survive the New York City summertime heat. While working
on an assignment one evening, my mother called me to say that my uncle had been
in a near-fatal motorcycle accident. He was put onto a ventilator and had to
endure an extensive hospital stay. This news was incredibly upsetting and
unexpected. I have always been close with my uncle and couldn’t help but feel
I pushed on through my classes and day-to-day routine, but I noticed that I was suddenly sleeping more, eating less, and often feeling unfocused and unmotivated. I chalked it up to stress from school and work, especially since it was my last year and I was expected to graduate that upcoming spring. Reaching out for help was a fleeting thought, and I firmly decided that I could handle these feelings on my own.
Turns out, I was wrong. Feeling down, unmotivated, and overwhelmed consumed me. I received a C minus in one of my summer classes, which coupled with a C minus that I had received earlier in my nursing school career. For a while everything felt so slow, but suddenly it was as if I were thrown into a time-lapse getting caught up with reality. I frantically reached out to my academic advisor who monotonously told me that if I was struggling with a personal issue I should have spoken up sooner and that two C minuses are not acceptable in the program, but I could speak with my professor directly about the grade. There was hope. Except there wasn’t, because my professor would not budge on the matter. With that being said, I was kicked out of nursing school the fall of my senior year.
My recently furnished dorm room had to be dismantled—clothing back in suitcases, photos taken off the walls. I had to say goodbye to my roommates who were confused and concerned. I had to say goodbye to my friends of four years. The reality that I would not be graduating after years of hard work crushed me.
I experienced panic like never before. I couldn’t breathe, couldn’t move, couldn’t feel anything but my lungs constricting. I felt like I was going to explode. A counselor diagnosed me with both panic disorder and generalized anxiety disorder.
I moved back home and tried to figure out what to do next in a frenzied state. No nursing school would accept someone who was dismissed for poor academic performance. The panic attacks only got worse. I was having them at least three times per day. Most people would have given up at this point and settled for less, but I had always known that nursing is the only career I wanted for myself. I would not settle, no matter how much I was hurting, no matter how impossible things seemed.
I began seeing a regular therapist in an effort to get my life back on track. Things seemed to be improving. During the winter of 2015, about four months after my dismissal, I was driving home from a therapy session down a road I’ve known my whole life. Suddenly, a car pulled out in front of me, taking me off-guard. I slammed on my breaks, but it was too late. I smashed into the car head on. My insides were screaming panic, but I couldn’t move. Bystanders got out of their cars to help, but my doors were locked and could not be opened. People were asking me through my window if I could move my legs and I didn’t know if I could. I heard sirens and thought to myself, “I have to be dreaming.” Paramedics had to cut through the top of my car, hoist me out, and strap me to a board that was put into the ambulance. More panic.
Though I questioned my faith during that time, I thankfully left the hospital banged up and bruised, but not detrimentally damaged. I sustained a treatable back injury. After my recovery, I applied for a job at an urgent care clinic because I wanted to maintain medical practice in my life. I thought it would help, both with my practice as a future medical care provider as well as my emotional state. I was happy to get the position, but that meant having to drive again. During that period of time, my drives to work consisted of multiple instances of having to pull over and having countless panic attacks. But I got there. I kept up with both my therapy sessions for the anxiety and physical therapy for my back.
That spring, I attended the graduation ceremony of the friends I was forced to leave behind. I can’t begin to describe how happy I felt for them. At the same time, I worried that they would end up leaving me behind. I felt that in a way, they already were. I felt awkward being with them in public because I didn’t want people from outer circles asking questions that I was too embarrassed to answer. I didn’t know how to fit in anymore with my best friends. This caused panic that I cannot forget.
Rather than closing in on myself, I mustered up the courage to apply back to the same nursing school that I was dismissed from for entrance the upcoming fall semester. I was asked back for an interview, which I graciously accepted and prepared for rigorously. On the day of my interview, I walked into a familiar building unable to control my shaking body. As I sat across from my old professors, I was asked what will be different this time around, should they allow me back. I told them the truth. I spoke about my journey dealing with anxiety and ways that I am now able to manage it, though it goes without saying that it is challenging. I highlighted my relentless drive to be a nurse, and that if the past year wasn’t enough to stop me, then nothing ever could. I was accepted back into the program; my faith was slowly being restored.
I was taking classes with students who had known each other their entire nursing school careers. I also struggled to grasp the material at first, being that I was rusty from having to take time off. I felt disoriented and like an outsider, but I didn’t let that distract me from achieving greatness. I made the dean’s list at the university that only a year ago had told me that I wasn’t good enough. I eventually made friends with my classmates and strengthened the relationships with my old friends.
That May, I graduated proudly. All my friends and family were there to support me. Panic took the backseat.
After passing the NCLEX, I worked in a couple of different clinics and health systems gaining invaluable experience. Despite my fear of rejection, I applied and was accepted into a master’s program for midwifery. I now happily work at a fertility clinic and am excited to graduate the midwifery program stronger than ever. I have discovered my interests within the nursing field, which include researching the United States’ shockingly high maternal mortality rates and normalizing breastfeeding, especially among women of color.
Now, I have been invited to become a member
of the Sigma Theta Tau International Honor Society of Nursing. Once more, I
have to ask myself whether I’m dreaming, only this time it’s under completely
different circumstances. I won’t lie, a sense of underlying anxiety persists
within me, but I can now recognize that I have valuable coping mechanisms that
I have learned through therapy, a group of friends and family members who are
my rocks, and a sense of proudness and empowerment in what I have accomplished
that cannot be taken away. I am eager to make my mark on the field of nursing.
I can’t wait for what will come next.
Many people feel called into nursing careers. Nurses get the
unique opportunity to directly serve people in achieving better health. But
while nursing offers many rewards, the stress of the job can also lead to
burnout. Left unchecked, career burnout can drive even the most dedicated
nurses to leave the profession altogether.
Anyone considering a nursing career should start by having realistic expectations of what day-to-day life is like as a nurse—especially in acute care settings.
Ingrid Flanders, RN, BSN, MN, FNP-C, a visiting assistant professor at the Linfield-Good Samaritan School of Nursing in Portland, Oregon, says sometimes the job is different from what a nurse might expect. “Maybe they don’t have a full understanding of the role and the responsibilities that go with it,” says Flanders. “Then they’re surprised at the level and intensity of the workload. Maybe they haven’t prepared themselves physically, mentally, and emotionally for the work involved; because a nursing role, regardless of what setting you’re in, is really demanding.”
Flanders notes that patients have high expectations of nurses’ proficiency, which can create pressure. There’s also the pressure that many nurses put on themselves. “Generally, the people who are drawn to be nurses have high expectations of ourselves and so we try to give it all away and we don’t always have enough left for ourselves,” explains Flanders.
What starts out as a passion for helping people can soon lead to chronic job stress or what Vicki S. Good, DNP, RN, CPHQ, CPPS, vice president of quality and safety at Mercy Hospital Springfield Communities in Springfield, Missouri, calls burnout syndrome (BOS)—work-related stress that remains unresolved. “BOS has three elements: exhaustion, depersonalization, and perception of decreased personal and professional accomplishment. BOS is directly related to stress at work and not related to stresses outside of work, although outside stresses may impact the stress at work,” explains Good.
Good says that nurses in high-risk, high-stress work environments (such as critical care nursing) are at especially high risk for developing BOS, where they are asked to care for patients during a vulnerable time in the patient’s life, and often at the end of life, with the accompanying ethical issues.
“Nurses are engaged in high-stakes decision making on a daily basis,” says Good. “The nurse is the clinician who is constantly at the bedside of the patient, giving their entire physical and emotional self to care for their patient and their family. Combine this with one of the most challenging workforce shortages in nursing and nurses have rates of BOS equal and often higher than their physician colleagues.”
One extreme consequence of nursing job burnout is nurses deciding to leave the profession—a choice that nurses are making in unprecedented numbers according to Good.
“By raising awareness and educating nurses on how to respond and mitigate symptoms of BOS we hope to prevent nurses from leaving the profession. BOS has been called a ‘silent epidemic’ because nurses and other clinicians have been afraid to speak up about their feelings, and instead the nurse ‘votes with their feet’ by leaving the unit and/or profession,” says Good.
Warning Signs of
Because nurses invest vast amounts of time, education, and money into entering the field and growing their careers, it’s important that they practice good self-care and watch out for the warning signs of chronic stress and burnout.
Nursing career burnout can be sneaky, warns Anna Rodriguez, BSN, RN, CCRN, PCCN, a critical care nurse who launched TheBurnoutBook.com to help nurses combat burnout. “It comes on so gradually, one bad shift at a time, and before you know it, you dread clocking in to work,” says Rodriguez. “Early recognition is key. You need to pause and assess yourself frequently for signs of fatigue, depression, or feeling cynical or apathetic toward your work. You might go home feeling emotionally or physically drained more days than not. You might feel anxious and find your mind racing, thinking about work. These are all unhealthy signs that the work is getting to you and, if it continues, will lead to full-blown burnout.”
Good says that unfortunately, most nurses do not realize when they are developing the signs and symptoms of BOS. “This is one reason that raising awareness of this syndrome is so important to our profession. As a professional nurse, it is critical to be able to recognize the warning symptoms so that one can then take action to mitigate the potential outcomes of the syndrome,” says Good.
So, what do nurses need to watch out for as they go about their daily work?
“As a nurse, the first thing to become keenly aware of are any changes in energy levels related to work—both physical and emotional. Exhaustion is one of the key symptoms. If the thought of going to work makes you exhausted, pay attention, ask questions, and seek intervention,” Good advises.
Flanders agrees that nurses should watch out for fatigue. Another common symptom is a lack of resilience or tolerance for challenging situations where you feel more impatient or more irritable than usual.
This lack of resilience may cause nurses to become disengaged in their work and interactions with coworkers and patients. “If a nurse was previously highly engaged in social events and activities on the unit and stops participating, this may be a sign of BOS development,” says Good.
Finally, watch out for the general feeling that you’re not making a difference as a nurse for your patients/community. Good notes that this lack of a personal and professional sense of accomplishment is a warning that burnout has set in.
How to Avoid Burnout—or Nip
it in the Bud
What can a nurse do if they are on the road to burnout or to prevent burnout from developing? Here are some expert tips from seasoned nurses.
Practice Self-Care. Flanders says it all starts with prioritizing
self-care. This includes reading for pleasure for a few minutes every day,
maintaining a healthy diet, getting regular exercise to reduce stress, and
making sure you get adequate rest. “Even if you’re a nurse working on a night
shift, it’s important to make sure your sleep pattern is one that’s
sustainable,” says Flanders.
Develop Resiliency Skills. “Resiliency is the antidote to burnout,” says Rodriguez. “It’s the ability to bounce back after feeling that emotional, physical, and psychological exhaustion that burnout creates. It’s finding a way to balance the energy you give to others and recharging yourself so that you can continue to care for others effectively.”
Rodriguez suggests the following tips to build resiliency as a
- Be intentional on your days off to regroup and rest so that you can come back a better nurse on your next shift. Don’t say yes to extra shifts if you need to rest.
- Take breaks during your shifts (and practice self-care strategies during your break, such as eating a healthy meal or reading for pleasure).
- Plan unit-bonding activities. Getting together with coworkers outside of work is a great way to fight off burnout.
Talk It Out. Having a support network is vital for nurses. Nurses need to ensure they have other nurses to turn to vent about a bad day, a troublesome patient, or frustrations. Having nursing friends at work and/or joining a professional nursing association dedicated to your specialty, such as the American Association of Critical-Care Nurses, can be an excellent outlet.
“We need a way to talk about the things we see every day,”
says Rodriguez. “There’s a lot of doom and gloom. There are morally distressing
moments. There are times when we’ve given so much of our energy to others that
we develop compassion fatigue and go into survival mode, shutting down our
empathetic side as a coping mechanism. The ability to vent in a healthy way
with our peers is essential to dealing with all of that and maintaining our
empathy. No one understands what you go through better than another nurse.”
Explore Your Options
If you feel that you are already in burnout mode, take some time to explore your career options. Some nurses who experience burnout leave the profession altogether. But that may not be necessary.
Start off by exploring ways you can remain in the field by taking some time off, changing units, or finding a new job in a less stressful environment.
“A sabbatical or some time off may help, but it’s generally not a
long-term fix,” says Paula Davis-Laack, JD, MAPP, owner of Davis-Laack Stress
& Resilience Institute. “Remember that burnout is more about work
systems, cultures, and values creating an environment that breeds burnout, so
until the workplace changes, burnout will likely remain a possibility. You may
just be in an environment that’s a disconnect for you. Can you switch teams,
organizations, or practice settings?”
If a change in work environment or position doesn’t help, then
it’s time to look at nontraditional career tracks such as becoming a health
coach, nurse entrepreneur, or nurse educator.
“One of the things I’ve enjoyed about being a
nurse now for almost 35 years is that there’s a variety of nursing roles within
the profession, and it’s important for young nurses to know that if they’re
getting to the point that they feel like they can’t do it anymore, there are other
options and other roles that might be a better fit for them at that point in
their lives,” says Flanders. “It’s important not to feel like you’re stuck in a
corner and that you don’t have the power or ability to make it different if it
needs to be different. Because when you’re in the role of taking care of other
people, if you’re not doing well, then how can we possibly do our jobs as