As a nursing student, asking for accommodations can help level the playing field by giving you a different environment or approach so you can adapt to any kind of physical or cognitive disability. As mentioned in a previous blog, extra time on tests, a quiet environment , or possibly even a note taker in class are all accommodations that can help nursing students perform their best.
Once you graduate and enter the workforce, how can you make sure you have accommodations you might need?
Many laws in the Americans with Disabilities Act prevent discrimination or retaliation based on accommodations, but the workplace isn’t always as adaptive to requested accommodations. If you know what you need, can request what has worked for you, and the accommodation will fit into the required job description, then your chances of successfully blending the two are much greater.
Keep in mind realistic expectations. If you can’t lift more than 30 pounds due to a previous injury, that will restrict you from doing some specific hands-on roles. But you might be able to with assistive devices. And if you have a hard time writing discharge information or charts in any kind of excessive noise, knowing that will help you prepare for what you need—possibly just a quiet space. If hearing loss makes listening difficult, amplified equipment can help. But not being able to lift heavy things, needing a quiet place to do administrative work, and progressive hearing loss never mean you can’t be an excellent nurse.
In fact, asking for an accommodation when you know it helps you do your job better keeps nursing standards high and ensures patient safety. Asking for an accommodation at work is often done through the human resources department where they can help guide you and determine what will best suit your needs and those of your unit or department. You might be asked to provide medical verification or some kind of official documentation of your disability.
From that point on, you are not obligated to share the reasons of your accommodation with anyone else at work. Accommodations are often a personal matter and many nurses fear a pushback or a stigma if others realize a change has been made for their benefit.
Is that fear realistic? Possibly. Revealing too much personal information in the workplace always has the potential to return to you in unexpected ways, so it is better if you keep the details to yourself. As long as your workplace helps you and assists you in working out a new approach or by offering different equipment, you can continue to do your job with the exacting precision expected of nurses.
Deciding when and how to talk about accommodations depends on how big of an impact it has on your work and then you should consider the impact it might have on your career. You don’t want to mislead a potential employer and you also don’t want to do substandard work because you are afraid to disclose your need for an accommodation in your current role. For example, if you have progressive hearing loss, but it is not impairing your job now, you might choose to wait a while to disclose. But if you are having trouble haring through a stethoscope, you cannot wait to bring that to the attention of your employer so you can get assistive equipment.
The decision is personal and weighing when and how to tell an employer is crucial to making sure you can do your job while also ensuring you are meeting the high standards expected in the nursing profession.
You might ask how a wannabe artist/photographer ended up working nights surrounded by medical equipment and really sick people. I blame it on my father. Of course, he’s not here to defend himself anymore, but take my word for it, there was no way that he was going to let any of his three daughters become starving artists.
So, now I’m a semi-starving nurse. When I started (not all that long ago…in dog years), my salary was $8.65 an hour. I do earn a bit more these days, but Bernie Madoff never solicited me for investment opportunities. What’s rather interesting is that we seem to pay more for interior decorators than we do for the people we depend on to save our lives.
I put aside artistic dreams for the reality of mastering the science and art of critical care nursing. There was this side of me that was fascinated by some of the “big” questions in medical care, such as: “What do you do when all the body’s organs start failing?” and “How do you help those people who are truly suffering without resorting to Jack Kevorkian measures?” Solving analytical problems humanely seemed far more rewarding than photographing magnificent images (although I still find tremendous pleasure stealing away and capturing the world through a viewfinder).
Oddly enough, my professional journey through medicine intersected with a personal medical condition—one that would remain undiagnosed and untreated for five years. Some doctors said that my facial tics (e.g., hemifacial spasms) and strange pains were due to stress or some hysterical “woman’s disease.” Yes, we’re talking this century.
Eventually, I picked the right door—it happened to be at Mount Sinai in New York City—and walked out with a few names and treatments for a disease that affected my head but was not “in my head.”
I started my nursing career with dysphonia, cervical dystonia, and even generalized dystonia. Early treatments might have been much more fun if they were given for cosmetic reasons, but the Botox, Myobloc, and eventually Deep Brain Stimulation (DBS) were prescribed to ease some of the less than glamorous symptoms.
Now, how much trust would you put in a nurse who twitched and twisted? Not much. So, at first, I worked in a soft cervical collar that allowed me to perform sensory tricks that convinced me that my body was aligned and not twitching and twisting.
Well, that didn’t last too long. I thought I was doing a terrific acting job, but as patients began asking me, “What’s wrong with you? Are you in pain? Should I call a doctor, a nurse?” I knew the gig was up. Since retirement at 30 was not exactly an option, I figured out a way to continue doing what I loved despite the pain and the drugs and the brain surgery. Has it been worth it? Yes. Am I an effective nurse? Ask my patients. Do I wish I could wake up and discover this has only been a long, bad dream? You bet. However, until a magic wand appears, you can find me at an intensive care unit doing what I love despite my physical limitations.
How do I manage? I’ve got the system semi-figured out. No one wants to work nights and weekends. I do. It’s not easier or quieter or better paying; it just makes me that much more
What’s it like to work from 7:00 at night to at least 7:30 in the morning? First, you should know that when you start at 7:00 p.m., you have to be at the hospital way before then. And, if you live in New York City (NYC) and happen to have dystonia, like I do, you should probably start out the day before. Find me a day without gridlock in NYC, and I’ll bet it’s either a national disaster or a holiday weekend.
Within the first half hour, we have the changing of the guard. The night team leader makes assignments and reports are exchanged. Let me take you with me as my shift begins.
A Typical Shift
7:30 pm: I have two patients, one who is on a ventilator and will probably be bleeding all night since a drug she has been taking for migraines, Methotrexate, has eliminated more than her headaches—it has eliminated the ability of her blood to clot. Oh, and her mouth is filled with packing material. My other patient weighs about 300 pounds, has pneumonia, and is in the second stage of lung cancer. How in the world am I going to turn her over? I should tell you that despite my height, I weigh slightly more than 100 pounds. I also have wires in my neck (no, you can’t see them) that connect a pacemaker to my brain. These wires are not industrial grade—they can snap. This would not be a good thing for me or my patient. I will deal with this issue later. I have work to do.
7:45 pm: I review the computerized order checklists to make sure what medications are due at 10:00 p.m.
7:50 pm: A family member asks for coffee. This is not a big deal except that walking with a steady, even gait is not my strong suit. With a rather interesting weave, I deliver hot coffee. No spills, no burns, no thanks.
8:30 pm: I stop in to see patient #1. The oral packing is bloody. The bed is bloody. It’s time to call the Ear, Nose, and Throat (ENT) residents. Her platelet count is only seven. Luckily, she is sedated, and her vital signs are holding steady.
8:50 pm: I see patient #2 and hear gurgling sounds. She is not gargling. You do not have to be a medical whiz to know that this is not a good noise. Should you have a medical background, you might recognize the sound as a signal that there’s water in the lungs. I call it a “wet” sound, and since this patient has also refrained from urinating for most of the day, I’m betting that she will be much, much happier if I suction her. I do. She is—and I even hear a faint, “Thank you.” I like this lady (but please, don’t fall on the floor).
9:00 pm: The ENT residents have ordered platelets for patient #1. Does that mean that I get them ASAP? No. That means I now have to call the blood bank and grovel. “I need them in a hurry.” Translation to their reply of “Yeah, yeah” (and in a Jamaican accent it sounds like “Ya-di-dah”): “You’ll get them when I get to you on my list of things-to-do, people-to-see, and dinner-toorder.” Am I happy? No. Is this stressful? Yes. Does this make my straight hair curl and my dystonia symptoms go away? Take a guess.
9:30 pm: I have got to work on my begging and pleading skills. They do not teach this in nursing school. The platelets have yet to be delivered, and no one has even called from the blood bank to say, “Come and get them,” or even more unlikely, “We’re on our way.” So, I call them again. Were they (a) delayed or (b) forgotten? My hunch is that the order was still sitting on the “to-do” pile.
10:00 pm: My 300-pound patient needs to be turned over for a skin assessment. This is not good. Before getting a chance to figure out this physics problem, I add two bags of antibiotics to her IV. As I’m doing this, it occurs to me that I’ve been on duty for a while, but I haven’t had a chance to enter anything about my patients into the computer. I’ll do it now. No, I won’t. Alarm bells go off. My other patient’s blood pressure is dropping. This is when all the years of training and experience pay off. I react automatically.
10:10 pm: I run into the drug room, and if you’ve ever seen someone with dystonia run, it is not going to rate an Olympic-scored 10 for style points. I grab a bag of premixed intravenous Levophed, a medication that’s administered to raise blood pressure—something I surely do not need. My heart is pumping away like I might actually have to break the sound barrier. I dash back to my patient’s room, hook it up, and remain by the bedside for the next half-hour.
10:45 pm: The bells are ringing, and they are all for me. Has anyone done a study on how many things a single person can do at the same time? I need to clone myself (and this time without dystonia, please). Okay, who gets priority: the bedpan seeker or the hungry patient? No contest.
11:00 pm: A knight in shining scrubs appears: Stu. He helps me turn my 300-pound patient. That’s the good news. Why is there always bad news? Suddenly, her oxygen level is doing that downward slide. Please, don’t make her need to be intubated or put on a ventilator. I call the resident on duty and ask for a C X-ray order. I hope she is not retaining fluid. I am retaining stress. This does not bode well for my next activity: writing status reports.
11:20 pm: I start off with a bang, but my hands have a mind of their own. I think “write.” They think “I’m cramping up, honey.” They win. Writing will come later.
11:42 pm: Half a miracle: C X-ray done. Patient’s blood pressure has stabilized. The blood bank remains a “no show,” and I really have to eat something and/or go to the bathroom. Can you get scrubs from NASA? Those spacesuits could work.
11:55 pm: I make an executive decision: I’m going to the blood bank for my patient’s platelets. If we needed them before, we really need them now. This isn’t an order for pizza.
12:10 am: Speaking of pizza, I’m still hungry, but if I don’t sit down for five minutes I may fall over. ICU nurse hits the floor. Patients and coworkers not impressed. Okay, now that I’m sitting, I look up at the clock and realize now would be a good time to start all the chart work. For most nurses, this would be slightly more relaxing than the dramas taking place at the bedside, but with dystonia it’s not quite so easy. In fact, it’s more than just a “pain in the neck,” it causes hand cramping and pain. So, I’ve learned to master the art of two-fingered typing. No speed records will be broken tonight.
12:15 am: The formerly illusive platelets are now finding a new home in patient #1’s bloodstream. However, patient #2 doesn’t look good and her breathing is labored. I think she needs more than suctioning, so an order goes out for a diuretic to get rid of some that water. This time we go for something a bit more formidable: 40 mgs of IV Lasix.
1:10 am: Some of my charting is completed, the platelets have infused, the Lasix seems to be working, but it’s time to turn both patients over. I still haven’t eaten. In the background, I hear a nurse arguing with the resident on-call about an emergency room admission. What’s new? There are not enough nurses on duty tonight. We are so short-staffed that I already know that coming off duty in the early morning is not going to be on my chart. Why? If you’re not in nursing, you might not know the mantra: “NOT documented, NOT done.” Remember my typing skills? This is an obstacle to nurses with dystonia.
1:30 am: I notice bloody urine coming from patient #1. With dystonia, you learn to make accommodations and work around the physical limitations. A secret: I usually rearrange the patient’s room so that everything is in my line of sight.Wondering if her liver is failing, I decide to draw her blood and send her lab work off early. She will need more platelets—she is not clotting well.
1:40 am: A patient is dying at the other end of the unit. He’s only 20 years old. The family is living by the bedside. No matter how many times I’ve seen this drama unfold, it never gets any easier.
2:10 am: Now that all the “labs” (as we call them) and diagnostic tests are completed, patient #2 raises my blood pressure to a nightly high. Her heart has gone into a lethal arrhythmia. Running into the room, I pound her on the chest, hoping beyond hope to get a normal rhythm to return. My neck is killing me. The precordial thump works. An EKG and complete labs are ordered. Uh oh, her oxygen level has dropped again. Does she need even more Lasix?
2:40 am: As I’ve now become to feel quite possessive of patient #1’s platelet activity, I feel like celebrating as her number goes up from seven to 24! Just for good measure, the ENT guys order more platelets and some liver function tests. Her blood pressure has been stable. I finish my computerized charting entries. However, due to the dystonia, my arms hurt from hanging bags of platelets on a barely unreachable ceiling pole. What do shorter nurses do?
3:00 am: The few of us on the unit tonight have been running, for what seems like forever. I do not want to come back as a hamster. Forget ordering take-out dinners, forget about even eating the healthy snacks that some of us have packed. In between ringing bells and critical care nursing, we gulp down chips, soft drinks, and the unhealthiest snacks imaginable. What if a dietitian happened to decide to spend the night here? We’d have to find her a bed.
3:10 am: The 20-year-old patient dies. I feel sad. His parents were at the bedside. Morgue care is ordered.
3:30 am: “My” platelets are ready. I ask the unit clerk to pick them up as well as stop by the pharmacy for some newly ordered antibiotics. This is not a medical mercy mission to a third world country, but you’d never know that. The pharmacist, right here in this very large, very busy, NYC hospital decides to let us know in no uncertain terms (read: venting) that the pharmacy doesn’t have the variety that was ordered. Am I in a new Twilight Zone? What kind of pharmacy is this?
4:00 am: Meanwhile, back on the floor, patient-turning is the next activity. What could be worse than trying to perform this task alone, especially when the bed and its surroundings are soaked with diarrhea? This is a job for the true angels of nursing: housekeeping. I clean the patient, giving her a back rub as well as a respiratory treatment. Before leaving the room, I do a platelet check.
4:30 am: Platelets are done. Will this shift ever end? Whatever could go wrong has already happened, I think. My feet hurt. Note to self and other would be nurses with dystonia: Clogs might as well be three-inch heels. My feet turn inwards, but my clogs do not. A new ER admission arrives on the unit. The few of us left standing all help the patient settle in. Do you think that any of us are contemplating Nurses’ Week every May? No. We just want to sit down and go home.
4:45 am: Some of the routine things that nurses do are no longer easy for me to accomplish without help. Night nurses are responsible for changing IV tubes for new ones. This used to be a nonevent, but now I can’t open the packaging without using scissors or a clamp or a helping hand. It’s frustrating.
5:10 am: A minor miracle: My paperwork is up-to-date, and there are only two more hours left to this awful night.
5:22 am: A colleague is having trouble inserting an IV. I offer to help. Even though I am unable to turn my head the “right way” anymore, I can do IVs by instinct. With dystonia, you learn to make accommodations and work around the physical limitations. A secret: I usually rearrange the patient’s room so that everything is in my line of sight. There’s another thing that I have to constantly be aware of since I had DBS: electromagnetic interference. All those security devices may be great, but they can cause havoc with my pacemaker, which goes to my brain rather than to my heart. This, among other things, is anxiety-producing, so my neurosurgeon has me taking a mild dose of Klonopin to reduce stress. Did I remember to take it this evening/morning? No. I will pay for it on the bumpy bus ride home.
5:47 am: An alcoholic in withdrawal wanders out of his room. His IVs are in disarray, he has a bloody gown, his EKG monitor is off, and he announces to all of us that he is ready to leave. Perhaps we should call the bellboy for his luggage and have the front desk prepare his bill. He resists our cajoling him back to bed and then hits one of the nurses. We call security and the docs. He isn’t listening to anyone.
6:00 am: Perfect timing. The head nurse is now walking down the hallway as the alcoholic is making his way to the nurse’s station. He is using four-letter words and making comments that will not be printed in The New York Times. Where is security? Are they in cahoots with the blood lab people? I really don’t want to be a punching bag, even if I’m beginning to feel like one. If my muscles get any tighter, I may explode.
6:10 am: Security arrives. Using less than spectacular intervention skills, they tackle the patient. Now what? We decide to ship him to the psych ward…stat!
6:24 am: Check patient #2 and discover more diarrhea. She is producing the type of diarrhea that is irritating to the skin and induced by antibiotics. To make matters worse, this 300-pound lady can’t breathe when she is in a prone position. Getting her out of bed would be impossible. I only weigh 115 lbs. Can it get better than this? Sure. There’s no protective cream available. I call my knight in scrubs, Stu, and we clean her up once again. Now I do the “uh-oh” check. Are my neck wires still intact? Yes. I can exhale.
6:45 am: Go back to the charts and enter final vital signs. Also need to compute things like intake and outtake of fluids. Have you ever had to estimate the amount of diarrhea produced? I must have missed this lecture in nursing school.
7:10 am: Patient #1 needs extra IV potassium. I grab a bag from the drug room and hang it on the IV pole. The day-shift staff begins arriving. I actually have a minute to swallow my dose of my medication, which helps relieve spasms related to dystonia.
7:26 am: Before giving a verbal report to the day shift, I review any last-minute orders to make sure nothing was missed. Nothing missed. It’s going to be a good day!
7:45 am: Shift over. Scalp pain erupts. Neck twisting and turning begins. I just want to sleep.
Intensive care nursing with dystonia is not for the faint of heart, but it is possible—and rewarding!
National Institute of Neurological Disorders and Stroke
Includes a detailed fact sheet on everything you need to know about dystonia
Dystonia Medical Research Foundation
Provides information on current research efforts, treatment and support options, and how to get involved
Dystonia Health Global Monitor
An open forum consolidating the latest news, research information, and education resources for a wide range of movement disorder issues
Deep Brain Stimulation
Explains how DBS therapy works and the risks involved
No one can say nursing is a stagnant profession. Even freshly minted grads can feel they are scrambling to keep up with new procedures, technologies, treatments, and processes. If you’re a nurse, you might start to wonder what skills you will need to succeed and stay current in the coming years.
There are a few qualities shared by all successful nurses. Being an excellent multitasker, having empathy, and being nearly obsessed with details never failed a nurse. No matter what your specialty, your location, or your aspirations, experts agree that a few skills in your wheelhouse will not only advance your career, but also help you satisfy your goals of being the best nurse for your patients.
“The first thing you have to have if you want to be the best nurse possible is you have to really want to do it,” says Leigh Goldstein, assistant professor of clinical nursing at the University of Texas at Austin School of Nursing. “You really have to want to be a nurse and not just bring people pills and plump pillows. To get there, you have to put in the hours and put in the study. There’s that little thing in you that tells you, ‘This is it,’” says Goldstein. “It makes learning all the other skills easier.”
LaDonna Northington, DNP, RN, BC, professor of nursing and the director of the traditional nursing program at the University of Mississippi Medical Center, agrees that nurses need a passion for the job. “This is not for the faint of heart,” she says.
Looking ahead, here are some of the essential skills nurses will need to meet job demands at any career juncture.
Develop Critical Thinking/Critical Reasoning
The best nurse thinks outside the box. Adapting to changing situations, unique patient presentations, unusual medication combinations, and a rotating team takes awareness. Assessing and evaluating the whole picture by using the critical thinking developed in school and on the job is essential to success.
“Nursing is not like working in a bank,” says Goldstein. “It’s not 9 to 5. It’s always a unique set of circumstances. You have to tailor and adjust the care you deliver based on the picture the patient is giving you.”
According to Northington, nothing in nursing is static. Nurses can’t usually just treat one patient issue—they have to determine how the patient’s diagnosis or disease has affected them across the lifespan, she says. And nurses have to consider not just the best choice for the patient and the best option for the nurse right now, but they also have to consider those things in light of the city they are in, the timing, and the resources they have at hand or that are available to them.
Make Friends with Technology
Nursing moves fast, but technological advances are sometimes even faster. While new nurses might lack years of direct patient experience, they often have essential technological familiarity. “Most nurses are probably aware that the world of electronics has just taken over,” says Barbara Vaughn, RN, BSN, BS, CCM, chief nursing officer of Baylor Medical Center in Carrollton, Texas. “The more senior nurses who didn’t grow up in the technology world tend to struggle more than nurses who grew up with that.”
With apps that allow nurses to determine medication dosages and interactions and websites that allow patients access to electronic health records, technology is an integral part of modern nursing. “Technology is changing how we practice and will change how nurses function in the future,” says Vaughn.The benefits are incredible. Instead of having to make the time-consuming drive into the ER when needed for an emergency, a specialist might now be able to save precious minutes by first examining a patient remotely with the help of monitors and even robotic devices. Nurses will have to adapt to this new way of doing things.
Nurses have to practice with technology to gain a fluent understanding, says Vaughn. Vaughn, who is studying for her PhD, says she didn’t grow up with online training as the norm, so when her new classes required online work, she wasn’t prepared. Realizing this could be a hindrance, Vaughn asked newer nurses about how to do things, and she practiced navigating the system until she became better at it.
Whether you are accessing patient records, navigating online requirements for a class, or learning a new medication scanning program, technology will improve your work day and help you take better care of your patients. In the meantime, Vaughn just recommends playing around with the computer when faced with something new. In her own department, Vaughn recalls some nurses who were especially stressed out about learning the new electronic health records system. With training and practice, they excelled. “They were later identified as superusers for their unit,” says Vaughn with a laugh.
Adapt to the Broader Picture
With all these developments comes new and greater responsibility.
“As an inpatient nurse, you used to worry about the 4 to 6 days when the patient was under your care,” says Vaughn. “Now if you are in a hospital based setting, you are going to be more involved in patient population health.” That means an inpatient nurse not only has to get the whole story of what happened before the patient arrived at the hospital, but also think about working with the care team to give specific instructions for when patients get home that will be practical.
“The more specialized medicine gets, the more fragmented health care becomes,” says Northington. Technology and that broad view can help reign that all in—and nurses need to know how the puzzle pieces fit together and where and how patients are receiving care.
“More patients will be followed in nontraditional health care settings,” says Vaughn. “Our world and the world we know is going to change,” says Vaughn of the health care industry. With more patients being followed by health care centers in easily accessed sites like Walmart and Walgreens, telemedicine is going to become more important to understand and to navigate.
Practice Effective Communication
Thirty years ago, communication about patient care was effective, but certainly not at today’s level, says Northington. “We have to communicate,” she says. “You have to ask, ‘What do you know that I don’t know that can help this patient?’ or ‘Are these therapies contradictory?’ Nurses are in that integral place to facilitate that interprofessional education and communication.”
Good communication isn’t always easy. Beth Boynton, RN, MS, author of Successful Nurse Communication, says the most effective communication is based in speaking up and in listening.
Especially in fast-paced and dynamic health care settings, the underlying interpersonal relationships can have a huge impact on how colleagues communicate and relate to each other. Nurses need to not only recognize the dynamics at play, but also learn how to work within the environment.
“We all think this is easy,” says Boynton, “but we have to recognize this is harder than meets the eye. Be patient with the learning curve.” Nurses might be assertive about speaking up for their patients’ needs, but not for their own, explains Boynton. So, as nurses look to the future, they should be mindful of not only fine-tuning their ability to speak up, but also listening to both patients and colleagues in return without judgment so everyone can work towards the best possible outcome.
“The nurse of the future has to stay committed to learning,” says Northington. “Take what the research is saying and use the best practices. Ask the questions like, ‘Why are we doing it that way?’ and ‘What can I do differently that will produce a better outcome?’”
To be the best nurse, you must stay current in the newest developments. Take the time to learn new procedures, but also recognize where your skills need updating. For example, if you know you’ll need to deal with chest tubes, don’t just assume you’ll know what to do when the time comes. Make an active effort to gain current experience.
Develop Mentoring Relationships
Every nurse needs a mentor. It doesn’t matter what your role is, how many years of experience you have, or even how many months you have been practicing. If you want to advance and learn the intangible skills needed to excel in nursing, you need to actively cultivate a mentoring relationship. Nurse mentors are often found at work, through networks, or within professional organizations.
Refine Your Personal Compass
A little bit of a thick skin will do wonders for any career nurse. “You have to defend your patient from everyone and take care of them,” says Goldstein. That means when a physician makes a call you disagree with or you overhear an unfriendly comment, you need to speak up when it matters and let it roll when it doesn’t.
And some of the personal work nurses have to do isn’t easy, including reflecting on and adjusting for any personal feelings or prejudices they have about patients in an open and honest manner. “We need to be able to take care of people no matter what their circumstances or color or what they did to get here,” says Goldstein. “You can’t treat patients differently. You need to take care of them and not make a judgment.”
Prepare for the Unexpected
You never know what your day will bring, so lots of personal reflection, discussions with others in your profession, and cultivating skills can help you when you are faced with something you’ve never had to deal with before.
“I think whether you are starting out as a new nurse or you are a seasoned nurse, nursing care is constantly changing, and being flexible to those changes is paramount,” says Princess Holt, BSN, RN, a nurse in the invasive cardiology department at Baylor Medical Center in Carrollton, Texas. It’s not easy, she says, to constantly adapt to new approaches and new practices, but nurses need to sharpen their focus. “When I get frustrated, I always go back to put myself in the mindset of my patient I am caring for or of my physician who is making this order or of the family I am taking care of to find new ways of looking at it. It grounds me and helps me understand.”
Developing all the coping skills to deal with job stress is a personal approach that nurses will cultivate as they go.
“New nurses don’t always take care of themselves and the emotional baggage you take with you,” says Goldstein. “You have to incorporate those experiences into a coping strategy that you have to develop on your own. Every nurse needs to figure out what they need to do to handle that.” And if you aren’t able to really learn how to cope, nurses must have the skills to either recognize that some kind of career shift is necessary (maybe even just moving from the ER to postpartum, suggests Goldstein) or to be open to hearing it when others recognize it.
Recognize Your Private Life Impacts Your Career
Nurses have to realize their career choice is 24/7. And while you have to balance your life and leave the hospital behind, you also have to somehow adapt to always being a nurse first. Family picnics can turn into a mini diagnosis session, neighbors might ask you to look at a child’s rash, and your private life can impact your job very directly in a way that won’t happen in other professions. “Nurses are held to a higher standard than the average citizen,” says Goldstein.
Learn Where to Learn
Yes, nurses in school learn the hands-on nursing skills like hand hygiene and infection control, says Goldstein, but, like any nursing skill, mastering them takes time.
Some hospitals have new nurse orientation programs that help new nurses acclimate to the setting, but if you don’t have that option, rely on your own observations, ask questions, and take classes to help get you up to speed. When you’re on the job, watch others to see how they incorporate things like patient safety into their routine interactions with patients. And Holt, who has worked in departments from ER to interventional radiology, says moving around builds skills. “I have seen it all,” she says, “and there is still more to see.”
Put It All Together
When nurses consider all the skills they need to succeed, some are easier to gain than others. “You need to understand what goes on behind all the mechanics,” says Northington. “It’s the knowledge behind the skills you need. They can teach nurses things. Nurses have the rest of their lives to learn things. We need nurses who know how to think, to problem solve, [and] who know when they are in over their heads to call for help. The most dangerous nurse is one who doesn’t ask a question.”
And nurses must keep moving forward and adapting even when the pace seems relentless. “We’ve come a long way,” says Northington. “And in 20 years, nursing won’t look like it looks now. Nursing is one of the best careers because it’s always evolving.”
As the United States becomes more of a melting pot, encouraging and nurturing a workplace that welcomes the different cultures, ethnicities, and lifestyles of staff are paramount to optimal collaboration, productivity, and success. In health care, where diversity increasingly is exemplified among patients as well as employees, such an embrace is critical to achieving best outcomes.
Health care institutions across the country are heeding the call for inclusion. Many have implemented initiatives to not only attract diverse staff, but also to keep and engage them.
The Mayo Clinic in Rochester, Minnesota, for instance, launched the Multicultural Nurses Mayo Employee Resource Group (MNMERG) in July 2014 to recruit and retain nurses from diverse cultures and offer them professional support and networking opportunities. The MNMERG also mentors and educates Mayo’s diverse nurses and involves them in community programs.
With some 25 members, the MNMERG welcomes all Mayo staff. It meets monthly at the hospital, but this year will add quarterly dinners off site and is evaluating online technologies such as Skype and Sharepoint to “engage a 24/7 workforce,” says MNMERG cochair Deborah A. Delgado, MS, RN-BC, a nursing education specialist in psychiatry.
Mayo Employee Resource Groups (MERGs) have been an important component of Mayo’s overall diversity initiative; the goal is to have the following five core MERGs—African American, LGBTI, Hispanic, Disability, and Veterans—at Mayo’s three major clinical sites. Each MERG has an executive sponsor who is a leader at Mayo, but not a member of the group. For example, the MNMERG’s sponsor is a male cardiologist with experience in developing family/patient advisory groups. All of Mayo’s MERGs have formally chartered to align with at least one of the organization’s strategic diversity goals.
“These range from culturally competent care to inclusion and addressing health disparities,” says Sharonne N. Hayes, MD, FACC, FAHA, director of diversity and inclusion and professor of medicine at the Women’s Heart Clinic at Mayo. She notes that the groups share innovations and hold cross activities. “By that collaboration,” she says, “you get more hands to do the work obviously, but you also get a wonderful side product of some cross-cultural mentoring and some cross-cultural experience.”
While the MNMERG is in its infancy, feedback has been positive. “By being visible, by engaging, and by contributing, it just leads to retainment,” Delgado offers. “People want to stay because they’re able to use all of their gifts and talents to affect the organization’s purpose and goals.”
The Clinical Leadership Collaborative for Diversity in Nursing (CLCDN) at Massachusetts General Hospital in Boston has realized recruitment and retention success with diverse students of nursing. A scholarship and mentoring program established in 2007 by Partners HealthCare (PHC), an integrated system of which Mass General is a member, the CLCDN draws applicants from the nursing program at University of Massachusetts Boston.
Students must demonstrate leadership qualities, have cumulative general and nursing GPAs of 3.0 or higher, and must be entering their junior year of study since the CLCDN will carry them through their senior year. They link with racially and ethnically diverse nurse mentors, attend unit meetings and social and educational events, and observe nurses and nursing leaders in action. Additionally, they receive a stipend and financial support for tuition and fees with the expectation they will pursue employment at a PHC institution after graduating.
“When you’re a minority and you’re going into an environment where you might be the only diverse person on your clinical unit, as an example, it can be really challenging; it can be very lonely,“ says Gaurdia E. Banister, PhD, RN, FAAN, the PHC CLCDN liaison to UMass Boston and executive director of the hospital’s Institute for Patient Care. “We wanted to put mechanisms in place to ensure the success of our students and, certainly once they graduated, the best possible [career] alternatives,” she says.
Mass General diverse nurse leaders who have successfully navigated such waters can “provide these wonderful, wonderful pearls of wisdom and support and encouragement and listening skills,” explains Banister, and they serve as mentors, as do CLCDN graduates. Of the 54 mentors to date (32 from Mass General), some are repeats. Other statistics are just as impressive—such as PHC’s 82.6% hiring rate among the 69 graduates thus far (47.8% of whom have been employed by Mass General) and the almost 80% retention rate for these graduates.
“They love being a nurse. It’s exactly what they anticipated their career to be,” says Banister. “They are constantly promoting how positive it has been for them and that they feel like our organizations are becoming much more of a welcoming and diverse place to work.”
At the Cleveland Clinic, location-specific Diversity Councils at each of the enterprise’s community hospitals and family health centers are effectively supporting and sustaining an inclusive work environment. These employee-led councils implement action plans and sponsor activities based on strategies and goals defined by an Executive Diversity Council, all aimed to enhance employee engagement and cultural competence.
While the Executive Diversity Council works “to set the tone and the agenda,” the location-specific councils “serve as the tactical team,” explains Diana Gueits, director of diversity and inclusion. The main-campus council, for one, formed the Nursing Cultural Competence Committee and the Disability Task Force; the task force, in turn, developed the Disability Etiquette Lunch ’n Learn, a program to assist caregivers in their interaction and communication with disabled individuals that has since been taken enterprise-wide. Gueits notes the councils share and cross-pollinate ideas.
Cleveland Clinic’s chief nursing officer sits on the Executive Diversity Council, and many nurses participate in the location-specific councils with several diverse nurses serving in leadership roles (the councils overall represent a cross-section of the clinic’s workforce). Two cochairs and a cochair-elect lead each council, act as local ambassadors for diversity, engage with executive leadership, and provide feedback to the Office of Diversity and Inclusion, which facilitates the business-like, SMART-goals approach of the councils.
“This is a passion for them,” says Gueits of the cochairs, who are selected based on their experience in leading transformative teams and their commitment to diversity and inclusion. “I think that what the councils provide them is an opportunity to see, to actually be part of an initiative and be part of that process from A to Z.”
Cleveland Clinic has 21 location-specific councils, a number that is sure to increase as the enterprise expands. “That is the intention,” Gueits says, “to make sure that we embed diversity and inclusion in our commitment to all our locations and give an opportunity or platform for all our caregivers to be engaged.”
Julie Jacobs is an award-winning writer with special interest and expertise in health care, wellness, and lifestyle. Visit her at www.wynnecommunications.com.
Where nurses work, as well as their education level and specialty, can all influence how much they earn in salary. But all in all, respondents to the third annual Minority Nurse salary survey report making more this year than they did last year.
With rising salaries, the outlook for nurses may be getting brighter, but there are still some differences in pay by ethnicity.
Last year, nurses reported earning a median $68,000, and this year they reported an increase that brought their median salary to $71,000—a $6,000 jump over what they’d said they earned five years ago.
While African American nurses reported earning more this year than last, a median $60,200 in 2014 as compared to this year’s $70,000, they still took home slightly less than the overall median. Hispanic and Asian nurses said they earned slightly more than the overall median salary, and more than they reported earning last year, while white nurses reported a salary close to the overall median salary and similar to what they reported taking home last year.
To collect this data, Minority Nurse and Springer Publishing e-mailed a link to an online survey that asked respondents about their jobs, educational background, ethnicity, and more.
Nearly 2,400 nurses from a variety of backgrounds and filling different job descriptions responded to the survey to provide a glimpse into their day-to-day roles, their plans for the future, and their current and past salaries.
The respondents work in various aspects of nursing from patient care to education and research, and have certifications in critical care, advanced practice nursing, and family health, among others. The nurses also work for a range of employers, from large organizations with more than 10,000 employees to ones with a hundred or fewer employees, and from public hospitals to colleges to home health care services.
Drilling down deeper into the data, wider gaps in pay start to emerge. For instance, white nurses working at private hospitals earn a median $80,000, while African American nurses earn a median $62,000. Similarly, at public hospitals white nurses earn $79,500, and African American nurses $71,000. However, nurses employed by college or universities reported largely similar salaries falling between $70,000 and $80,000, with African American and Asian nurses reporting receiving the higher end of that range.
Salaries also vary by region in the United States. Nurses take home the most in the Northeast, followed by the West, though there also appear to be slight variations by ethnicity as white and Hispanic nurses living in the western US earn a median $80,000, while African American nurses earn a median $73,000.
Education also affects take-home pay, and nurses reported higher salaries with increased education. Nurses with associate’s-level degrees reported earning $67,000, while nurses with bachelor’s-level degrees said they earned $70,000. And that increased further with advanced degrees as those with master’s degrees reported taking home a median $72,000 and those with doctoral degrees said they made $82,000.
There, too, were slight differences by ethnicity. For instance, African American nurses with associate’s-level degrees reported taking home a median $65,119, less than the overall median, while white nurses took home a median $68,320, slightly more than the median. At the bachelor’s and doctoral levels, though, African American and white nurses reported earning approximately the same salary.
Despite rising salaries—and recent raises—more than a third of nurses still said they are contemplating leaving their current jobs in the next few years. When they left previous jobs, respondents said it was mostly to pursue better opportunities, and this year’s respondents reported that the best-paying places to work are in private practice or at private or public hospitals.
Knowing your rights and options—and even more important, how to advocate for them—can help you break through the barriers on your path to career success.
Nurse practitioner George Copeland, MSN, NP-C, NRCME, is at the top of his profession. He’s been a nurse for 25 years, has earned advanced degrees and certifications, has his own family practice in southeast Florida, and teaches part-time at a community college.
Yet achieving a successful nursing career wasn’t always easy for Copeland, who was diagnosed with bipolar disorder in 1981. Like many new RN graduates, he started off working in the traditional hospital setting. But he quickly realized that he couldn’t handle the constant pressure of shift work.
“I tried, but I cannot work in that setting,” he explains. “I can’t take that particular kind of stress. Stress is the number one trigger for people with bipolar disorder. That’s why I went back to school to become a nurse practitioner so that I could work at my own pace and at what I wanted to do.”
“The Stigma Is Real”
It’s impossible to make generalizations about nurses and nursing students who are living with mental health disabilities, because the term encompasses such a broad range of conditions—including bipolar disorder, schizophrenia, depression, post-traumatic stress disorder, anxiety disorders, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, and more.
But this often-unrecognized population of minority nurses does have one thing in common. All too frequently, they face formidable barriers on the path to career success in nursing, from self-doubt and stigma to bias and outright discrimination in education, licensing, and employment. That’s in spite of the fact that the Americans with Disabilities Act (ADA) has been the law of the land since 1990 and will celebrate its 25th anniversary this year.
“Nurses with mental health challenges are struggling, and the stigma is real,” says Donna Maheady, EdD, ARNP, founder and president of ExceptionalNurse.com, an online resource network for nurses and students with disabilities. “Often they are very hesitant to ask for accommodations [under the ADA], or to come out in public as needing help, because of the fear of potential discrimination. They’re scared silent.”
Researcher Leslie Neal-Boylan, PhD, RN, CRRN, APRN, FNP-BC, dean of the University of Wisconsin Oshkosh College of Nursing and author of Nurses with Disabilities: Professional Issues and Job Retention, has documented ample evidence that disability-based discrimination is alive and well in the nursing profession.
“Many administrators don’t seem to understand that they’re really leaving themselves open to legal action,” she says. “The nurse develops a disability, or reveals it, and then the discrimination begins—the assumptions that these nurses can’t do the things they’re supposed to do, and that people will be uncomfortable around them.”
But even though a surprising number of nursing gatekeepers still seem to be clueless about their obligations under antidiscrimination laws, that doesn’t mean you have to be. If you’re a nurse or student with a mental health disability, your most effective success strategy is to actively be your own best advocate.
“It’s very important for nurses with any kind of disability to know their rights going in, rather than feeling vulnerable and being afraid to make waves,” says Karen McCulloh, BS, RN, co-founder and co-director of the National Organization of Nurses with Disabilities (NOND). “But not all of them do, and not all of them are good self-advocates.”
Do’s and Don’ts of Disclosure
Because chronic mental health conditions are “invisible disabilities,” your biggest self-advocacy decision is whether or not to disclose your disability to potential or current employers, says Robin Jones, MPA, COTA/L, ROH, project director and principal investigator for the University of Illinois at Chicago’s Great Lakes Disability and Business Technical Assistance Center and an instructor in the university’s Department on Disability and Human Development.
First, be aware of what the law says about your disclosure rights. According to the Boston University Center for Psychiatric Rehabilitation, a research and service organization dedicated to improving the lives of people with psychiatric disabilities, “Under the ADA, a person with a disability can choose to disclose at any time, and is not required to disclose at all unless s/he wants to request an accommodation or wants other protection under the law.”
The pros and cons of the decision to disclose must be weighed very carefully, because disclosure can be a double-edged sword. If you know that you’ll need the employer to provide accommodations that will help level the playing field for you, then you must disclose. But the unfortunate reality is that bringing your “hidden” disability out into the open may result in discrimination.
If you decide that the benefits outweigh the risks, then when, what, and how much should you disclose?
“The general consensus is to disclose as little as possible. Disclose only as much as you need to get the support you need,” Maheady advises. “If you’re talking with your co-workers, you don’t have to go into every detail of how long you’ve been in therapy and what meds you’re on. That kind of information should be shared only with the designated people in the organization whom you’d request accommodations from, such as the human resources or equal employment opportunity departments.”
It’s also important to know that you don’t necessarily have to make your disclosure immediately. “The whole issue of when to disclose is totally based on when you believe you need to ask for an accommodation,” says Jones. “You have no obligation to disclose until that time.”
Adds McCulloh, “Sometimes when you start a job, you don’t think you’re going to need an accommodation, but you may end up needing one after all. So if you need to disclose later, you can. I know that some employers are not pleased about that. But you do have the right to do that.”
Still, many experts recommend that it’s usually better to tell the employer up front. This not only establishes your legal rights from day one but also increases your chances for success by enabling you to receive accommodations right from the start. Furthermore, if you don’t disclose but later experience problems on the job as a result of your condition, such as a bad performance review, employers are less likely to be sympathetic—and the ADA may not protect you—if you suddenly pick that time to reveal that you have a psychiatric disability.
Early disclosure makes good sense for nursing students, too. “From my standpoint as an instructor, I would say the earlier the better, so that I can make accommodations for that student at my end,” says Patricia Giannelli, DNP, APRN, FNP-BC, PMHCNS-BC, ACNS-BC, assistant professor at Quinnipiac University School of Nursing in North Haven, Connecticut. “In our program, we always encourage students with disabilities to let us know as soon as possible, because we want them to succeed and to have all the tools they need.”
Know the Law(s)
Knowledge is power. That’s why another key self-advocacy strategy is to make sure you’re thoroughly knowledgeable about all the various disability rights laws that apply to you. You may find that you’re protected by more laws than you thought.
At the federal level, nurses who work at, or are applying for jobs at, private health care facilities with 15 or more employees are covered by Titles I and III of the ADA. If you’re a nursing student, or a nurse who works for a governmental or federally funded employer, such as a VA hospital, you’re covered under Title II of the ADA and Section 504 of the Rehabilitation Act of 1973.
Both laws protect people with disabilities from discrimination and entitle them to receive “reasonable accommodations” that will help ensure that they can perform the essential functions of the job or education program. For example, says Copeland, “When I was in nursing school, I had problems with not being able to concentrate. So I went to the Office of Students with Disabilities and asked for a quiet place to take exams, and extra time to take them. They gave that to me and they also gave me free counseling.”
Next, you need to be well-informed about what kinds of accommodation options you have the right to ask for. The federal Job Accommodation Network’s 2013 report, Accommodation and Compliance Series—Nurses with Disabilities, provides some examples of reasonable workplace adjustments a nurse with a mental health disability could request, including:
• Reduced distractions in the work environment, such as a quiet place to chart;
• Being able to take breaks or time off to see your therapist, talk to your therapist on the phone, or give yourself some downtime to relieve stress;
• More flexible scheduling, such as being able to work a shorter shift or one that’s less demanding and stressful;
• Modifications in the way you’re managed, such as having your supervisor provide to-do lists, written rather than verbal instructions (or vice versa), reminders about upcoming deadlines, and more frequent feedback about your performance.
In addition, the ADA Amendments Act of 2008 clarifies and expands the definition of “disability” in a way that’s especially beneficial for people living with chronic mental health conditions. The Amendments stipulate that “an impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active.”
In other words, Jones explains, “You don’t have to always be exhibiting the limitations of your mental health disability to be covered under the ADA. For example, a nurse may be doing fine without any accommodations but then suddenly starts having problems as a result of switching to a new medication. That’s an episodic situation in which the nurse would be entitled to receive a temporary, short-term accommodation.”
Federal protection for working nurses doesn’t end with the ADA. “Many nurses with disabilities don’t know that they can, for instance, take time off under the Family and Medical Leave Act if they need to leave work to go to a medical appointment [or if they need to be hospitalized],” Neal-Boylan says.
And don’t forget about state and local equal opportunity laws. “Many state laws provide greater protection for people with disabilities than the federal laws do,” Jones points out. “For example, if you live in California, you would be much better off pursuing an employment discrimination claim under your state’s civil rights laws than you would under the ADA. It’s just a stronger law.”
Should You File a Complaint?
Being fully aware of your rights as a nurse or student with a mental health disability also means understanding what action you can take if those rights are violated. In cases of obvious discrimination, such as being denied accommodations that would clearly not be an unreasonable burden for the employer or school, or being pushed out of your job or nursing program after disclosing your disability, knowing how to stand up for yourself becomes more important than ever.
Filing a discrimination complaint isn’t your only recourse—and it definitely shouldn’t be your first choice. “Try to see if you can get some resolution as close to the fire as possible,” says Maheady. “Is there a leader in the organization whom you can talk with to try to deal with the problem in a more effective way? Could you get a transfer to another unit? You need to explore every possibility for working it out internally.”
But if you’ve exhausted all of your internal resources without getting results, it’s crucial to do your homework about how the complaint process works.
Nursing students should start by reviewing their school’s grievance procedures. If going through the grievance process doesn’t end the discrimination, you can file a formal complaint against the school through the US Department of Education’s Office for Civil Rights (OCR). To find your nearest state or regional OCR, and learn more about how to pursue a complaint, visit www2.ed.gov/ocr. Students also have the option of suing the school directly rather than working with OCR.
Employment discrimination complaints are usually handled by the federal Equal Employment Opportunity Commission (EEOC). Unlike students, working nurses are required by law to file a complaint with the EEOC first before they can take their employer to court. EEOC complaints must be filed within 180 days of the date the discrimination occurred.
After the EEOC reviews your complaint, one of two things can happen. “The EEOC may decide that they will pursue your case against the employer,” says Jones. “Or they can issue a ‘Notice of Right-to-Sue’ letter, which gives you the right to go into the federal court system on your own and pursue the complaint with a private attorney.”
But before you decide to make such a drastic move, sit down and do some soul-searching about this question: Is it worth it?
“Be careful what you wish for,” Maheady cautions. “You have to ask yourself: Is this the hill you want to die on? If you lawyer up, do you think you’re going to be welcomed in that hospital? I’m not saying that suing your employer is never warranted. But I always advise nurses with disabilities to take that step very, very carefully.”
McCulloh agrees. “It’s not an easy process,” she emphasizes. “The right to sue still means that you need to have the financial resources to hire a lawyer, file a case, and take it to court. And it’s not a quick fix. Going through the legal process takes a very long time, which could put you in a situation where you’re not working, and not earning any income, for that entire period.”
Empower Yourself for Success
Ultimately, the most empowering pathway for nurses and students with mental health disabilities is to find positive alternatives that will let you create the best possible working or learning environment for your needs—one that will minimize your triggers and maximize your ability to succeed.
One way to do this is to connect with resource organizations that can provide advice and support—from university or employer disability services offices to peer advocacy groups, such as NOND and ExceptionalNurse.com, where you can network with other nurses who have similar disabilities to learn what’s worked for them. (See “Resources” sidebar.) These support systems can also help you identify employers who are more welcoming to nurses with disabilities because they recognize the value of having a diverse, inclusive, culturally competent nursing staff.
If you can’t change your current working conditions, or if you find that your job is just too stressful even with accommodations, consider following Copeland’s example of pursuing a specialty career niche that will be a better fit for you. For instance, one nurse from the ExceptionalNurse.com community (who asked to remain anonymous) comments: “I have bipolar affective disorder and I work as a clinical documentation improvement specialist. I couldn’t handle [bedside] nursing, but I found another area where I could be successful and use my clinical knowledge.”
Copeland offers this firsthand advice: “Don’t let yourself be defined by the fact that you have a mental health condition. If your goal is to be a nurse, or to be a nurse practitioner or a DNP, don’t let other people tell you that you can’t do that because of your disability. There are so many nurses out there who have multiple disabilities, and yet they’ve proved they can do it.”
Pam Chwedyk is a freelance health care writer based in Chicago. She is a former editor of Minority Nurse.