For Native American nurses, many of their stories have been lost to the past. Scholars have generally paid scant attention to the lives and deeds of rural minority women, and few articles have been written about the early education of Native American nurses and their contributions to health care. The people of the Catawba Indian Nation use storytelling to keep their culture and the memory of their heroes alive. Consider this one such story, one such hero.
The Sage Memorial Hospital School of Nursing, known simply as “Sage Memorial,” operated from 1930–1953. It was the only nursing school ever opened for the sole purpose of educating Native American women as nurses.1 One of these nurses was Viola Elizabeth Garcia, a graduate of the Class of 1943.2 Viola’s life illuminates the struggles for education common among the women who attended Sage Memorial. Her contributions and experiences as a World War II nurse demonstrate the hardships encountered and outstanding contributions made by many of her fellow alumna.
Ganado
By law and custom, most nursing schools were segregated by race before the passing of the Civil Rights laws of the 1960s. From the 1880s through the 1960s, most schools of nursing were comprised of either all white or all African American student bodies, leaving few opportunities for Native Americans, Asian Americans, or Hispanic Americans to obtain a nursing education.
The Board of National Missions of the Presbyterian Church was unique in its efforts to address this inequality. In 1901, the National Presbyterian Church opened the Ganado Mission on Navajo Nation land, in the northeast quadrant of Arizona, near the New Mexico, Colorado, and Utah borders, in the community of Ganado.
After a church and school were successfully operating at the Mission, the home missionaries turned their attention to health care.3 In 1929, Dr. Clarence Salsbury and his wife, Nurse Cora Salsbury, took over the mission work at Ganado. One of their first priorities was expanding the antiquated 12-bed hospital into a modern facility of 150 beds, an operating suite, a delivery suite, and a laboratory. This new hospital was named Sage Memorial Hospital after one of its largest benefactors and was accredited by the American College of Surgeons.
In order to staff the hospital with nurses, as well as to provide skilled employment opportunities for Native American women, the Salsburys opened Sage Memorial Hospital School of Nursing in 1930.4
The school opened while naysayers proclaimed no Native American woman would ever be up to the academic task of completing a Nightingale-based nursing education program. They also claimed these women, given their culture, would not be willing to interact with the sick or dying. Sage Memorial graduates proved these assumptions wrong.
Dr. Salsbury felt training Native American nurses was crucial. “They would be able to understand the patients as no white personnel ever could,” he said.1 Sage Memorial started small, with an entering class of two Navajo women: Adele Slivers and Ruth Henderson. They both graduated three years later and passed the Arizona State Board of Nursing Examinations. Their graduation exercises in 1933 were a festive event with scripture readings, vocal duets, a piano solo, and a pinning ceremony. Dignitaries including the Arizona governor, an Arizona State Board of Nursing member, and one of the chief Navajo medicine men praised the graduates and the school during the proceedings.3
As word and reputation of the school expanded among minority communities, the student body increased in number and diversity. By 1943, students from 28 tribes, including the Navajo, Kiowa, and Catawba; students who identified as Eskimo, Hawaiian, Spanish American, Cuban, and Mexican; and one Japanese student from a relocation camp were either enrolled or graduates of Sage Memorial.6 By all accounts, this unique experiment in multicultural education was a success.
In the 1930s and 1940s, such training and cultural exchange among Native Americans and other minority women was not found anywhere else in the United States. The nurses developed a camaraderie and commitment to their work that consistently earned them the highest marks on state licensing exams. The students lived in interracial cooperation while learning the nursing arts and sciences. The school’s stellar reputation drew the attention of white applicants—who were denied consideration because they had access to many other schools of nursing.1
Viola Elizabeth Garcia
Viola Elizabeth Garcia was born on April 12, 1919, in Sanford, Colorado, a poor, rural Mormon community home to approximately half the members of the Catawba Nation. Viola’s family was financially impoverished, but rich in family and culture. The older brothers, George and Labon, left school after completing the fourth and fifth grade to help their ailing father support the large family. Viola’s father was ill for much of her young life and died when Viola was only 11 years old, leaving behind 10 children for his wife to support.
Viola completed the ninth grade in Sanford, but due to the Great Depression, the public high school was closed. For the next three years, Viola tried desperately to complete her high school education by repeatedly applying for admission to the Bureau of Indian Affairs Haskell Boarding School in Lawrence, Kansas. Finally, she was admitted at 18 years old and completed her high school diploma in 1940 at the age of 21. Viola’s classes focused on cooking skills, sewing, home care, and arts. As graduation neared, she was offered full-time employment as a cook’s assistant on the Apache reservation in New Mexico, but Viola was determined to continue her education.2
With the guidance of the staff at Haskell Boarding School, Viola applied to several nursing programs but was only admitted to Sage Memorial. One such rejection stated that she was too old at 21 years of age to begin the nursing program. There was also a concern, as World War II loomed and U.S.-Japan relations became strained, that her Native American features would appear Japanese and frighten patients.6
The head mistress of Haskell wrote in a reference letter about Viola, “Whatever Viola decides to do, she does.” Several months after Viola enrolled at Sage Memorial, Dr. Salsbury personally wrote the Haskell headmistress asking if she had any other students like Viola, and if so, to please send them to his school.6
Studying at Sage Memorial
Applicants to Sage Memorial had to be unmarried high school graduates between 18–30 years of age. Their applications had to be accompanied by a health certificate, as well as four character references, with one being their pastor. Tuition was $100 for the first year with additional fees of $1 for laboratory courses, $0.50 for library use, and $3.50 for health fees. The hospital provided room, board, and laundry services. In addition to their course work, students tended the hospital floors eight hours a day, six days a week. However, students had time to relax outside of their rigorous classroom and clinical schedules, enjoying picnics, parties, movies, and glee club, as well as mandatory gym class and chapel.4
Although Viola was accepted to Sage Memorial, she was not sure that she could afford the tuition, fees, and living expenses. As the months progressed, Dr. Salsbury procured the funds to pay for all her education expenses except for personal items she needed to bring with her.6 According the 1940 catalog, all students had to supply for themselves the following: a bag for soiled clothing, rubbers or galoshes, toiletries, two fountain pens (one for red ink and one for blue), a watch with a second hand, an alarm clock, two standard-size loose-leaf notebooks, a napkin ring, and coat hangers.4 Viola’s eldest brother, George, gave her an entire month’s wages so she could buy the required watch with the second hand sweep. With her determination and supplies in tow, Viola began her three-year long education at Sage Memorial.6
Over the next three years, Viola and her fellow students not only studied the nursing curriculum but also spent many clinical hours on the hospital floors. They made and rolled their own patient bandages and folded disposable patient trash bags and slippers out of newspapers. Third-year students were expected to help teach the lower-level nursing students. Viola not only learned the nursing skills that she would use throughout her life, but she developed a deep devotion and admiration for the Navajo people. She even taught herself to speak Dine, the Navajo language.6
A nurse in practice
Though Viola grew up in the rural, remote, and poor town of Sanford, she was surprised to learn that her new community at Ganado was even more so. Patients were brought to the hospital on horseback and buckboard wagons, and sometimes by rattling old vehicles over rutted and narrow dirt roads. Many roads were so rough and rocky that they were impassable in wet and winter weather. The nursing students were expected to go on home visits with the nursing staff to the homes of the Navajo people, traditional dwellings known as hogans.7 They made these visits in buckboard wagons. Viola would write back to her mentor at Haskell Board School that these hogans were “loving and cozy homes.”6
Viola viewed success as the ability to provide for herself, and she felt her education was essential to achieving that level of self-reliance. Viola studied hard and was the 1943 class valedictorian. She was awarded a set of surgical instruments for her academic success.
In 1943 Viola took her Arizona nursing boards and returned home to Colorado to await the results. She had been worried because she did not have an additional $75 to retake the nursing board examination if she failed. One day a letter arrived addressed to Viola Garcia, R.N., and she knew she had passed. In fact, Viola received the highest test score in the entire state of Arizona. Viola’s academic and nursing success, however, was common among the students who graduated from Sage Memorial.
World War II
Not long after graduating from nursing school, Viola found herself working in Denver, Colorado, when President Roosevelt delivered an ominous speech. While the war efforts in Europe were drawing to a close, battles were still raging in the Pacific, and there might be a need to draft nurses into the military. Viola was told that if she volunteered for military service, she could select her location of duties. In January 1944, she enlisted in the United States Army Nurse Corps, requesting no surgical duties or overseas assignments. Within weeks of her enlistment, she was assigned to Camp Carson (now, Fort Carson, Colorado Springs, Colorado) in the surgical suite where she assisted with amputations from the war-wounded returning from the bitter winter campaign in Europe under General Patton. There were endless mounds of amputated ears, fingers, toes, hands, feet, arms, and legs that filled the air with putrid smells. Viola approached her supervisor and informed her of what she had requested: “No surgery and no overseas duties.” She was promptly informed, “Honey, you are in the Army now.”6
Step Back in Time The curriculum at Sage Memorial Hospital was based on the National League for Nursing Education criteria, accredited by the Arizona Board of Nursing Examiners. But what was nursing school in Viola Garcia’s day really like? Around 1940, courses required for graduation at Sage Memorial included: First-Year Courses: Basic sciences, professional adjustments, nursing arts of bandaging, massage and personal hygiene, nutrition, cookery, pharmacology and therapeutics, aseptic techniques, and nursing care of conditions involving respiratory, circulatory, gastro-intestinal, endocrine, and muscular-skeletal systems Second-Year Courses: Medical-surgical nursing; nursing conditions of the eye, ear, and reproductive tract; and communicable diseases such as tuberculosis, gonorrhea, syphilis, obstetrics, diet therapy, and social problems in nursing Third-Year Courses: Psychiatric, pediatric, emergency, and public health nursing, along with another course in professional adjustment
Within a few months, First Lt. Viola Garcia shipped out from Camp Carson to Los Angeles, where she, along with 600 other nurses, embarked on the largest U.S. Army Hospital Ship at the time, the USAHSMarigold, with an unknown destination. After two weeks, the ship arrived in Hawaii, and 300 of the 600 nurses disembarked, but Viola’s group remained on board. After leaving Hawaii, ship’s public address system announced their destination: Tokyo, still a heavy battle area as the war in the Pacific raged on. “My heart just dropped, I was so frightened,” Viola recalled. The U.S. military was fighting Japanese troops on many Pacific Islands and an invasion of the Japanese mainland was thought to be imminent. The costs in human life for both sides would be high.6
The ship was under the command of General Douglas McArthur, who over saw the military operations in the Pacific. The 300 nurses in Viola’s grouping were to be part of the U.S. invasion actions in Japan. Military leaders expected heavy casualties among those nurses during the invasion operations; the 300 nurses left behind in Hawaii would be their replacements.
Under international rules of combat, hospital ships were not to be attacked at sea, and thus were to be lit up at night and clearly marked with a red cross. Not long out at sea, the Japanese attacked one such marked ship, and the Marigold was immediately ordered to go into complete darkness. As the lights were put out, those in surgery raced to cover the windows of surgeries in progress. A frightening silence fell upon the crew as the Marigold steamed along in darkness on its way across the Pacific.
The Marigold stopped in the Philippines, and the nurses were allowed to disembark for a few days before the ship went to Japan. While docked there, however, the United States dropped the atomic bombs on Japan, and World War II was brought to a close. Yet, the Marigold continued on to Tokyo, but this time with a different mission. The USAHSMarigold was the first U.S. ship to enter Yokahoma Bay after the Japanese ended the war, and it was in Tokyo Bay where General McArthur accepted the formal surrender of the Japanese on the USS Missouri. That day the sea was filled with ships and the air was filled with flyover planes celebrating the end of the Second World War.
Rebuilding in Tokyo
Over the next eight months, Viola was stationed in Tokyo at the 42nd General Hospital. She treated survivors of the Bataan Death Camp and Corregidor Island (a military stronghold in the Philippines). The hospital had five surgical rooms that had been stripped of all equipment by the Japanese at the end of the war. They were filled with soot and rubble. Several Army nurses ranking higher than Viola were assigned the task of restoring these rooms to their full function. According to Viola, none of the higher-ranking nurses could deal with such an overwhelming task; each time, Viola was asked to “fill in.” After a third nurse was left in tears at the monumental task, Viola was asked to take on the responsibilities as acting head surgical nurse.6
Viola walked into surgical suites devoid of the equipment necessary for performing operations—no surgical tables, no IV stands, no surgical tools. She remembered entering the rooms: “I just wanted to cry too and said to myself, ‘Oh Lordy, what am I going to do?'” But Viola went on to do what she had always done—she rolled up her sleeves and got to work. Viola called in her military crew and ordered them to wash and scrub all the rooms from top to bottom. When that was done, she began looking for equipment for her surgical rooms, including salvaging items from the hospital ship.6 She even taught herself to speak Japanese, just as she learned to speak Dine as a nursing student.
First Lt. Garcia’s work in Tokyo was supported by her own ethic of care, as well as the training she received at Sage Memorial Hospital School of Nursing. From those days following the war until her death in 2004, Viola continued caring for others, marrying Herbert Schneider, another member of the U.S. Army, and raising three daughters. Her legacy, one of determination and pride, compassion and grace, lives on.
References
Salsbury, C.G., & Hughes, P. (1969) The Salsbury Story. Tucson: The University of Arizona Press. 152–153.
People of Catawba official website, “Life of Viola Schneider.” Cynthia Walsh. http://www.catawba-people.com/viola_schneider_eulogy.htm. (Accessed 2011).
Trennart, R. (2003). “Sage Memorial Hospital and the Nation’s First All-Indian School of Nursing.” The Journal of Arizona History, vol. 44, 353.
Prospectus of School of Nursing, (Ganado, Arizona: Sage Memorial Hospital, n.d), 1-11; Presbyterian Historical Society, Philadelphia, Pennsylvania: Ganado Mission Records.
“Excerpts from Statement re: School of Nursing, Sage Memorial Hospital, Ganado, Arizona sent in on January 3, 1939.” Document from Ganado Mission Records, Presbyterian Historical Society; Philadelphia, Pennsylvania.
Viola Garcia, personal comm. with author.
Salsbury, C.G. (1932). “Medical Work in Navajoland.” The American Journal of Nursing, 32(4), 415.
Most colleges and universities have strategic plans that articulate goals to strengthen faculty search procedures to increase the diversity of their staff. While such goals are important, they have come under attack in the past, even needing legal support. For example, Justice Sandra Day O’Conner in her Supreme Court majority opinion clearly communicated that the skills needed in today’s global market can only be developed by exposing students to “widely diverse people, cultures, ideas, and viewpoints.”1 The Association of American Universities has long communicated that diversity experiences not only enhance the education quality and outcomes of students from underrepresented populations, but of all students.2
The Sullivan Commission on Diversity in the Healthcare Workforce articulated that the health professions of the United States have not kept pace with changing demographics and may be more directly related to disparities in health access, status, and outcomes than the overall lack of health insurance. With minority populations projected to become the majority by 2050, health disparities may continue to worsen if health care professionals do not become more reflective of the populations they serve.3 The diversity challenge is even greater in the academic settings that educate undergraduate and graduate nurses. The American Association of Colleges of Nursing reported that less than 10% of faculty in baccalaureate and graduate nursing programs are from underrepresented groups, with 5.6% African Americans, 1.5% Hispanics, 1.9% Asian, and less than 1% American Indian/Alaskan Native documented.4
The lack of minority nurse educators communicates to students and communities of color that the profession does not value diversity. Lacking mentors and role models to support and enhance their education, students from underrepresented populations may not recognize the professional opportunities that exist for faculty in higher education, and the academic leadership that is needed from a diverse nursing workforce to eliminate health disparities in the 21st century.
The growing multicultural world that all student nurses enter requires exposure to a diverse faculty who bring varying research perspectives, pedagogy, and life experiences to the classroom, the laboratory, health systems, and the surrounding community. A critical need exists to create, implement, and evaluate blueprints for action that will attract, retain, support, and promote the leadership and success of faculty from underrepresented populations in schools of nursing. Action steps to be considered in blueprints should strive to:
Increase the applicant/pipeline pool of diverse faculty candidates from underrepresented populations
Promote a climate of diversity
Market for diversity
Prepare search committees to review diverse candidates
Retain diverse faculty
Increase the applicant pool
U.S. colleges and universities are educating a larger and more diverse group of students than ever before. According to the Educational Testing Service, student diversity will increasingly evolve over the next decade, with 80% of the anticipated 2.6 million new college students from underrepresented populations, including African Americans, Hispanics, Asian/Pacific Islanders, or American Indians. Undergraduate minority students enrolled in colleges and universities will increase from 29.4%–37.2%.5,6 Most recently, the report on the future of nursing acknowledged the need to respond to the under-representation of racial and ethnic minority groups, including men, in the nursing workforce.7
While a steady increase in the minority university student population has occurred, similar diversification among university faculty has not happened.8 Faculty diversification not only attracts diverse students, thus increasing the applicant pool and supporting academic program growth, but it also contributes directly to the quality of student education. Diverse faculty expose students to a wider range of scholarly perspectives and ideas that build on a variety of life experiences, create intellectual stimulation with new research questions, and foster fresh perspectives in the academic enterprise. Diversification is also the right action, not only from a social justice perspective, but based on business.9 The corporate world has long accepted a mandate that they must expand markets to serve diverse communities to survive in a competitive environment.
Action steps
A number of changes are needed to increase the applicant pool, such as developing partnerships with minority-serving institutions and establishing alumni directories of doctorally prepared minority graduates for consideration in post-doctoral or visiting scholar appointments. This action will promote scholarship and research of mutual interest to the scholar, the school, and the community.
Metrics should include memorandums of understanding with individual colleges or universities with results measured by the number of candidates identified from partnering institutions for recommendation to search committees. To assure the success of these partnerships with minority-serving institutions, ambassador programs could be developed by assigning faculty members to communicate and represent their respective schools of nursing at designated partner institutions.
Faculty who teach at these institutions could be invited to do a presentation and talk about promising students for post-doctoral consideration through a faculty exchange initiative. Schools of nursing must set aside resources to support minority scholars in residence as well. Finally, an academic faculty network should be considered so introductions can be made through the network to administrators from underrepresented populations at member institutions.
Promote a climate of diversity
While organizational climate has a range of definitions, Baird suggests common descriptors include friendliness, hostility, or acceptance.10 Organizational climate includes the current attitudes, behaviors, and standards/practices that concern the access to, inclusion of, and level of respect for individual and group needs, abilities, and potential. This definition includes all groups, not just those who have been traditionally excluded or underserved by colleges and universities.5
If a school of nursing is to succeed in terms of the retention and recruitment of faculty of color, it must embrace diversity. Turner and Myers report that faculty of color leave for many reasons, including hostile environments—a major factor discouraging potential applicants.6 In contrast, a school of nursing that provides an environment that supports the success of diverse faculty is attractive and facilitates recruitment and retention. Research has shown that endorsement from leaders provides credibility for such programs.11 It’s important that administrative support is reflected by publicly rewarding departments, divisions, and units who demonstrate measurable improvement. Support from the top and rewards for increasing diversity have been shown to be the two key factors that determine the success of diversity programs.12
Action Steps
Fostering assessment and accountability must begin with a faculty diversity climate survey and should include an exit survey for those that leave. Faculty surveys should include both quantitative and qualitative data that measures the diversity climate within the school of nursing. Results should be reported through school departments and discussed in faculty meetings with recommendations to the faculty at large, as well as search committees, specifically.
Activities that promote a supportive climate should be identified through departments and the faculty panel discussion. The PBS film Shattering the Silences: Minority Professors Break Into the Ivory Tower could be shown at department meetings, followed by faculty discussions led by a diversity expert. A panel discussion focused on faculty diversity should be a yearly faculty event. It is also recommended that faculty who have led and created activities that support a climate of diversity receive merit recognition from those administrators held accountable for achieving faculty diversity in their departments.
Resources should be established to conduct climate surveys and maintain an office of diversity to assure that planning, implementation, and evaluation occur. Ideally, a faculty leader who is also a member of the dean’s leadership team would coordinate these activities. This nurse faculty leader should provide a vision and structure for faculty initiatives that will not only support the inclusive climate needed for recruitment, retention, and promotion of diverse underrepresented faculty but that will involve the entire school in a program that sets achievable and measurable goals with a business plan.
As research is needed to investigate diversity, equity, and climate beyond race and ethnicity to include differentials in power and privilege, external research support through federal, foundational, and private grant mechanism should be explored. The diversity office should address the need to continue to support and develop academic programs that focus on issues of diversity, underserved populations, and societal disparities, which will attract diverse faculty and scholars. Pilot research on faculty climate could also be supported through these mechanisms; then a larger study could be launched with funds sought through the National Institute of General Medical Science, an NIH program.
Marketing for diversity
Communicating a school’s commitment to diversity, whether through conferences, national meetings, publications, posters, brochures, and/or official websites, ensures the transparency of the school’s diversity recruitment goals. Business research shows diversity marketing reduces turnover costs and inspires a desire to be part of a dynamic and responsive team. It also helps institutions win the competition for talent by attracting, retaining, and promoting faculty and leadership from underrepresented populations. Organizations cited as the best places for employment by diverse underrepresented groups also experience an increase in applications.13 Furthermore, research has shown endorsement from the organization’s leadership brings credibility to diversity programs and influences attitude change.11
Sullivan (2007) underlined the critical role academic leaders play in successful diversity programs. These leaders must create a culture within their academic units that supports the implementation of a strategic plan—one that establishes goals, defines success, and fosters accountability, best practices, and financial resources.14
Action steps
Schools of nursing can maintain a diversity website that links to the school’s departmental sites. This site must communicate that diversity in the organization is critical to the recruitment of faculty from underrepresented groups. It should also showcase the successes of faculty from underrepresented populations in research, teaching a diverse student body, collaborating with university faculty and diverse communities, and scholarly achievements.
An interactive school of nursing Facebook page reflecting the diversity of the school’s leadership team, faculty, and students is also needed for effective marketing. It should be updated on a regular basis and evaluated by the number of hits and links made by browsers. A member of the school’s leadership team should be designated to work with appropriate media resources to maintain and update an interactive website that showcases the school’s successful recruitment, retention, and promotion of diversity.
Strengthen the search committee’s success
Nationally, hundreds of campuses are engaged in competitive efforts to diversify their faculties in response to external and internal pressures. Yet, according to Caroline Sotello Viernes Turner, in her book Diversifying the Faculty: A Guidebook for Search Committees, five prevalent myths have hindered the hiring process of ethnically, racially, and gender underrepresented diverse faculty.15
Good minority faculty only go to the best universities.
To hire minorities, standards must be lowered.
Minorities prefer the private sector.
Espousing equal opportunity doctrine is sufficient.
Minorities will not go to predominantly white institutions.
Research published in the Journal of Higher Education in 2004 showed that among institutions with predominantly white populations, the hiring of faculty from underrepresented groups occurs when at least one of the following three conditions are met. First, the job description explicitly engages diversity at the department level. Second, an institutional “special hire” strategy is used, such as waiver of a search, target of opportunity hire, or spousal hire. Third, the search is conducted by an ethnically/racially diverse search committee.16 Search committees often approach their charge in a passive, routine way (i.e., advertise the position in publications, evaluate résumés, invite three to five candidates for campus interviews, and then make an offer).
To address the need to recruit faculty from underrepresented racial/ethnic or gender diverse populations in a school of nursing, the search committee must take a more proactive approach to finding candidates from such populations. All steps taken during the search process can contribute to a solid foundation for the successful retention of diverse faculty hired as well as ongoing successful recruitment into the future.
Viernes Turner writes that schools of nursing should focus on eight action steps to form successful hiring committees:15
Diversify the search committee itself.
Educate the search committee on personnel issues and prepare the members through an annual retreat.
Debunk the myths listed above.
Create tailored position descriptions.
Attract diverse candidate pools.
Examine hiring biases.
Host campus visits
Make the offer.
The campus visit is also a critical moment of opportunity that allows the candidate to make a well-informed decision on whether the position and the school of nursing is a right fit. Evaluation forms should be provided to all campus parties involved in the visit and discussed by the committee. Asking the candidate to comment on the process will also provide the school’s search committee with information to improve the process for subsequent campus visits. It is important to not only evaluate the candidate, but also the search committee process, in order to improve the chances of reaching the desired outcome.
Action Steps
First, assuring that the composition of the search committee has different points of view is critical to its success. Members who represent diverse populations must be appointed.
Next, preparing the committee through a yearly retreat that addresses unconscious hiring bias and debunking of myths must be used in conjunction with current university guidelines to prepare new members and refresh returning members for the year’s goals. An annual search committee evaluation plan should be implemented to review the effectiveness of the diversity recruitment process. Metrics should include a percentage increase of the diversity applications and a percentage increase in hires.
Departments then need to conduct their own hiring patterns audit, examining the tenure track and associated clinical and research faculty patterns. At the annual evaluation discussion of department recruitment needs, a diversity recruitment plan must be developed and sent to the search committee prior at the beginning of the academic year.
Finally, a departmental diversity awards program will need to be established to acknowledge excellence in diversity recruitment and support of a climate of diversity that recruits and retains racially/ethnically and gender diverse faculty.
Retain a diverse faculty
The most successful universities have both a strong commitment and action plans that support faculty diversity.17 An important and overlooked strategy to retain professors from underrepresented populations is to create a critical mass to prevent feelings of isolation and alienation that result in leaving.15
Action steps
Mentorship programs should be established that help guide diverse faculty through promotions and tenure tracks. These programs should be advertised on school of nursing websites and shared with potential candidates. Diverse faculty should also be mentored in their achievement of awards that recognize excellence in research and teaching. Finally, ongoing mentorship will be needed to develop the leadership potential of diverse faculty, with recognition given for such leadership.
Resources must be designated to support family policies as needed by candidates; these should be marketed through the search committee process and the website. Funds will be needed for startup packages that will support pilot work and presentations of scientific findings at national or international meetings. Support may be needed for the development of untenured new faculty hires as well. Finally, exit interviews should be considered for tenured and untenured diverse faculty at departure to explore reasons for leaving the university.
Using a blueprint to transform an institution to reflect a pluralistic society requires the collective evaluation of attitudes, the behaviors they generate, and the unconscious bias that shape faculty actions.18 Critical to this process is a vigilant and widespread diversity campaign that promotes individual ownership of the blueprint for change and is advocated and supported by both the faculty and school leadership.
A need exists for schools of nursing to showcase a vision and strategy for recruitment, retention, and promotion of a faculty that reflects the diversity of the United States and the world whose health they plan to promote. And as Benjamin Franklin once said, “By failing to prepare, you are preparing to fail.”
References
Barbara Grutter v. Lee Bollinger, et al. 124 U.S. 35 (2003).
Association of American Universities (1997, April 24). “On the Importance of Diversity in University Admissions.” The New York Times, p. 27.
Sullivan, Louis W. (2004). Missing Persons: Minorities in the Health Professions, A Report of the Sullivan Commission on Diversity in the Health Care Workforce. Sullivan Commission, p. 66
Berlin, L., E., Stennett, J., and Bednash, G.D. (2004). 2003–2004 Salaries of Instructional and Administrative Nursing Faculty in Baccalaureate and Graduate Programs in Nursing. American Association of Colleges of Nursing.
Rankin, S. & Reason, R. (2008). “Transformational Tapestry Model: A comprehensive approach to transforming campus climate,” Journal of Diversity in Higher Education, 1:4, 262–274.
Turner, C., S.V. & Myers, S.L. (2000). Faculty of Color in Academe: Bittersweet Success.
Institute of Medicine (2010). The Future of Nursing: Leading Change, Advancing Health.
Sullivan, C.W., & Bristow, L.R. (2007). “Summary Proceedings of the National Leadership Symposium on Increasing Diversity in the Health Professions.” Sullivan Alliance, 1–12.
Correll, S. J. & Benard, S. (2006). “Biased Estimators? Comparing Status and Statistical Theories of Gender Discrimination.” Social Psychology of the Workplace (Advances in Group Processes, Shane R. Thye and Edward J. Lawler eds.) Vol. 23, 89–116.
Baird, L. L. (2005) College Environments and Climates: Assessments and Their Theoretical Assumptions. In J.C. Smart (ed.), Higher Education: Handbook of Theory and Research, Vol. 20, 507–538.
Fiske, S. & Taylor, S.E. (1999). Social Cognition, 2nd edition.
Rynes, S. & Rosen, B. (1995). “A Field Survey of Factors Affecting Adopting and Perceived Success of Diversity Training.” Personnel Psychology, Vol. 48, 247–270.
Robinson, G., & Dechant, K. (2007). “Building a Business Case for Diversity.” Academy of ManagementPerspectives, 11:3, 21–31.
Siantz, de Leon, M.L (May – June 2008). “Leading Change in Diversity and Cultural Competence.” Journal of Professional Nursing, 24:3, 167–171.
Viernes Turner, C.S. (2002). Diversifying the Faculty: A Guidebook for Search Committees, Association of American Colleges and Universities.
Smith , D.G., Turner, C.S., Osei-Kofi, N., Richards, S. (2004). “Interrupting the Usual: Successful Strategies for Hiring Diverse Faculty.“ The Journal of Higher Education, 75:2, 133–160.
Piercy, F.; Giddings, V.; Allen, K.; Dixon, B.; Meszaros, P.; & Joest, K. (2005). “Improving Campus Climate to Support Faculty Diversity and Retention: A Pilot Program for New Faculty.” Innovative Higher Education, 30:1, 53–66.
Handelsman, et al. (2005). “More Women in Science.” Science, 309:5738, 1190–1191.
As just about everyone knows by now, Hispanics are not only the largest ethnic minority group in the U.S., they are also the fastest-growing. Yet study after study–from the Institute of Medicine’s 2003 Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care to the Agency for Healthcare Research and Quality (AHRQ)’s annual National Healthcare Disparities Reports–has shown that Hispanics’ access to health care, as well as the quality of care they receive, is severely lacking in comparison with that of the Caucasian majority population.
Gloria Ceballos, MS, RN, CNAA, BC
Other studies, such as the Sullivan Commission on Diversity in the Healthcare Workforce’s 2004 Missing Persons: Minorities in the Health Professions, have strongly suggested that increasing the number of Hispanic nurses in the health care system can help make a profound difference in improving health outcomes for Hispanic patients and communities. In fact, culturally competent, bilingual Hispanic nurses are uniquely qualified to be more than just participants in the effort to close the gap of Hispanic health disparities–they are the ideal choice to lead these efforts.
But in order to have leadership, you must have leaders. The problem is that Hispanic nurses account for only about 2% of the nation’s RN population, which makes for a shallow pool of potential nurse leadership talent. And many Hispanic nurses who want to be leaders may lack the confidence and skills to do so and have few role models to emulate.
Creating new Hispanic nurse leaders is the goal behind the Institute for Hispanic Nursing Leadership, a leadership development workshop that is a collaborative effort between the National Association of Hispanic Nurses (NAHN) and the American Organization of Nurse Executives (AONE). Now in its second year, the workshop is offered free to NAHN members as a special half-day session at the association’s annual conference. The first Institute, held last summer at the 2006 NAHN conference in Phoenix, attracted 40 to 50 attendees, says Gloria Ceballos, MS, RN, CNAA, BC, a former chief nursing officer at Kettering Medical Center in Kettering, Ohio who is now pursuing her doctorate.
Ceballos teamed up with NAHN’s 2004-2006 national president, Rudy Valenzuela, FSP, MSN, RN, FNP-C, to create the Institute after several NAHN members requested information about how to develop their leadership skills.
“Most of NAHN’s members are working at the staff nurse level,” Ceballos explains. “So what we wanted to show them was how they can progress on the nursing leadership ladder. [America] not only needs great Hispanic nurse clinicians, we also need leaders to develop the structure by which nurses can understand the diversity in their patient populations and have a closer relationship with those communities to promote the prevention of disease or to help the patients through their illnesses.”
Ceballos was also a member of AONE’s Diversity Council. “[NAHN] had never done a leadership development program and several members were asking , I saw the opportunity to [capitalize on the expertise of] both organizations and bring them together to see what we could do.”
The response to last year’s Institute was so positive that the second installment will be held this July 17 at NAHN’s 32nd Annual Conference in City of Industry, California. Its theme will be “Leaders and Leadership: Are You the Leaders You Want to Become?” and it will focus on topics such as knowing your leadership style, preparing to become a leader and influencing change. Nursing leaders scheduled to speak at the session include NAHN past presidents Antonia Villarruel, PhD, RN, FAAN, and Carmen Portillo, PhD, RN, FAAN, along with Fortuna “Tuni” Borrego, MSN, RN, president of NAHN’s Broward County (Florida) chapter, and Angelica Millan, MSN, RN, NP, president of the Los Angeles chapter.
“Think About Your Leadership Potential”
By popular demand, the 2007 Institute will feature an expanded format. Feedback from last year’s attendees indicated that they wanted more time, more speakers and, especially, more Hispanic speakers, says Valenzuela, who is now president of Camillus College, a nursing school in Paramount, California.
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“I think most of the nurses who [attended the Institute] were there because they wanted to be there and they wanted to make an impact,” he adds. “I encourage nurses to think about their leadership potential and to grab a hold of it and go with their heart so they can improve their lives, they can improve their careers and, most importantly, so they can improve the health of their communities.”
One of the speakers at last year’s Institute was Maria Warda, PhD, RN, who until June 2007 was dean and professor at Georgia Southwestern State University. She is now director of the nursing program at the University of Tampa in Florida. The 2006 workshop, she says, covered topics such as strategies for success, dealing with discrimination, staying focused and planning educational and career mobility.
Many of the participants were young Hispanic nurses who had either recently started graduate school or were considering it. For the most part, they were searching for role models who could serve as inspiration, Warda says.
“There are a lot of barriers for minorities in America, and certainly for minorities in nursing,” she notes, “because there are so very few of us. There are so few role models in either the service arena or, especially, in the academic arena who can understand the unique strengths and the unique barriers.”
The need for Hispanic nurse leaders is enormous, Warda continues. “We need to recruit more Hispanics into the nursing profession, and beyond that we need to help them continue their educational journey, so we can have future leaders who are also Hispanic. Those few that I know who are deans of nursing or in leadership positions are aging. We are close to retiring and we don’t have the new generation coming in to take our places and to mentor others.”
Leaders Get Involved
Valenzuela believes nurses who wish to become leaders must first get involved–both in their workplaces and in their communities. “Nurses need to come out of their shell and become involved in issues that interest them,” he says. “Attend meetings, speak to doctors, administrators and other nurses about how the quality [of care] can be improved.” He also advises nurses to become advocates and speak up about issues that are important to them, such as making more culturally sensitive care available to Hispanic patients. “We’re never going to make any progress toward improving the health of the community if we don’t speak up for it,” Valenzuela maintains. “[Hispanic nurses] need to be vocal about what is important to them and to their patients.”
Rudy Valenzuela, FSP, MSN, RN, FNP-C
Tuni Borrego, who is director of nursing for a med/surg and telemetry unit at Memorial Hospital West in Pembroke Pines, Fla., says getting involved helps nurses see an organization’s big picture rather than just their own area of interest. And that’s an important perspective for future leaders to gain.
“Learn how decisions are made, how changes come about and why they come about,” she recommends. “You need to know the ‘whys’ of things before you can understand the ‘hows.’”
Borrego took her first step into leadership by becoming a charge nurse just a few years after beginning her nursing career. “A lot of the other nurses were afraid to do charge or didn’t want the extra responsibility,” she says.
Warda advises Hispanic nurses interested in becoming leaders to first prepare themselves educationally. “No one is going to promote you just because you are Hispanic or intelligent,” she argues. “You have to have a strong education. Pursue graduate education, go as far as you can.”
She also stresses the importance of developing a strong support network of people who are accomplished leaders in the areas you want to pursue. In other words, mentors–and they don’t necessarily have to be Hispanic. Look for a mentor who is committed to diversity and wants to help. “There’s not enough of us [Hispanic nurse leaders] to go around,” Warda points out.
Getting involved also means joining professional organizations, taking advantage of opportunities and being willing to take risks, such as moving to another city or state to pursue career advancement, even if it means being farther away from family and friends.
From a clinical standpoint, Borrego advises new nursing graduates to avoid working in a specialized area right out of school. Many new nurses go straight into specialties like home health, emergency nursing or labor and delivery, where their patient population and/or the conditions they treat are limited.
“If you get your foundation in med/surg first, you can pretty much work your way up and do anything,” she says. “Take at least six months to a year to get your feet on the ground. Get to know the med/surg population and from there you can go anywhere.”
Moving Into Leadership
Another topic that will be covered at this year’s Institute for Hispanic Nursing Leadership is understanding the roles and responsibilities within an organization. Borrego says it’s important to understand this so you know what’s expected of you when you’re given a task. That, in turn, helps you become a better leader. “You can’t really do things if you don’t know what’s expected of someone in that role,” she explains.
Fortuna “Tuni” Borrego, MSN, RN
Warda, whose various career roles over the years have included being a military nurse, clinical nurse specialist and hospital administration executive, used the GI Bill to obtain a master’s in nursing in the late 1970s. Because there were so few nurses with master’s degrees in those days, “that gave me the opportunity to move into a leadership position in nursing.”
She later became interested in pursuing a PhD when her immediate supervisor at the hospital at which she worked enrolled in a doctoral program. This provided a role model for Warda to emulate. “I had never thought of doing that before,” she says. “Because I knew somebody else who was doing it, I decided to apply and I was accepted into the doctoral program at the University of California, San Francisco.”
By her second or third year in the program, Warda knew she wanted to go into academia, so she took a teaching job at San Francisco State University to develop her skills as an educator. Because she had extensive leadership experience, including several years in hospital administration, it was a natural transition when she was offered a job as assistant dean at the University of California, San Francisco.
After three years in that position, Warda was presented with still another opportunity to move up the leadership ladder. “My supervisor, who had been my academic advisor when I was a doctoral student at UCSF, just one day walked into my office and said, ‘I believe you will make an outstanding dean one day and you should consider pursuing that career path.’” That led her to apply for the dean’s position at Georgia Southwestern State.
As Warda’s career journey makes clear, learning to be a Hispanic nursing leader is a continuous, lifelong process. Leadership development workshops like the NAHN/AONE Institute are great, she says, because they energize and motivate participants and give them the confidence they need to work toward becoming leaders. “But unless that is followed up by having a network of mentors who are close to you and can work with you on an ongoing basis,” she emphasizes, “it will be an injection of enthusiasm that will only last so long.”
Cedars-Sinai Medical Center and The Foundation for the Elimination of Diseases Attacking the Immune System (DAISY) recently honored Cedars-Sinai’s neuroscience nursing staff with the inauguration of the hospital’s DAISY Award for Extraordinary Nurses program. The awards recognize the outstanding and often overlooked efforts of nurses who work with critically ill patients.
The DAISY Award is the country’s first national program conducted by patients and their families to honor excellence in nursing through monthly awards at participating hospitals. The program highlights the irreplaceable role nurses play in treating patients and providing emotional support to their families. The first Cedars-Sinai awards were presented to two nurses: Larie Padre, RN, is Cedars-Sinai’s first DAISY Award Neuroscience Nurse of the Month. Evelyn Ledin, RN, also received an award in appreciation of the care she gave to George Doll, a former neuroscience patient.
Cedars-Sinai is the third hospital in the nation to join the DAISY Award program. Every month, a nurse in the hospital’s Neuroscience Unit will be selected from a pool of nurses who have been nominated by patients and staff.
“We at Cedars-Sinai are proud to be among the first hospitals in the nation participating in the DAISY Award program,” says Linda Burnes Bolton, PhD, the African-American vice president and chief nursing officer at Cedars-Sinai Medical Center. “Nurses are heroes everyday. Given the current national nursing shortage, the DAISY Award could not be launched at a better time. The DAISY Award and other nursing recognition program awards are an appropriate way to recognize nurses for providing the very best care to their patients.”
The DAISY Foundation also recently announced that it is launching a new initiative to encourage patients and their families who have had extraordinary experience with a nurse to apply to The DAISY Foundation to co-sponsor The DAISY Award for their hospital. Applications can be made via the foundation’s Web site at http://www.daisyfoundation.org/.
Not long ago, I was facilitating a workshop on fostering civility in nursing education when a faculty member approached me during the break. The soft-spoken professor related her thoughts in a quiet voice, her eyes reflecting a certain sadness as she spoke. She said, “Please think about us—the clinical faculty, I mean—when you are speaking about incivility in nursing education. I am a member of the clinical faculty, and I can tell you, unequivocally, that we are a marginalized group. We are not considered part of the ‘real faculty’ and are often referred to as ‘minions and underlings.’ We are frequently told that we have no clout nor can we provide input into the theoretical courses or exams.” I asked the faculty member how she responded to these incivilities. She said, “I just take it—it’s like swallowing a very bitter pill.”
What I call the in-group and the out-group of nursing faculty teams—and I use the word “team” lightly—is further illustrated by a story described in a study I recently conducted to examine faculty-to-faculty incivility and ways to effectively address the problem. Approximately 13% of the respondents reported experiencing racial, ethnic, sexual, gender, or religious slurs within the past 12 months. One respondent wrote, “During a faculty workshop, faculty members were asked to work in small groups. One group contained four minority faculty members. A non-minority faculty member asked, ‘Do I have to paint my face black to be in this group?’”
Another faculty member related the incivility of perceived ageism that exists in her nursing program. She explained that when she met with her dean to seek advice about returning to graduate school to complete her doctoral degree, the dean laughed and said, “Are you kidding, at your age? You can’t be serious. By the time you finish your degree, you’ll be ready to retire. We prefer to invest in younger faculty.” Other forms of discrimination are also apparent: a student recently commented on faculty bias in the classroom, saying, “Students are often subjected to religious, racial, and anti-gay/lesbian content. We [students] feel vulnerable and do not know how faculty and administrators will react if they complain. It’s appalling and inexcusable.”
Regardless of their origin, uncivil encounters are an affront to human dignity and an assault on a person’s intrinsic sense of self-worth. The effects can be devastating and longlasting. Incivility may come from myriad sources; it is complex, disordered, and multidimensional. Taking time to engage, communicate, and listen with intention has a profound effect on preventing and healing the effects of incivility.
I often refer to incivility as a dance, an expression of feeling and social interaction that gets articulated through a variety of movements, gestures, and actions.1 Each observer and participant interprets the dance within the context of his or her personal experiences, through the lens of his or her own world-view. Because of this individual perception and interpretation, it becomes essential to actively listen, consider the intent of the action, and engage in meaningful and solutionbased conversation.
More than two decades ago, Ernest Boyer asserted that institutions of higher education play a vital role in helping students develop a sense of civic and social responsibility, and become productive citizens of the academy and the community.2 The promotion of civility and good citizenry is especially important in nursing and other health-related disciplines where the risk assumed by not addressing uncivil behavior reaches well beyond the college campus and can negatively impact patient safety, recruitment and retention, and commitment to the nursing profession. Because nursing programs are places where students and faculty provide direct care to patients through clinical experiences, uncivil and disruptive acts must be addressed so that such behaviors do not spiral into aggression and jeopardize the learning and practice environment.
While promoting civility is one of the primary functions of higher education, in some respects the system is failing. This failure may be related to a lack of understanding about the topic in general, and ways to prevent and address incivility in particular. I define incivility as rude or disruptive behaviors that often result in psychological or physiological distress for people involved, and if left unaddressed, may progress into threatening situations.3 Exposure to uncivil behaviors can result in physical symptoms such as headaches, interrupted sleep, and intestinal problems and can cause psychological conditions like stress, anxiety, irritability, and depressive symptoms. Thus, it is important to foster civility—an authentic respect for others requiring time, presence, a willingness to engage in genuine discourse, and an intention to seek common ground.4
Similarly, it is important to raise awareness about the importance of fostering a civil and healthy academic work environment. According to researchers, a healthy academic environment consists of a number of factors, including a clear mission with shared values and norms; high morale, job satisfaction, and an esprit de corps; competitive salaries and benefits; reasonable workloads; positive employee recruitment and retention; policies to eliminate incivility; respectful communication, teamwork, and shared decision making; organizational support and collegial relationships; and competent, honest leaders who collaborate with faculty to share decision making.5,6,7
Awareness may be raised by describing specific rationale for establishing and sustaining healthy academic work environments. First, the costs of incivility are vast. Uncivil behavior adds to employees’ stress level, erodes self-esteem, damages relationships, and threatens workplace safety and quality of life.8 Incivility also lowers morale, causes illness, and leaves workers feeling stressed, vulnerable, and devalued. The human and financial costs of these behaviors may be disastrous.9 Second, the recent Institute of Medicine Report10 includes several recommendations that call for nurses and other health care workers, such as physicians, to collaborate to advance the nation’s health. To fulfill these recommendations, we must establish civil and respectful relationships and interactions. Third, the American Nurses Association Code of Ethics for Nurses with Interpretive Statements Provision 1.5 promotes a civil, healthy work environment by requiring nurses to treat colleagues, students, and patients with dignity and respect, and states that any form of harassment, disrespect, or threatening action will not be tolerated.11 Similarly, the American Nurses Association Standards of Practice reinforce the need for objective standards such as collaboration, ethical conduct, and communication for nurses to be accountable for their actions, their patients, and their peers.12 These rationales and fostering a healthy academic work environment are difficult, if not impossible to achieve in the absence of skilled, ethical leadership. Successful change requires both formal and informal leadership—leaders who hold formal positions as well as individuals without a formal title or authority, but who have significant influence with members throughout the organization.
Once awareness is raised and leaders agree that changes are needed to foster a civil workplace, it is highly desirable to use empirical measures to determine levels, types, and frequency of civil and uncivil factors, and to reveal strategies for fostering a healthy workplace. Some examples of empirical measures include the Organizational Civility Scale (OCS)13 and the Culture/Climate Assessment Scale (CCAS).14 Other data sources are also helpful, such as formal and informal reports, evaluations, satisfaction surveys, performance evaluation information, regulatory reports, and information from focus groups and open forums. Once a comprehensive organizational assessment has been conducted, strategies can be implemented to improve areas of concern and to reinforce efforts already in place to enhance areas of strength and excellence.
Specific strategies include aligning the organizational mission and values with a focus on civility and respect. Successful organizations intentionally focus their vision for the future so that employees are able to meet organizational objectives as well as achieve personal satisfaction in their work. Organizational values undergird the formulation and implementation of norms of decorum. Without functional norms, desired behavior is ill defined and thus, members of the campus community are left to “make things up as they go along.”
Healthy academic work environments do not occur by accident—creating them requires intentional and purposeful focus. Unfortunately, many faculty, students, and administrators are unaware of how their behaviors affect others, and many are ill equipped to deal with incivility. Thus, strategies to prevent and address incivility must be taught, practiced, reinforced, and supported. We must make civility a priority. Faculty and staff meetings are excellent venues to raise awareness, discuss acceptable and unacceptable behaviors, establish norms of behavior, and practice and role-play civil interactions. When faculty and staff collectively co-create norms for behavior, they are more likely to approve of and conform to these behaviors. Once the norms are agreed upon, they become the standard for faculty and staff interactions. It is also important to establish, implement, and widely disseminate confidential, non-punitive policies and procedures for addressing incivility. This includes enforcing sanctions if indicated, and perhaps more importantly, to reward civility and collegiality. Although positive motivators are preferred, the consequences for violating the agreed-upon norms must be clearly stated and enforced. Ignoring or failing to address the uncivil behavior damages the organization as much, if not more, than the incivility itself.
Acting civilly and respectfully isn’t always easy, especially in a high-stress learning environment where constant change is the norm, and where faculty and students experience complex and demanding workloads. Yet, we must make civility a priority for our students, colleagues, practice partners, and ourselves. Incivility takes a tremendous toll on everyone throughout the campus and practice community. In a fast-paced work environment, patience is often in short supply, yet it remains a virtue we should value and uphold. Each individual must set a positive example to lead the transformation for cultivating civility in nursing education.
References
C.M. Clark, “The Dance of Incivility in Nursing Education as Described by Nursing Faculty and Students,” Advances in Nursing Science (2008), 31(4), E37–E54.
E. Boyer, Campus Life: In Search of Community. Princeton: The Carnegie Foundation for the Advancement of Teaching, 2009.
C.M. Clark, “Faculty Field Guide for Promoting Student Civility,” Nurse Educator, 34(5),194–197.
C.M. Clark and J. Carnosso, “Civility: A Concept Analysis,” Journal of Theory Construction and Testing, 12(1), 11–15.
C.M. Clark (in progress), “Pathway for Fostering Organizational Civility.”
M. Brady, “Healthy Nursing Academic Work Environments,” OJIN: The Online Journal of Issues in Nursing (2010), 15(1),Manuscript 6.
National League for Nursing. “Healthful work environments for nursing faculty.” Retrieved February 26, 2012, www.nln.org/newsletter/healthfulworkenv.pdf.
P.M. Forni, The Civility Solution, New York, NY: St. Martin’s Press, 2008.
C. Pearson and C. Porath, The Cost of Bad Behavior: How Incivility is Damaging Your Business and What to do About it. New York, NY: Penguin Group, Inc, 2009.
Institute of Medicine Report (2010). “The future of nursing: Leading change, advancing health,” Robert Wood Johnson Foundation Publisher.
American Nurses Association. (2001). Code of Ethics for Nurses With Interpretive Statements. Washington, D.C.: American Nurses Association.
American Nurses Association. (2010). Nursing Scope and Standards of Practice. (2nd ed). Silver Spring, MD: American Nurses Association.
C.M. Clark and R.E. Landrum, “Organizational Civility Scale.” Retrieved February 26, 2012, http://hs.boisestate.edu/civilitymatters/
C.M. Clark, M. Belcheir, P. Strohfus, and P.J. Springer, “Development and Description of the Culture and Climate Assessment Scale, Journal of Nursing Education (2012), 51(2), 75-80.
