The stress of nursing can take quite a toll on nurses emotionally and psychologically. Learn to recognize the signs, what to do, and when to seek help.
Abbegail Eason, RN, remembers some of the most devastating moments she’s witnessed as a nurse: a teenage girl learning she would never walk again after being shot by a gang member, a mom who gave birth but then died from a cerebral aneurysm just days later, and a baby who was left in a store’s parking lot and ended up dying.
“In these types of situations, it’s almost impossible not to be affected after your shift is over,” says Eason, a holistic coach at Abbegail Eason, LLC.
“Every nurse is susceptible to suffering from emotional distress,” explains Lucia M. Thornton, RN, MSN, AHN-BC, a consultant, educator, and author of Whole Person Caring: An Interprofessional Model for Healing and Wellness. Thornton and other sources we interviewed say that while all nurses can be affected emotionally, those in particular specialties may be more apt to experience this kind of issue. Some of the areas where nurses are especially at risk: emergency departments and trauma, intensive care unit (ICU), hospice, oncology, pediatrics, HIV clinics, homeless medicine, high-risk pregnancy clinics, palliative care, and neonatal intensive care unit (NICU), among many others.
“Anyone who is empathetic and works in a caregiving role—including nurses and certified nursing assistants—are at risk for developing compassion fatigue and increased caregiver stress, which affects emotional health,” explains Karen Whitehead, MS, LMSW, DCC, CCFP, who provides counseling in the greater Atlanta area and at TurningPoint Breast Cancer Rehabilitation. “Nurses who over-identify with patients and blur boundaries, as well as nurses with personal trauma histories, poor social support, isolated working conditions, or a previous history of unmanaged anxiety are at greater risk. Feeling a lack of control about your work environment—including schedule, lack of recognition, or sense of community—can also contribute to caregiver stress.”
“Working in these areas with these types of patients triggers the sympathetic nervous system and keeps the body in fight or flight mode. This heightened stress reaction can, over time, lead to compassion fatigue and ongoing emotional distress,” she adds.
It can also be especially difficult for nurses because they are on the frontline of patient care, says Carl J. Sheperis, PhD, NCC, CCMHC, MAC, ACS, LPC. “Aside from the ongoing stressors of variable schedules, budget cuts, and constant technology changes, nurses are faced with a broad range of emotions experienced by patients,” explains Sheperis, a licensed professional counselor as well as the program dean for the College of Social Sciences at the University of Phoenix. “According to the American Nurses Association 2011 Health and Safety Survey, over 56% of participating nurses had experienced some type of threat or verbal abuse from patients. All of these stressors compound and result in high incidences of compassion fatigue and burnout for nurses.”
Compassion Fatigue, Moral Resilience, and Burnout
Mary Bylone, RN, MSM, CNML, president of Leaders Within, LLC, and a former board member of the American Association of Critical-Care Nurses (AACN) often lectures and writes about the AACN’s healthy work environment standards. Bylone says that while compassion fatigue, moral resilience, and burnout are terms often used interchangeably because they do have a lot of overlap, they also have some differences.
“Burnout is best used to describe a situation in which an individual feels overwhelmed and exhausted. It can be seen when people sacrifice themselves for work or become overwhelmed with the feeling that the work is never done. Compassion fatigue refers to the weariness that develops from caring for individuals when the caregiver feels saddened that they cannot change the situation and give of themselves in the hope of relieving pain or suffering in the patient,” explains Bylone. “Moral resilience refers to the aspect of an individual’s character to rise above situations creating moral distress, such as being asked to provide futile care or care against a patient’s wishes. Resilience comes when the nurse is able to restore and maintain their integrity by challenging or pushing back when asked to do things they do not feel are right. It involves using one’s bold voice to speak up when others would remain silent—to ensure that the morally right thing is done.”
For the past decade, the AACN has addressed all these issues. Its National Teaching Institute recently held a special interactive session during which more than 300 nurses spent an afternoon sharing the types of experiences that would cause these feelings and sharing their solutions with their colleagues as well. “The AACN puts a lot of energy into hope and resilience rather than dwelling on the negative,” says Bylone.
Recognizing the Signs
“Experiencing emotional reactions is human and appropriate,” says Sheperis. “The key is recognizing when the emotional reactions are out of proportion to a situation or when they have a negative impact on you or others around you. Nurses are often good at compartmentalizing emotional reactions, but sometimes the compartments become full, and the emotions spill out.”
Some of the signs that a nurse is experiencing negative effects from emotional overload are: using a greater number of sick days and/or dreading going to work; feeling exhausted; problems sleeping; using drugs or alcohol to sleep; having work-related dreams, nightmares, or intrusive thoughts; being angry a lot either at work or home; yelling at patients or families; changes in mood or behavior at work; crying all the time; feeling angry at supervisors or coworkers; developing fears about the safety of friends or family; feeling less engaged in their personal and/or professional life; the inability to think clearly; headaches; gastrointestinal problems; irregular breathing patterns, feeling devalued, and losing the capacity to care about themselves, their patients, their family members, or really anyone.
This doesn’t even touch on the signs of clinical depression, which nurses may also experience. The point is that if nurses notice vast changes in themselves or in their coworkers, they may need to seek or suggest help.
The first action that nurses can take to keep their emotional health intact is to set boundaries, says Gail Trauco, RN, BSN-OCN, a grief mediator, owner of Front Porch Therapy, and author of Conquering Grief from Your Own Front Porch. Nurses can do small things to make themselves happy. “Be sure you have things that you visually see which create an immediate ‘happy sensation,’” suggests Trauco. “This can be a favorite coffee mug, bright-colored scrubs, flowers on your desk, or even a funny stethoscope cover.”
One of the biggest problems nurses have is that they tend to put everyone else’s care above their own, says Jill Howell, MA, ATR-C, LPC, a board-certified registered art therapist, professional counselor, and author of Color, Draw, Collage: Create Your Way to a Less Stressful Life. While she works at Pocono Psychiatric Associates, Howell worked with many nurses at the Pocono Medical Center. “It’s all about self-care—nurses will, of course, react by saying that they don’t have time,” says Howell. “Please remember what they say on the airplane—put your oxygen mask on first before you try to help others.”
When working with nurses, Howell would check in with them to see how they were dealing with work, give them an opportunity to vent, and make small self-care suggestions. She would also do quick guided meditations with them, teach a relaxation technique, or set up large sheets of mural paper and have them draw out their frustrations.
“I have found that most nurses, while they can care for others continuously, have a very difficult time in caring for themselves,” says Thornton. “Self-compassion is an important and useful practice for nurses to develop.”
“Nurses are givers. We go into the field because we are caretakers,” says Eason. “Many of us feel we are at our best when taking care of others.” She says that it’s important, though, for nurses to understand that they have to take care of themselves first. “Ensure you are getting adequate, quality sleep. You are eating a well-balanced meal. You are getting adequate exercise. You are spending time cultivating a life that is meaningful, rich, and deep outside of work,” says Eason.
After a particularly stressful experience at work, Lisa Radesi, DNP, CNS, RN, academic dean at the School of Nursing, College of Health Professions, University of Phoenix, says that nurses and other staff should have a debriefing session and remember that, despite all of the “bad” that occurs in their jobs, the “good” is the most rewarding part of what they do.
“Nurses should work together to ensure that they are okay after an incident. If a nurse notices a coworker is not doing well, they should talk with the coworker and bring it to the attention of the supervisor or manager,” says Radesi. “Above all, nurses should feel comfortable seeking treatment and communicating about emotional issues they may experience. Keeping this information bottled up can lead to issues and stress that have long-lasting effects. Know that it is not weakness, but strength, to acknowledge emotional disturbances and respond to them accordingly.”
If you see a coworker in distress, you can do something as simple as strike up a conversation with her or him, advises Bylone. “Use open-ended questions to find out how they are doing. Sometimes hearing the other person’s story really puts things into perspective. Let them know you care, and you are there to help, if only to listen. Please do not watch them suffer alone. Left unattended, these feelings only deepen and create lasting impact, often causing them to leave the profession,” she says.
Seeking Professional Help
Let’s face it: there are times when a spa day, time out with friends, or a bubble bath just won’t cut it in alleviating emotional problems. That’s when nurses need to seek professional help.
“If you are experiencing distressing symptoms over an extended period of time, it’s a good idea to check in with a professional therapist or counselor,” says Whitehead. “Whether it is distress from work or something related to your life outside of work, connecting with a professional can help you be a more effective caregiver and build your own resilience to mitigate the effects of your chosen population at work.”
If you need professional help, first see if your workplace has a program for staff members. If not, Sheperis says that the National Board for Certified Counselors has a directory of board-certified counselors across the United States (visit nbcc.org for more info). PsychologyToday.com also has a therapist directory that includes profiles of providers who can help.
There’s no shame in seeking help to get better. Sheperis says, though, that all nurses should do whatever they can to prevent their emotional stress from getting to this level. “Most people only seek professional help after something in their life had caused significant distress. While it is important to seek help if you are reaching a level of burnout or compassion fatigue, it is much better to take proactive steps and to work with a counselor to build resilience prior to hitting an emotional wall,” he says.
Sheperis also suggests that nurses focus on wellness practices at the onset of their careers. “It is easy to become engrained in a high-pressure system and to become emotionally overwhelmed if you don’t have a set of wellness practices in place.”
Few nurses have a solid grounding in personal finance about making decisions about their own financial future. Money management can be overwhelming. But you don’t need to learn the fine points of microeconomics – just the fiscal facts that pack a wallop on your wallet.
The good news is that the economic outlook for most nurses is rosy. Employment prospects are strong, says Donna Cardillo, RN, nurse entrepreneur and inspirational/motivational speaker. “The job market for nurses is much better. The market is cyclical and always has been. The last slump lasted about seven years, but that has all changed and many employers are now offering sign-up bonuses,” she explains.
The bad news? Many nurses still struggle to lead financially empowered lives, rather than being slaves to debt or just getting by paycheck to paycheck. Here are nine ways to make powerful personal and career decisions.
Evaluate an Employer’s Salary and Benefits Package
Often nurses decide to accept a job offer based only on the hourly wage, without being aware of the entire salary structure and how it can drastically pump up your pay.
Jon Haws, RN, CCRN, nurse educator and founder of NRSNG, wrote a popular article about how he doubled his first-year earnings as a new nurse. In “How I Made Over $70,000 My First Year as a Nurse (how I learned to game the system),” he recounts his experience as a newly graduated critical care nurse at a Level I Trauma center in Dallas, Texas.
According to Haws, that article “is a bit dated and I realize the $70,000 is nothing to a California nurse, but I outline some step-by-step ways to really maximize what you can make right out of school.”
Some of his steps included grabbing the pay differential for nights and weekends, getting an automatic raise after 6 months and a year, and working overtime and bonus shifts. That strategy requires that you make yourself an expert on your HR department or union contract rules, of course, which may be difficult before you’re hired. Not every employer is transparent about its pay policies. It’s easy enough to check Payscale.com or Salary.com for comparisons. Also, be sure to consult with a tax professional about the ramifications of higher compensation—you want to be ready when the tax bill arrives.
“The benefits package is something that employees don’t always take into consideration, but it can be significant,” says Launette Woolforde, EdD, DNP, RN-BC, vice president for nursing education and professional development at Northwell Health in New Hyde Park, New York.
She encourages nurses to plan for the next step of their education and especially note those related benefits. “Some organizations offer employees some sort of tuition reimbursement plan. When you get a job and get through adapting to your new role as nurse, that’s the time to take advantage of those benefits.”
According to Woolforde, some organizations provide employees with a discounted rate or deferred payment options for a number of nursing schools. “So a $500 a credit may be reduced to $400 a credit and the student isn’t invoiced until after the class is over. By then the tuition reimbursement will have kicked in so students don’t suffer out of pocket expenses that disrupt their cashflow,” she says.
In addition, many organizations pay a stipend or differential based on a nurse’s educational achievements. “For example, let’s say the salary is $50,000 a year to start, but if a nurse has a bachelor’s degree, they may add $5,000 a year. If you’re certified they may add even more,” she explains.
Decide on Your Financial Priorities and Make Every Step a Learning Point
There may be a sunny employment outlook for nurses, but you still have to earn and save to fund your priorities. Not every nurse will have the same financial needs and not every nurse will experience life transitions in the same order. Yet, there are some goals, such as starting a family, buying a house, or early retirement, which many nurses aim to achieve and can—with some work on their inner and outer game.
“I made $35,000 or $45,000 my first years in nursing and had to figure out a way to increase income or reduce spending,” says Brittney Wilson, RN, BSN, nurse influencer at TheNerdyNurse.com. “I opened the door to those possibilities.” Wilson carried $40,000 in student debt that she now believes was avoidable, if she’d lived at home, attended a community college, worked a part-time job, etc.
As a young wife and mother, she tried many methods to economize, as she wasn’t emotionally able to work more hours at the bedside. “One example, I tried extreme couponing and was able to take our $600 grocery bill down to $100. I had to figure out a way to get diapers and formula for my baby,” she explains. Wilson started her blog a couple of years later, mainly for personal expression, but she also started getting free products and fees from brands. “People kept offering me money but initially I felt some guilt about it,” she says. “When I came to terms with it and actively decided to monetize my blog, I hung the ‘I’m available to be paid’ shingle directly, and even more offers came in.”
As Wilson felt more and more confident that she was providing a valuable service, she increased her ad and consulting rates, and focused her blog on her nursing specialty. “Earning extra income is like walking down a hospital hallway. It’s a journey. You can open each door and look around or keep going down the path. Just keep opening doors until you find the one that is right for you,” she advises other nurses.
Wilson got so good at earning and saving that she and her husband are on-track to pay off their house mortgage in a little over five years.
If you’d like to get better at the nuts and bolts of budgeting, bill paying, and tracking various financial accounts, you may want to try apps and programs like Mint.com. By corralling everything into one place, you get a better handle on your spending and saving, and can see in charts and graphs how well you’re doing with your finances.
There are also minority personal finance experts you can follow for advice from someone who figuratively speaks your language. For example, African American pros include Michelle Singletary, who writes “The Color of Money,” for The Washington Post and syndicates. Or, if you prefer podcasts, Rich Jones and Marcus Garrett host Paychecks & Balances for Millennials aiming to pay down debt
Decide When to Make Major Purchases
Even if a purchase is appropriate for your life stage, try to minimize your total household overhead. Even well-paid nurses risk fatigue from worry or overwork to manage bills and payments for one-time splurges or ongoing financial commitments.
Woolforde encourages nurses to carefully consider whether a major purchase is a sound money investment. “I see this often—the first thing a nurse graduate buys is a flashy, brand new car, as a reward for all that hard work in school. A flashy new car is nice but it’s a rapidly depreciating item as opposed maybe holding out for a down payment on a new home that appreciates for a good long-term return,” she explains.
You might decide that your next major investment will be in your own higher education or specialized training. If so, be sure to take advantage of employer-provided assistance programs before taking out large student loans. Maybe your current workplace has a tuition reimbursement plan if you’ll commit to working there after graduation, but you hesitate to limit your options. Find out how often graduates using that program decide to stay with that employer; usually the figure is high. If your circumstances and goals match theirs, you’re likely safe in taking the same route.
So many students lament how little they knew about educational loans that a free interactive game called Payback was created by a financial literacy non-profit. The makers warn: “College can help you realize your dreams, unless it leaves you with a student loan nightmare.” Students navigate an online maze of decisions: What school to attend, what major to declare, whether to focus on studies for a higher GPA or social life for more connections, etc. At the end, if a player does decide to borrow educational funds, it’s with eyes wide open.
Choose a Specialty That’s Fulfilling—And Remunerative
Whether you’re a new nurse graduate or you’ve been in the field for years, now might be a good time to switch to a specialty or workplace with better long-term prospects for pay and benefits.
Cardillo encourages nurses to explore non-traditional career options and to take risks. “Your next job may not pay as much, but may have many other advantages. When it comes to being a bedside clinical nurse in a hospital, there’s only so much you can make, even with overtime. Some other health care related industries have greater earning potential over the long run even if you have to take a pay cut in the short term,” she says.
Cardillo points to a variety of popular nurse settings and roles that pay well, such as: Nurse informatics, quality management nurse, corporate wellness nurse, insurance nurse, or nurse consultant.
You may also want to check out DiscoverNursing.com for interactive features that guide you through the process of choosing from scores of specialties. Some under-the-radar titles have surprising rewards, including high demand or ease of entry. You’ll get information on the education, training, and certification required to fill a role, as well as its average salary and employment outlook.
Decide to Cut Hours or Leave the Bedside Altogether
Reducing your hours to, say, care for a family can be a difficult choice that depends on many conditions, but it can be the right choice, if done right.
“If you opt to get out of the job market for a while, stay in touch with nursing colleagues through professional associations [and] keep up with credentials and licenses,” advises Cardillo. “Keep yourself current, marketable, and connected.” She warns that nurses who let their licenses lapse—accidentally or not—won’t be ready to jump back in when they need to or want to.
“Some nurses drop out of the workforce to take care of elderly parents, but then the parents die and they’re left with literally nothing and can’t find a job,” she warns.
Cardillo recommends that you first explore opportunities to work at home, which are more common today for nurses. If that’s not possible, check to see if your state allows for an inactive status license, rather than outright letting it lapse.
Another life stage when nurses may be tempted to let their license lapse is at retirement, but Cardillo sees downsides to that. “Nurses retire, but after so many years they get bored or financially need to work again because they don’t want a lower standard of living.”
Care for Yourself and Your Career Longevity
“Nurses are leaders—they advocate for their patients, but they struggle with advocating for themselves,” says Diane Neustadt, director of operations at New York-based Forest Hills Financial Group.
Her firm supports the National Association of Hispanic Nurses New York chapter, of which Neustadt is an active member. Because of her involvement with the chapter, she’s able to explain the importance of managing one’s own financial life in terms that nurses relate to. “I tell them it’s like being proactive about your own health. Nurses work long, unpredictable hours so self-care is so important: physically, emotionally, and spiritually. I’m a spiritual person and also know the importance of financial well-being—live one day at a time but not just for today.”
Neustadt believes in “protection first,” which means having enough insurance and the right kind. “Employer-sponsored benefits are a good thing,” she explains, “but not only may company benefits not be portable and go with you, generally those employer-provided benefits are minimum benefits and should be viewed as the base of benefits to build upon. Three areas that normally need attention are disability, additional retirement income, and long-term care.”
Make the Most of Expertise from Family, Friends, and Coworkers
Woolforde received informal money mentorship from two unexpected sources who guided her to become financially savvy. The first was her older brother, who went to college when she was in her senior year in high school and was surprised at the expenses beyond tuition that he hadn’t anticipated. “When he came home at his first break he told me frankly, ‘You’re going to have to get scholarship money if you plan on going to college.’ So, we spent countless hours in the library combing through books and catalogs looking for scholarships. That was before everything was available online.”
She was doubtful about her ability to garner scholarship funds—others will have a higher GPA, more financial need, better applications. “At first, I said, ‘there’s no way I’m going to get it’ and he said, ‘you don’t know until you try,’” she explains. After piecing together several small scholarships—$600 here and $2,000 there from various sources—Woolforde was able to fund her freshman year at a commuter college. Good grades allowed her to garner full scholarship funding for the rest of her bachelor’s degree in nursing.
Woolforde next got valuable advice from a nurse preceptor who insisted they visit the hospital credit union after one shift. “She helped me open a retirement account and set up direct deposit of part of my paycheck into that account. I was just starting my career, so retirement was the farthest thing from my mind as a 21-year-old,” she says.
Try to find a money mentor who understands your situation and connects or relates to you in that way, advises Woolforde. “My brother understood the home situation and my preceptor maybe recognized me as her younger self—she was an African American female, too. Everyone who has walked this path, grown in professionalism, grown in a nursing career, it’s our responsibility to share what we’ve learned,” she says.
Make the Most of Your Employer’s Financial Programs
Your organization may offer employee benefit education, such as having an HR representative provide short updates at staff meetings, or making a vendor available for one-on-one consultations. Take advantage of these resources if they can help you fill in the financial puzzle pieces of your life.
“My family emigrated from Armenia when I was nine years old,” says Anna Dermenchyan, RN, MSN, CCRN-K, senior clinical quality specialist in the Department of Medicine at UCLA Health and a PhD student at UCLA School of Nursing. “At the time, my parents didn’t know the language or the culture, and thus we struggled financially as a family.” When she worked at a bank as a senior in high school, she learned about financial concepts and became more proactive about managing money.
Dermenchyan now actively engages with the University of California system’s excellent financial program for employees and students, which include onsite classes as well as live webinars on financial wellness and retirement.
“I’m an early Millennial and we think about work-life balance and living in the moment, and this necessarily doesn’t help us save enough money for the future. We want to earn, spend, travel, and just enjoy life,” she explains. “However, financial health is part of achieving wellness and maximizing potential benefits for the future. Just like with Maslow’s hierarchy of needs—personal finance is at the basic level, and everything rests on it.”
Most nursing schools don’t include a financial component in the curriculum, so many workplaces fill in the gaps with seminars, consultations, and program “nudges” to encourage fiscal health. “At first, I just put in $100 a month towards retirement; that’s what I could afford after paying loans and family expenses,” says Dermenchyan. “The automatic deduction from each paycheck makes it easier, and some institutions make a matching contribution. In addition, I was advised by a financial consultant that with every salary increase, I should increase my contribution to retirement,” and she has continued to ramp up her rate of saving and investing.
Prepare for Retirement
Some nurse leaders point to numbers of disengaged older nurses who are forced to continue working because of under-funded retirement plans. They didn’t put aside enough money for the future, and early social security payouts at 64 are too small to support even modest lifestyles.
“Nurses are unlike other caring professions—police, firefighters, and teachers—because they don’t earn pensions from municipal government employers,” says Ric Edelman, a #1 New York Times bestselling author of personal finance books such as The Truth About Money and The Truth About Retirement Plans and IRAs. “That puts their financial future in jeopardy.”
Edelman is also the founder of Edelman Financial, one of the nation’s largest independent financial planning firms. His firm offers a free financial plan to nurses, waiving its customary fee for the two-meeting process—either in person or via teleconferencing—which results in recommendations for investments, insurance, estate planning, and more.
By starting the process toward financial stability and independence, you can empower yourself as an earner, saver, and investor. It is possible to experience the feeling of security that comes from having your financial life firmly in hand. This moment is the best time to take that first step.
Planting the health policy seed has become increasingly important to professional nursing organizations, nurse educators, and even nursing students who applaud the call for integrating health policy and advocacy content in today’s nursing curricula. As nursing students become acquainted with the policymaking process, they are also encouraged to familiarize themselves with the various professional and specialty nursing organizations who advocate on behalf of the nursing profession and the patients/consumers they serve.
Numerous nursing organizations including the American Nurses Association (ANA), National Council State Boards of Nursing (NCSBN), and National League for Nursing (NLN), to name a few, work to ensure that nursing’s voice is represented during policy discussions on issues that impact health care delivery, patient outcomes, nursing workforce development, and other issues of concern to the profession. These and other organizations advocate to ensure that students have financial support to attend nursing school, have access to loan repayment programs, and support to advance their nursing education and training. These organizations work diligently to help ensure that today’s nursing workforce is well prepared to meet the demands of providing high-quality health care services in an ever-changing complex and challenging health care environment.
In this article, we present information about the American Association of Colleges of Nursing (AACN) and share insights from AACN Chief Policy Officer Suzanne Miyamoto, PhD, FAAN, RN.
The American Association of Colleges of Nursing
Since 1969, AACN has been a leader in advancing nursing education, research, and faculty practice. Moreover, AACN serves as a national voice for baccalaureate and graduate nursing education. In addition to creating standards for designing and delivering quality nursing education programs, AACN represents over 810-member schools and colleges of nursing nationwide. The AACN has a Government Affairs Committee and a Health Policy Advisory Council that coordinate and spearhead several public policy initiatives and activities focused on advancing nursing education, research, and faculty practice. Currently, the association’s federal policy agenda focuses on four key areas: workforce, higher education, research, and models of care—all ongoing public policy imperatives.
Here, Miyamoto shares some insights about her organization and health policy advocacy.
Describe Your Role and the Role of the AACN in Preparing Today’s Nursing Students in Becoming Influential Advocates in the Health Policy Arena.
As Chief Policy Officer, I oversee AACN’s policy and advocacy work at the federal level working with all three branches of government. My role and that of our team can be described as strategist, lobbyist, and analyst. To ensure we meet the needs of our member organizations, the association has a Government Affairs Committee and Health Policy Advisory Council that provides guidance when we are reviewing legislative proposals or federal regulations. We want to ensure that what we support, oppose, or remain neutral on is in line with the experiences or challenges of our member institutions. AACN is in a unique position that we represent the schools of nursing, which includes the deans, faculty, and students. This requires our advocacy work to be nimble and abreast of the key issues Congress and the Administration are discussing. It is our role to not only develop the strategy but to educate and inform our membership on our position and why we take it. Information is the best offense and the best defense. That is why AACN fully supports all members of a nursing school to be engaged in our advocacy efforts. We have a grassroots network with other 11,000 students, faculty, and deans. This network has great potential to grow and offers real-time, advocacy opportunities.
What Are Some Top Priority Policy Issues Impacting the Profession and Health Care Today?
Some key issues impacting the profession today include
• Securing funding for Nursing Workforce Development Programs, Title VIII of the Public Health Service Act, National Institute of Nursing Research, National Health Service Corps, among others
• The Title VIII Nursing Workforce Reauthorization Act (H.R. 959, S. 1109)
• Health reform
• Deferred Action for Childhood Arrivals (DACA)
• Public Service Loan Forgiveness
• Opioid epidemic
What Can Students Do Within Their Area of Influence to Advocate for the Profession?
It is important that students stay informed of the issues. Students need to be active participants in their own learning. To understand what is happening at the federal level, a student must embrace the policy from multiple lens. It is not enough to read one source or one disciple. To truly garner the depth and breadth of the issue, the more voices, for and against, the better one’s understanding becomes. Securing a basic level of knowledge on an issue that may impact one’s education, research, or future practice is an excellent starting point.
Grassroots campaigns are central to any of our efforts. We can be more effective if we know how our national organizations are weighing in on issues. It’s also important to listen to all perspectives. Again, policy think tanks like the Center for American Progress or the Heritage Foundation may have different political viewpoints, but on some issues, they may see eye to eye. Their rationale for getting there may be different, but it is that difference that can help further an argument depending on the audience. Students can also join forces with faculty and others to reach out to legislators at the federal, state, and local level on issues important to nursing. Discussing issues with nursing faculty, who can serve as tremendous mentors for those interested in policy, can ignite a passion for this work in the future. That is how I came to seek a career in health policy and advocacy. It was the foresight of my faculty mentors who gave me the opportunities to succeed.
What Resources Are Available for Nursing Faculty Who Are Preparing the Next Generation of Health Policy Activists?
AACN established a Faculty Policy Think Tank that worked to prepare a set of recommendations for AACN’s Board of Directors on this exact question. The charge of the group was to inform and improve the state of health policy education in undergraduate and graduate education. The ultimate goal was to consider ways that will help create a generation of future nurses who understand the micro and macro drivers that impact policy—most importantly, how nurses in the future can continue to skillfully insert nursing expertise into policy discussions. The report was released in October 2017.
Turning to the continued need for policy advocacy at the student level, AACN also offers a three-day student policy summit open to undergraduate and graduate nursing students enrolled at AACN member institutions. The program helps to prepare students to engage in policy advocacy and the federal policymaking process. For more information, visit http://www.aacnnursing.org/Policy-Advocacy/Get-Involved/Student-Policy-Summit.
As mentioned earlier, AACN’s 2017–2018 Federal Policy Agenda is well suited to serve as a foundation for shaping policy discussions during online and classroom discussions as well as during virtual and/or actual lobby days. Students are encouraged to speak with their deans and faculty at their nursing programs to learn more about what’s happening within their institutions regarding public policy advocacy efforts that impact nursing education and nursing practice.
Seeking Federal Support for Nursing Workforce Development Programs: A Clarion Call for Continued Advocacy
Very central to this discussion is the need for ongoing advocacy to secure funding to support Title VIII programs. Title VIII programs are administered under the U.S. Department of Health and Human Services, Health Resources and Services Administration. The Nursing Workforce Development Program (Title VIII of the Public Health Service Act) continues to benefit countless numbers of nursing programs, practicing nurses, faculty, students, patients, and communities. In fact, numerous minority nurses continue to benefit from diversity grants because of Title VIII funding. During 2015–2016, the Nursing Workforce Diversity grants supported 7,337 students. Numerous other minority nurses, including minority nurse faculty, have received funding through this program to support their advanced nursing education or pay back student loans. To learn more about how Title VIII programs are making a difference for nursing students, practicing nurses, academic institutions, and communities at large, visit http://www.aacnnursing.org/Policy-Advocacy/Title-VIII-Community-Impact.
As a nursing student, speak with your faculty and professional organizations about how you can play a role in policy advocacy. Throughout nursing’s history, nurses have made a tremendous impact in advancing the profession and the delivery of health care by advocating for issues of importance to them. Developing your knowledge base about these and other issues impacting the profession is a great first step to becoming an influential advocate on behalf of the profession and the patients and communities you serve.
We all sat around in my living room, friends in the fight against those nursing school teachers who seemed hell-bent on making our lives miserable. There were about ten of us crammed into my small living room for this Saturday study group, and I was the de facto leader. I didn’t need to be there. I didn’t need much more than to glance through the notes to get good grades, but I wanted to help these on-the-bubble students pass. I taught what I knew. Everyone wanted to study with me because, well, test scores speak for themselves in nursing school.
Yes, I was one of those, and I always have been. Give me a book, and I can ace a test. It isn’t really genius. It’s just that I know how to take a test. Of course, I was immensely proud of my 4.0. I didn’t lord it over people, but I did feel rather smug I guess, rather superior. I felt this meant the nursing world was my oyster. I was cocky that I would breeze through orientation, but I certainly didn’t feel I knew it all. I also didn’t put my fellow students down. In fact, I enjoyed helping them, fighting the good fight to get them to pass.
One day, my teacher said something that made the bottom drop out of my stomach: “The best nurses are usually those in the middle of the pack. Those who score high tend to not do so well.”
Was she talking to me? She said it to the class, but was she talking to me?
Maybe I was paranoid, but it turns out that there was a kernel of truth in what she said.
When I interviewed out of nursing school, no one cared that I graduated at the top of my class, although I told them repeatedly. They were more interested in how I would handle a crisis and what sort of person I was and whether or not I would fit in with this culture. Despite my obvious hubris, I am actually someone who can work well with others, can care for patients, and can be a part of the team. The only thing is that my work in school didn’t matter a damn to them.
What really opened my eyes was orientation. I was lost. Everything I had learned was so much chaff. It came into play from time to time, but it really and truly did not matter.
I remember the first time I had four patients. It was a juggling act. The fact that I knew all the bones of the hand by heart was completely irrelevant. I needed to look at vital signs and know what they meant. I needed to know when to pass meds and when to chart. Most importantly, I needed to know when I didn’t know something, and I needed to ask for help.
Fortunately, questions have never been a problem for me, and I was able to become a safe nurse because of that. This 4.0 student spent more time with her preceptor or charge nurse than she did with her patients in the first year of nursing.
And still, all that book learning I had was merely peripheral. Sometimes, it came into play. I would know obscure things about electrolyte imbalances, for instance. I was also considered one of the go-to nurses with problems in my later years.
But my knowledge is not what makes me a good nurse.
I found that my personal sense of patient safety was the most important. My ability to handle more and more stress became the calling card of my practice. My life was about looking at a situation and making a decision. Do I call a doctor about this, or do I have the means to fix it myself? Do I delegate this responsibility, or do I do it myself? Should I ask for help, or do I know enough?
My mentors—my preceptor, my manager, the various charge nurses, and the more experienced nurses—made me into a nurse. It wasn’t that huge book I lugged around for so many years. It takes a village to raise a nurse. Not a textbook.
These are skills that are not measured by GPA. These are skills that I have but don’t come as easily to me as multiple-choice questions. The point is that if you are a 2.5 student, don’t worry. Your ability to pass tests and get good grades has nothing to do with real world nursing. Trust me. I’ve been there. I am a good nurse. I worked hard to become one, but it didn’t have anything to do with what I did in school. It was about a fabulous preceptor, a supportive group of experienced nurses, and hard work on my part.
Not graduating at the top of your class? You may just be the best nurse yet. If you are someone who can manage your time well, you will make a good nurse. If you are someone who can stare down a stressful situation and make decisions, you will be a good nurse.
Most importantly, if you can and will ask questions when you don’t know the answers—and accept that you know very few of the answers—you will be well on your way to becoming a fantastic nurse. If you just eked by in nursing school, don’t let it bother you. Take it from someone who has been there: It doesn’t matter at all.
One of the most commonly heard phrases right from day one of nursing school is “critical thinking.” The common consensus is that everyone has to develop sound critical thinking in order to be a safe and effective, registered nurse (RN). This necessity is magnified when it comes to critical care areas where one decision by the RN can change the patient’s outcome. Nursing has changed from a simple caregiving job to a complex and highly responsible profession. Hence, the role of nurses has changed from being task-oriented to a team-based, patient-centered approach with an emphasis on positive outcomes. Strong critical thinking skills will have the greatest impact on patient outcomes.
So, what is critical thinking and how do we develop this? A precise definition was proposed in a statement by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987. “Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness,” reads the document.
Simply put, critical thinking in nursing is a purposeful, logical process which results in powerful patient outcomes. “Critical thinking involves interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes,” according to a 2010 study published in the Journal of Nursing Education. This definition essentially covers the nursing process and reiterates that critical thinking builds upon a solid foundation of sound clinical knowledge. Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet. Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.
How does one develop critical thinking skills? A good start is to develop an inquisitive mind, which leads to questioning, and a quest for knowledge and understanding of the complex nature of the human body and its functioning. A vital step in developing critical thinking for new nurses is to learn from those with a strong base of practical experience in the form of preceptors/colleagues. An open-minded nurse can learn valuable lessons from others’ critical thinking ability and will be able to practice for the good of their patients.
Critical thinking is self-guided and self-disciplined. Nursing interventions can be reasonably explained through evidence-based research studies and work experience. A strong sense of focus and discipline is also important for critical thinking to work. If thinking is unchecked, nurses can be easily misguided and deliver flawed patient care. A constant comparison of practice with best practices in the industry will help guide a nurse to think critically and improve care. This makes it easier to form habits which continue to have a positive impact on patients and colleagues. Every decision a critical thinking nurse makes affects not only the patient but also his or her families, coworkers, and self.
In summary, the take-home message for nurses is that critical thinking alone can’t ensure great patient care. A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside.
There have always been challenges facing nursing students. What are the biggest ones today, and how can students deal with and overcome them? Some experts weigh in.
Frederick Richardson, a BSN student and the Breakthrough to Nursing director for the National Student Nurses’ Association, had no doubt about how much of his time would be taken up when he began attending nursing school. Yet, he says, this seems to be one of the toughest aspects of attending nursing school that students struggle with.
“One of the biggest issues that nursing students face is time—making time for everything,” explains Richardson. “Nursing school is very demanding, and when you add in the coursework, reading for homework, and the clinical work, there usually isn’t time for anything else.”
Richardson says that he was fortunate enough to learn about this before choosing to attend nursing school. His older brother had attended nursing school, and Richardson saw firsthand how often he didn’t see his brother during that time. “He would be at the library studying, at class, or at clinicals,” recalls Richardson. “When I’d see him, it would be late at night. And he would be out of the door first thing in the morning. At the time, I recognized that when I would get to nursing school, I would probably have a similar schedule, and sure enough, it’s been exactly the same way.”
To overcome this, Richardson says that students need to have perspective and be realistic regarding what they can accomplish in their lives while attending such vigorous programs. “Our schedules can get really hectic. But I think that when you get into nursing school, you have to recognize that you’re going to devote the majority of your time to your nursing program. A lot of students don’t realize that,” he says.
Students need to set their priorities straight and decide how they are going to organize their time. Richardson, for example, says that he had to learn how to plan his time, organize his life and tasks on a calendar, and then follow that calendar every single day. From his perspective, quite a lot of students expect to attend nursing school and still have an active social life and do everything they did before, like watch all their favorite television shows.
“I think that the trouble students run into is they believe they can have everything—do well in nursing school, have an active social life, et cetera. If they go in with that kind of view, I don’t think they’re going to survive nursing school,” says Richardson. “They’re going to have to sacrifice a lot of that time, but once you get into it, it gets a bit easier.”
Martha A. Dawson, DNP, MSN, FACHE, assistant professor and coordinator of Nursing and Health Systems Administration at the University of Alabama at Birmingham School of Nursing, as well as the current historian for the National Black Nurses Association, agrees that having enough time can be an issue for nursing students. Traditional nursing students still face challenges that relate to study time, finances, and part-time work. In addition to the challenges of traditional students, however, second degree nursing students, such as those in a BSN to MSN bridge or other accelerated degree program, may also have immediate family obligations, explains Dawson. For instance, some may be primary caregivers for older parents. “Many students in these new and emerging programs are older, and these added life demands can lead to both high stress and exhaustion,” she adds.
Money, Money, Money
Richardson and Dawson agree that financial issues can also be a big challenge for nursing students. Dawson says that with the varying nursing programs and the older student population in them, these students may have greater financial obligations besides school, like a mortgage. “The current economic climate is making it more difficult for students to gain access to scholarships, trainee grants, and other forms of funding without going further into debt,” says Dawson.
In addition to taking out loans to attend nursing school, Richardson says that there are a number of scholarships available for students. Believe it or not, though, not a lot of students are applying for them. “There are a good number of scholarships available,” says Richardson. “After speaking with some people who have scholarships or who fund scholarships for students, I’ve discovered that they’re not getting a lot of applications. One reason is because of the time. A lot of students don’t know that the scholarships exist, and a lot who know they exist feel like they don’t have the time to fill out the applications because of the high demand of nursing school.”
The reality, Richardson says, is that studying takes up so much of the students’ days that many don’t think they could take the time to do what some scholarships may require in their applications—like get a letter of recommendation, write three essays, get transcripts, and the like.
Recently, Richardson had a heart-to-heart talk with a student who was frustrated because of going to school, clinicals, and a part-time job. “I said, ‘If you took about three hours applying for a scholarship, you would get more money to help you out with your school fees,’” says Richardson. He continued to explain to the student that he was working twice as hard and putting in twice as many hours at his part-time job to make the same amount of money that he could get if he applied for a scholarship—which would ultimately free up more of his time. “It would help the student more in the long run,” says Richardson.
Along with not getting enough financial support, some nursing students don’t have as much family support, says Rebecca Harris-Smith, EdD, MSN, BA, dean of Nursing and Allied Health at South Louisiana Community College. “Nursing classrooms across the nation are filled with an intergenerational, multicultural group of students that range from millennials to baby boomers,” explains Harris-Smith. “This nontraditional classroom of students has many that are parents who frequently do not have siblings, parents, or other relatives to assist them with child care. The expense of child care, transportation, and after-hours coverage often impacts the nursing student’s classroom, clinical, and study time.”
Richardson says that family support and encouragement is often needed, but not every student has it. “I noticed immediately that I needed a lot of support,” says Richardson.
“In my personal experience, soft skills as they relate to interpersonal people skills have become an issue for nursing students. The ability to communicate both verbally and in writing appears to be a challenge,” says Harris-Smith. She says that because Gen Xers and millennials have grown up with a lot of technology, they have spent a lot of their early years communicating that way.
“Basic socialization has changed in that the younger generations would prefer to text over having a verbal conversation. The lack of appropriate communication skills has an impact on the students’ ability to work collaboratively with physicians, fellow nurses, and other members of the health care team,” explains Harris-Smith.
“Effective communication is essential due to the intra- and interprofessional team collaboration essential in the health care arena,” Harris-Smith explains. “Additionally, nursing students must learn flexibility, professionalism, and a strong work ethic—which are essential to the development of the new nurse graduate. Being able to adapt to an ever-changing environment is important as health care facilities have staffing issues often requiring nurses to work beyond their shifts.”
Challenges for Minority Students
Although the challenges for nursing students are often the same for students of color and those who aren’t, “students from underrepresented groups in the nursing profession and in society . . . have them on a much larger scale,” says Dawson. “There are barriers and biases that these students experience such as academic skills, perceived perceptions about their abilities, lack of faculty role models, limited peer support, and major financial issues that ‘majority’ students do not have to deal with on a daily basis. Many minority students also struggle with the very basics of housing and food.”
An additional burden that minority students face, says Harris-Smith, is that of access and equity in education. “A selective admission process is used by schools of nursing across the nation, and this very process can serve as a barrier for students of color. Academic profiling of students ensures admission of the most academically prepared students that rank highest among their peers, but students from underrepresented populations are often the first-generation college students that struggle with the issues of being the first in the family to attend college. This situation places a heavy burden on the student because s/he may be dealing with the pressure of being the ‘savior’ for the family. These students are generally not savvy enough to apply for multiple college programs, have difficulty completing financial aid forms, and generally come to college with limited resources,” says Harris-Smith.
“Nursing programs tend to address diversity in their mission statements but fail to explain how this is accomplished. Merely placing the statement in the mission statement does not explain how the school of nursing addresses the issue. To ensure transparency, each school of nursing could better address this issue by providing information on the way in which this mission is accomplished,” says Harris-Smith. For example, she says, schools could use a statement that’s more explanatory: This school of nursing addresses diversity via academic profiling of students but is careful to admit a diverse student body that resembles the demographics of the community in which we live.
“There is a need for schools of nursing to restructure their admission process to address the lack of the underrepresented students in attendance at their colleges and universities,” Harris-Smith adds.
Richardson says that’s why he is a part of the Breakthrough to Nursing committee because its goal is to increase diversity in the nursing profession. Another challenge he’s seen is that some minority students don’t last in nursing school because they have different ways of learning. “Culturally, students from different backgrounds learn differently. I’m a kinesthetic learner. If you show me how to start an IV, I will know how to start an IV more efficiently than reading three chapters about how to start an IV,” Richardson explains. “A lot of nursing school is geared toward your textbook. But a lot of students are visual, auditory, and kinesthetic learners.”
He says that there are also students from various cultural backgrounds who don’t know how to study. “For students who come from the other side of the world to America to learn, their views are different from yours, and when you have a different perspective, you’re able to become more aware. You’re able to see a different view. It actually makes us stronger and allows us to become smarter to look at the way that other people do things,” suggests Richardson.
“With diversity, we need to recognize and communicate to understand what the other person’s thinking is and allow them to realize that though their culture is different, it’s not a bad thing,” says Richardson. “It’s just a different view and perspective for them.”