Hi, everyone! During our brief time together, let’s discuss the frequently forgotten but essential skill of making a bed. Some readers are thinking, “Why are we discussing this topic, and why should I be an expert at making a bed?” So, for those that are unfamiliar with the importance of mastering this essential skill, I will shine a light on its significance in a nurse’s playbook. As a nurse working in the real world, you are chiefly responsible for all aspects of patient care. Some readers are saying, “Yes this is true, but I can delegate this task to a certified nursing assistant.” Then, I will quickly rebut, ” Touché you are certainly correct, but who will you delegate that task to if you don’t have a certified nursing assistant?” Typically, after that remark, I gaze upon a bewildered expression that simply translates to ” It looks like I will be delegating that to myself.”
Nurses are usually prepared for the common disasters they see at work- a code blue, code red or maybe even a code black, but have you ever thought about what you would do if an emergency occurred at home?
I recently lost electricity in my home for a period of about 9 hours. Luckily it was overnight, but nonetheless, I was in the dark without electricity and wasn’t prepared. You never know when an emergency situation may occur. Mother nature doesn’t let us know when she decides to bless us with a tornado, flash flood or hurricane.
Being without necessities such as water, electricity and food for any period of time is an inconvenience at best and downright dangerous in some situations, especially if you have medical problems. Being adequately prepared for disasters can help you get through and minimize your stress at the same time.
A list of potential items you may want to have on hand include:
-Copies of your important documents in a waterproof and portable container (insurance cards, birth certificates, deeds, photo IDs, proof of address, etc.)
-Extra set of car and house keys
-Credit/debit cards and cash, especially in small denominations. I recommend you keep at least $50-$100 on hand.
– 3 days worth of bottled water and nonperishable food, such as energy or granola bars
-Flashlight: Note: Traditional flashlight bulbs have limited lifespans. If you’re going to use one of these then make sure you have extra batteries. Light Emitting Diode (LED) flashlights, however, are more durable and last longer than traditional bulbs.
-Battery-operated AM/FM radio (and extra batteries)
-Keep a list of the medications each member of your household takes, why they take them, and their dosages. Keep at least a weeks’ worth of meds on hand if you can. If you store extra medication in your emergency kit, be sure to refill it before it expires.
-First aid kit
-Contact and meeting place information for your household, and a small regional map
-Childcare supplies or other special care items
-Lightweight raingear and Mylar blanket
This list isn’t all-inclusive but will get you started with a good emergency kit if needed. Place the items in a duffle bag in an easily accessible area. The items you include will vary with the region you live in and what natural disaster(s) your area is prone to. The bottom line is to be prepared for the unexpected.
Do you have a home emergency kit? If so, what’s in it?
The issue of embittered race relationships in the United States has been on my mind since August 9, 2014, when a white police officer named Darren Wilson shot and killed Michael Brown, an unarmed black teenager, in Ferguson, Missouri. The violent protests that erupted after the shooting culminated in even more pronounced violent protests in the early morning hours of November 25, 2014, following the grand jury decision not to indict Officer Wilson for the fatal shooting of Brown.
Not being close to the case, or having examined the evidence upon which the decision not to indict was based, I wondered whether that decision was purely based on evidence, or whether historical and institutionalized racism, discrimination, and injustice against blacks in the United States played a role. While I have no answers to my question, I struggled to think about what we, as a nation, can learn from Michael Brown’s death that will help this nation heal.
I believe that each one of us in the United States needs to think long and hard about race relations in this country. I allowed my mind to wander as I took this journey myself. I thought about the Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. In this report, the committee—charged by Congress with identifying and recommending strategies to eliminate racial disparities in health care in the United States—chronicled the pervasiveness of poor health outcomes for minorities.
As a minority and an academic nurse researcher with a focus on health disparities in pain management, I thought about historical and institutionalized racism, discrimination, and injustice that contribute to poor pain management for patients with sickle cell disease—an inherited blood disorder suffered by an estimated 100,000 Americans, mostly of African descent—and for patients with other pain conditions. I thought about an article I had written for Minority Nurse back in 2003 titled “Mentorship in Black and White,” where I narrated my experience of being mentored by a white senior professor when I was a nursing student. This mentorship experience affirmed my belief that humanity is inherently good, but social constructions such as race taint our good nature. I thought about my current experience as an assistant professor of nursing in higher education and how I have reacted when I encountered interactions I felt were unjust. I wondered about how I have interacted with students in my capacity as a nursing faculty where I have the opportunity to teach and mentor both black and white students. I wonder if I have done everything humanly possible and within my power to pay forward the inherent human goodness to improve race relations with my students, colleagues, and friends.
I thought about the slave ship captain and later an abolitionist, John Newton, who, after his repentance, wrote the hymn “Amazing Grace.” This hymn is sung in Christian churches around the world by many Christians to confess and repent of sins and enlighten the spirit. The song has also become the mainstay of funeral services around the globe— a way to send the dead home believing they had the chance to repent of their sins at the time of death.
Now, in the United States, we must sing “Amazing Grace” in unison. Why is amazing grace important in this moment of pain and hurt, loss of faith in humanity, and lack of trust in race relations in the United States? The nurse in me feels that this nation needs healing. We must repent for whatever we might have done consciously or unconsciously, overtly or covertly, to contribute to racial unrest and the suffering of blacks and other minorities in the United States,. We will not stand and just sing the lyrics of the hymn paying lip service. We must be on our knees and feel the words break through our hearts, minds, and spirits. The words must purge us of the biases, injustices, discriminations, racism, sexism, ageism, and other “isms” that have deadened our spirits in this country. We have to let the spirit that connects us as humans and make us one with the universe—the trees, the oceans, the winds, and the animals—emerge to help us heal. We must let the light of our spirit unite us, and together we can outshine the darkness in our hearts and minds that we use to oppress others who look different than us.
We must heal our nation by checking our individual biases that encourage us to treat others unfairly. Like Newton, we must repent so that God and the universe will shower our spirits with the everlasting peace that comes with positive race relationships in the world full of turmoil and unrest. We must heal our nation, the United States of America.
Miriam O. Ezenwa, PhD, RN, is an assistant professor in the Department of Biobehavioral Health Science at the University of Illinois at Chicago, College of Nursing.
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.
It was an intentionally simple question the clinical nurse in the examining room heard. “Lynn,” I said, “Have you ever been bullied?” There came a pause. Then, she responded with a torrent of emotions reflecting anger and disappointment that took her back to the start of her career 23 years ago. I posed the question as she prepped me for the ECG my doctor ordered.
After completing her nursing degree, Lynn went to work as a registered nurse in the emergency department at a suburban hospital in North Carolina. For the next two years, she was abused, intimidated, openly berated, and humiliated by staff nurses with more seniority and the nurse manager.
“What was that like?”
She said it was just how you were treated. “You were made to feel stupid when you sought clarification of a physician’s charted instructions, for example, or asked for input to correctly respond to a patient’s request. Eventually, I left.”
What happened to Lynn is not a rare occurrence among nurses, unfortunately. On July 9, 2008, The Joint Commission, which provides oversight to over 20,000 hospitals and other care facilities, issued a policy directive to its membership called a Sentinel Event Alert. Its instruction was to have procedures in place to deal with “behaviors that undermine a culture of safety” by January 1, 2009. It described “intimidating and disruptive behaviors” in great detail, which is the most widely accepted definition of bullying. Its rationale was clearly embedded within the body of the policy: “There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.”
With mounting evidence that bullying was surprisingly prevalent within the health care sector, the intended purpose of the Sentinel Event Alert was to amend its leadership standards. Accredited health care organizations would be required to create codes of conduct that define disruptive and inappropriate workplace behaviors as well as establish and implement procedures for managing such behaviors. Additionally, the institutions The Joint Commission accredits were expected to make their data available for review, according to Gerard M. Castro, PhD, The Joint Commission’s project director for patient safety initiatives.
Nursing’s Dirty Little Secret
“Nurses eat their young,” wrote Theresa Brown, a registered nurse, in an article in The New York Times in February 2010. “The expression is standard lore among nurses, and it means bullying, harassment, whatever you want to call it. It’s that harsh, sometimes abusive treatment of new nurses that is entrenched on some hospital floors and schools of nursing. It’s the dirty little secret of nursing.”
Her story is not exceptional, and it prompted me to contact Gina, a clinical nurse in Worcester, Massachusetts, with a master of science degree in nursing education and 35 years of experience—15 of which were on a nursing school’s faculty.
“There are nurses that I do not assign a new-to-nursing nurse to because of what I know would be their experience,” Gina tells me. Then, she describes her very recent experience where she accepted a per diem assignment in the operating room (OR) of a local hospital with which she is very familiar: “I almost never survived a month because of the bullying that went on. I had never seen anything like it and never experienced anything like it in my years in nursing.”
It seems that there had not been an assignment of someone new to the OR in 10 years, so Gina was treated as an outsider and not part of the clique. So targeted was the hostility that after three months of enduring the treatment, she says, “I began to feel myself spiraling down, losing my self-confidence. I endured badgering criticism; I couldn’t do anything right; there was an absence of kindness.”
Fortunately, there was a change of supervisor who observed the climate in the OR and stepped in to end the intimidation by referring the preceptor for retraining.
An Occupational Hazard
Scenarios similar to the one Gina describes must have been alarmingly common to have prompted The Joint Commission to issue a specific directive regarding workplace bullying, or lateral violence, as it is technically referenced. Diverse studies identify nursing as a risk group for workplace bullying; further, they confirm that the problem of hostility in the workplace is very common in the health care sector.
Indeed, health systems are aware of this hostility and responding to the Commission’s directive. Duke University and the University of North Carolina, for instance, have policies and procedures to deal with workplace behavior. Duke shies away from describing intimidating and disruptive behaviors as bullying per se—and perhaps may have tacitly not reinforced the implications that bullying is specific and disruptive conduct that impacts the delivery of care.
Carole Akerly, BSN, director of accreditation and regulatory affairs at Duke University Hospital, responded to my inquiry. “Duke,” she says, “has identified behaviors that are appropriate and has not specifically described intimidating and disruptive behaviors, and I don’t know whether we have identified it as that close.” But if bullying is as prevalent as the research and reports indicate—and there are many—it is unlikely that Duke and other health care providers have an incident pattern less than the norm.
The University of North Carolina Health Care System, on the other hand, provides a detailed description of intimidating and disruptive behavior and a very specific description of what constitutes appropriate behavior, so the employee has no room to allege ambiguity. The rationale for its disruptive and inappropriate behavior policy admits that disruptive behavior “intimidates others and affects morale or staff turnover [and] can be harmful to patient care and satisfaction as well as employee satisfaction and safety.” Further, the policy acknowledges the possible presence of such behavior: “While this kind of conduct is not pervasive in our facilities, no hospital or clinic is immune.”
Carol F. Rocker, PhD, RN, the lead investigator of a study of nurse-to-nurse bullying and its impact on retention in Canada, reported in OJIN: The Online Journal of Issues in Nursing in September 2008 that Canadian nurses are not alone when it comes to workplace bullying and emphasized that workplace bullying among nurses is now recognized as a major occupational health problem in the United Kingdom, Europe, and Australia. Why did The Joint Commission go to the trouble of defining bullying if it was not to delineate behaviors that threatened patient safety and care quality? The answer is embedded in what led the Commission to do this in the first place. It’s found in the promulgation of the Universal Protocol (UP).
In addressing the need to create a climate of safety related to wrong site, wrong patient, and wrong procedure within a health care facility, the Commission became aware that one of the contributing factors was the failure to speak up. What stops a clinician from speaking up? Oftentimes, it’s the deference to the physician and other clinicians.
“We have heard of abusive behavior by physicians when clinicians in the operating room, for example, have corrected the physician. Not speaking up is the result of deference to the physician,” says Castro. The UP team became aware at that time that this harmful behavior within care facilities was a safety issue.
A 2003 survey on workplace intimidation conducted by the Institute for Safe Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. Elaborating on this issue, the Commission’s Sentinel Event Alert cites several reasons why disruptive behaviors go unreported, such as fear of retaliation, the stigma associated with “blowing the whistle” on a colleague, and leniency towards physicians who generate high amounts of revenue.
But, so serious is the epidemic of workplace bullying—with particular emphasis on the nursing sector—that 26 state legislatures have proposed legislation to address this concern, beginning with California in 2003. The model, the Healthy Workplace Bill, provides very specific employee and employer remedies, protections, and sanctions. There is clearly a movement to expand safety in the workplace from the purely physical aspect to the equally important emotional and psychological aspects.
When Nurses Hurt Nurses
Kathleen Bartholomew, RN, MN, renowned for nursing consulting and training, cites episodes of nurse bullying that astonishes: a nurse hides a surgeon’s favorite instrument when a substitute fills in as the scrub; a circulator, a nurse who makes preparations for an operation and continually monitors the patient and staff during the surgery, doesn’t tell a new nurse who is scrubbed that she knows the shunt the surgeon selected has fallen on the floor; a newly hired RN who was previously a scrub technician is shunned by both camps. These episodes, Bartholomew says, pose the question whether this is what life is like in the OR.
When the administration at Indiana University Ball Memorial Hospital studied the issue of bullying, it was clear that the problem existed beyond nursing units. “It starts with physician to physician and then trickles down the chain of command,” says Renee Twibell, PhD, the lead investigator and an associate professor of nursing at Ball State University. “If the doctor kicks the nurse, that nurse turns around and kicks the new nurse or the CNA.”
The consequences of adult bullying have led investigators to name it as a significant occupational stressor in the workplace. Moreover, the Center for American Nurses labels workplace bullying a serious issue affecting the nursing profession in particular, and defines it as any type of repetitive abuse in which the victim suffers verbal abuse, threats, humiliating or intimidating behaviors, or behaviors that interfere with the victim’s job performance and are meant to place the health and safety of the victim at risk.
Are all nursing sectors equally at risk? Specifically, I was curious to know whether military nurses have a similar experience. Having spoken with Lieutenant Colonel Angelo D. Moore, PhD, the deputy chief for the Center for Nursing Science and Clinical Inquiry at Fort Bragg Womack Army Medical Center for a previous story, I remembered what he had said. Moore turned my inquiry around and wondered whether gender issues might be at work in some bullying episodes. The ratio of male to female nurses in the military is thrice that of the nonmilitary nursing sector and, according to Moore, the combination of having been to war and the culture of the military contributes to very few incidents where bullying was alleged.
Still, bullying is a complex phenomenon. Although bullies are responsible for their behaviors, investigators have analyzed several potential factors that prime the workplace for bully behaviors, which include organizational leadership and culture, the social system, character traits of the victim, and character traits of the bully. Bullying clearly qualifies as hostile workplace behavior, and if the target can claim protected class status, it becomes a major legal issue for hospitals and care centers. A 2011 study of student nurses by the American Nursing Association reported that 53% of study participants had been “put down” by a staff nurse, and 52% had been threatened or experienced verbal violence at work.
Cheryl Dellasega, PhD, faculty member at the Penn State University College of Medicine and author of When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of Bullying, provides significant research that led her to state that there are cases where the nurse manager or charge nurse—often a highly competent, valuable nurse that the administration does not want to lose—may act as a bully, playing favorites when it comes to assignments or time off. “If they are role modeling this stuff, it will be worse among the staff,” Dellasega told NurseZone.com. “If they get the message that it’s OK to treat people like this, everybody will.”
Moving Forward
So, what’s the remedy? Bullying in the workplace is both an awareness and a leadership issue. Moreover, as is so often the case in workplace practices, the leadership should be careful not to be caught being party to making case law by a complainant seeking to link hostile workplace to bullying as a protected class member. Hospital management might address the presence or prevalence of bullying behavior by examining how it is factored into their training in root-cause analysis, as well as what their whistleblowing protection policy provides.
Nurse leaders must establish clear guidelines about what behaviors will not be tolerated and what is unacceptable, Dellasega believes. She also recommends creating a suggestion system so nurses can anonymously report things that happen on the unit, and asking for feedback about what would make the work environment better.
Gabriela Cora, MD, takes a harder stand, saying hospital administrators should have zero tolerance for bullying behavior. “Lay a plan for improvement,” Cora adds. “Reward them when they improve their behavior and be ready to fire them if they continue the bullying behavior. Second, avoid praising or rewarding nurses for their work performance if they are bullies. Instead, respectful treatment of patients and positive interactions with colleagues should be rewarded.”
Ultimately, it’s all about modeling positive behaviors and holding employees accountable. If the policy is zero tolerance for bullying, it should mean just that—zero tolerance.
