Americans possess unwavering faith in registered nurses. Year after year, nurses top the list of most trusted professionals. But ask most people just what nurses do and their answers lack clarity, conviction, and a clear-eyed understanding of nursing’s sundry roles.
The American Nurse: Healing America, a documentary film that premiered during National Nurses Week in May, teaches audiences about the diversity and scope of nursing and the critical roles these warriors of healing play during the most vulnerable moments of life, says award-winning photojournalist and filmmaker Carolyn Jones.
“These nurses will knock your socks off. They were so open and free with sharing their inner thoughts and souls, and I am very grateful, and we are lucky to have it on film,” says Jones, whose high-energy persona was palpable during a phone interview.
Two years in the making, the film follows the path of nurses working in hospitals, rural homes, city streets, helicopters, and prisons. The film captures nurses on the front lines of the biggest issues facing America—poverty, aging, war, and justice.
“The main thing is to raise the volume on the voices of nurses in this country,” says Jones, whose film follows the lives and work of five nurses who represent a spectrum of the country and its health care system. “They are a treasure chest of unbelievably rich information. They can make our hospitals run better; they can make schools run better; they can make our communities richer; and they can make the end of life so much better than it is right now.
“I just want to shine that light on nurses and turn up the volume so that they are part of every conversation,” says Jones, who crisscrossed the country to interview more than 100 nurses for The American Nurse: Photographs and Interviews by Carolyn Jones, a coffee-table book published in 2012 that includes the nurses in the documentary.
The nurses featured in the film include: Brian McMillion, MSN, MBA-HCM, RN, at the Veterans Health Administration San Diego Medical Center; Sister Stephen Bloesl, RN, from the Villa Loretto Nursing Home in Mount Calvary, Wisconsin; Tonia Faust, RN, CCN/M, from the Louisiana State Penitentiary; Naomi Cross, RN, from The Johns Hopkins Hospital, Baltimore; and Jason Short, BSN, RN, with Appalachian Hospice Care in Kentucky.
The film follows the path of nurses in different practice specialties, debunks common misconceptions about nurses, and raises questions for society about the challenges of healing America, say the five nurses spotlighted in the film. The featured nurses say they hope the documentary, praised by the White House, The American Journal of Nursing, and national media, educates audiences about their professionalism and the complexity of their roles.
For McMillion, coordinator of the Caregiver Support Program and VA clinical services director, the film is an opportunity to rebrand the profession. The documentary counters the unflattering and unrealistic media portrayals such as Nurse Jackie and raises awareness about stereotypes, says the Army vet and former medic who rehabilitates wounded soldiers returning from war. “We still hear ‘male nurse’ rather than just ‘nurse,’” McMillion says, chuckling. “When I was in school, people used to ask, ‘Are you studying to be a male nurse?’ and I would say, ‘Oh, no, I don’t need to study anymore to be a male; I have pretty much mastered that. I am studying to be a nurse.’”
The film will help the public realize that nurses work outside the hospital and toil deep in the community, says McMillion. (His third title is Major McMillion, 144th Minimal Care Detachment Commander.) “We are in the most intimate places, like their homes, and sometimes we are out in tents taking care of homeless people, which is an outreach I participate in every year as the VA clinical services director. I hope we can show people this is a profession that doesn’t require gender and that it has compassion, critical thinking, and technical proficiency requirements.”
McMillion was most impressed that the film crew, which followed him to Germany and a homeless center, was able to “translate the heart and humor of our profession in a masterful way.”
One message that Sister Stephen, director of nursing at Villa Loretto Nursing Home and president of the home’s board of directors, hopes viewers walk away with is that the nursing home industry is working hard to make care resident-centered. She runs a nursing home filled with goats, sheep, llamas, and chickens. It’s a place where the entire nursing staff comes together to sing for a dying resident.
“In my small, religious nursing home, we feel we can make the remaining years quality. We can be there with them and the families at the end of their life and offer them whatever comfort we can, whatever love we can, and assurance [that] there is an eternity for them, a beautiful life afterwards. If you look at it from a religious point of view, we are the hands and hearts of Jesus reaching out to these people. That’s what it’s all about for me,” says Sister Stephen, who is also president of Cristo Rey, a respite program for special needs children.
Sister Stephen, who has worked at the Villa Loretto Nursing Home since 1965, credited making the film and book projects with adjusting her attitude. “At one time, I was disillusioned with nursing because at times it is so non-hands-on, especially if you are in an administrative [position] or management. So many hours are devoted to paperwork,” she says. But after talking with many of the nurses featured in the book and attending related events, “I think, ‘Wow, I am really back on board.’ I tell people to really see what a gift they can be, what a service they can be to whatever area they decide to go in.”
The documentary also explores the work of a nurse inside a prison. Jones says she wanted to understand how a nurse can take care of people who committed horrible crimes. Tonia Faust, hospice program coordinator, has addressed that question numerous times during the 13 years she has worked at Louisiana State Penitentiary in Angola, the country’s largest maximum security facility. Faust, who runs a prison hospice program where inmates serving life sentences care for their fellow inmates as they’re dying, says treating prisoners requires skills, not judgment.
“I don’t actively look to see what their crimes are. My first year, I looked in the guys’ jackets to see what they did and sometimes I was shocked,” she recalls. “I thought, ‘I don’t need to do this for fear I may not treat them the way I am supposed to.’ Over the years, I realized people make mistakes in their lives. People don’t have the same upbringing as others.
“Some people may not have a choice. They have gone through the court system and been sentenced. It’s not my part to judge them or hold it against them. It could be my brother, my father, or me or my children in a prison. I look at them as patients, and my job is not to judge them, but to take care of them as best as I can with the skills I have learned through my education.”
One common misconception the public has about nurses is that their role is limited with the doctor making all of the decisions about care, says Naomi Cross, a labor and delivery nurse and the perinatal bereavement coordinator at The Johns Hopkins Hospital in Baltimore, Maryland. In the film, Cross coaches patient Becky, an ovarian cancer survivor, through the cesarean delivery of her son. “I had a patient two days ago who had a complicated cancer, and we were going to deliver her baby early. I spent four hours preparing her for surgery and coordinated the doctors and other team members, about 15 people that took care of her during her surgery.
“I remember I am holding her hand, and we are about to put her under, and I’m telling her everything will be OK. And she said, ‘I didn’t know you were going to come with me. I didn’t know you did all these things.’ She was surprised by the whole view of what nursing does. So many times people have said, ‘I thought the doctor did that.’ The biggest misconception is how skilled, intelligent, and knowledgeable we are. I get that so much from my patients. They are always surprised . . . by our expertise.”
The film provides the audience an honest portrayal of the men and women who spend the most time with patients, says Jason Short, who works for Appalachian Hospice Care. Short provides home care to patients in eastern Kentucky, one of the poorest areas in the nation. The film shows him driving up a creek to reach a home-bound cancer patient in Appalachia.
“What I like about [The American Nurse], it captures the journey. It’s almost like nursing has been lost. And I think this was unique because all of us in the film, we are allowed the opportunity to do what nurses do, and that’s just care for people,” says Short, a former auto mechanic who is currently studying to become a nurse practitioner.
A nurse since 2007, Short was drawn to the field after a terrible motorcycle accident at age 18 and he “found out what it’s like to be helpless” and in need of compassionate care.
For Jones, the film, book, and online videos share the inspiring stories of the women and men who have pledged their lives to the care of others. Her desire to elevate and celebrate the nation’s most trusted professionals and their calling also stemmed, in part, from a life-altering experience with the nurse who administered her chemotherapy for breast cancer back in 2004. The memory left an indelible impression.
“The book was an idea brought to me by Fresenius Kabi USA [a global health care company]. This is what I love to do, take pictures and interview people. They wanted to do something to celebrate nurses. I had a nurse who got me through chemotherapy, and she was incredible. Once it was all finished, I never really thanked her properly,” recalls Jones. Over the years, “I thought of her many times. I think you go through an illness like that and you don’t want to turn around and relive it. I thanked her at the time, but not enough, and she never knew how much it meant to me.”
So when approached with the idea, Jones embraced it. The book, website, and accompanying online videos were a hit with nurses. Accolades flowed. Yet, Jones felt her mission was incomplete. “I learned so much doing the book about what role nurses serve in society, that I felt I wanted to do something that could really broadly reach the public. Nurses have enjoyed the book greatly; it’s about nurses, and it’s very much for nurses. It was to celebrate nurses. But I didn’t feel like I was really able to cross that threshold into the realm of the public and let the public really see and know what nurses do, and so that became my driving passion.
“The other reason is I wasn’t ready to leave this world of nurses.”
Being a nurse is hard. And stressful. Depending on where you work your daily stress level can escalate from 0 to 10 in a matter of seconds when a critical situation arises. Even worse, the average nurse’s stress level can fluctuate greatly over the course of a shift frying ones’ nerves by the time it’s time to punch the clock and go home.
What’s the best way for a nurse to manage daily on-the-job stressors? By using stress relieving methods on a regular basis. There are many ways to ease tension when stressed.
Here are 8 ways to combat stress:
Take a deep breath. Deep breathing does more than giving the brain a boost of oxygen. Stopping to take a deep breath when times get rough has been shown to reduce cortisol levels, which in turn can lead to reduced stress and anxiety.
Listen to music.Music has a soothing effect people and can prove beneficial when tension runs high.
Exercise. Exercise releases endorphins, which instantly makes you feel better. Imagine punching out your stress on a punching bag or running your best mile. Trust me, after you’re done exercising you’ll feel much better.
Cuddle with your pet. Dogs and cats are good cuddle buddies and can help you feel more at ease when times get tough.
Hug somebody! Have you ever hugged someone while you were feeling tense? If you’re like most people, you immediately feel a release during the act. That is stress leaving your body!
Get a massage. Getting a massage from someone can relieve physical tension in your muscles. Another added benefit from a massage is human touch. Think of the human touch of a massage the same way you would of receiving a hug.
Write. Writing when stressed can help release stress-related symptoms. Have you ever heard of someone writing a letter and then burning it to “let it go?” Writing allows you to say whatever it is you need to say about what is bothering you. You don’t have to burn it when you’re done because the act of writing is actually a release within itself.
Go out with friends. Surrounding yourself with people you love and trust is good for your mental health. Aside from being able to speak to someone about what is bothering you, you could probably use a fun night out.
In addition to working as a RN, Nachole Johnson is a freelance copywriter and an author with her first book, You’re a Nurse and Want to Start Your Own Business? The Complete Guide, available on Amazon. Visit her ReNursing blog at www.renursing.com for more ideas on how to reinvent your career.
Romeatrius Moss, RN, MSN, APHN-BC, DNP, doesn’t mince words when she advises other nurses about advancing their careers. “If you aren’t geared and ready and have everything in your toolbox, you are going to be left behind,” says Moss, the executive director of the Mississippi Gulf Coast Black Nurse Association. “Getting an advanced degree is extremely important. It pushes our profession forward.”
As more minority nurses advance, they are positioned to assume leadership roles and increase the diversity of nurse leaders, all of which reflects the patient population.
Moss’s outlook mirrors one that is hotly debated in nursing. The Institute of Medicine (IOM) garnered attention with its 2010 report, The Future of Nursing: Leading Change, Advancing Health, which calls for a highly educated nursing workforce to keep pace with the changing demands of both the health care environment and the patients who are served. An 80% goal of nurses with BSN degrees and a doubling of nurses with doctorates are imperative for the nursing community, the report stated.
“It’s good for the professions, but equally good and equally more important for the people who are coming into the health care system who deserve an educated workforce,” says Jane Kirschling, PhD, RN, FAAN, president of the American Association of Colleges of Nursing (AACN). “The bottom line is about patient safety and providing health care that is high quality, efficient, and cost effective.”
In light of the study and others like it, nurses—who build careers on change—are debating the best and most reasonable ways to achieve career satisfaction and advancement. A nursing career includes different options, and one work day is never like another. To achieve maximum career success and optimize your salary potential, learn to embrace the changing atmosphere, says Janice Phillips, PhD, MS, RN, FAAN, director of government and regulatory affairs at Commission on Graduates of Foreign Nursing Schools International, an authenticity credentialing service of foreign-educated nurses.
Advancing Your Education
The 2010 IOM report brings the issue of higher nursing degrees into sharp focus, causing some nurses to reevaluate their goals and some hospitals to implement new minimum requirements for employment. “Whether it is an associate’s, bachelor’s, or master’s-prepared nurse, the reality is that nursing requires lifelong learning,” says Kirschling.
Nurses have choices about how to advance, but a degree appeals to many organizations. “A minimum of a bachelor’s in nursing will open doors when you are competing for a job, and it shows a level of commitment,” says Marie-Elena Barry, a senior practice and policy analyst at the American Nurses Association. And even Kirschling says that an associate’s degree is often considered a point of entry into nursing now, not the final point.
Nurses are taking notice. Results from the Health Resources and Services Administration’s (HRSA) “2008 National Sample Survey of Registered Nurses” showed that half of registered nurses hold a bachelor’s degree or higher, and just over a third hold an associate’s. The rest have a diploma in nursing. Most nurses initially receive an associate’s degree, but about a third start out with a BSN. And for those who eventually earn higher degrees, the study showed approximately half of nurses with master’s degrees work in hospitals while the rest work in academia or in an ambulatory care setting.
According to a May 2012 occupational employment and wages report by the Bureau of Labor Statistics, an RN can expect to earn a mean annual wage of $67,930. Furthermore, the 2008 HRSA study revealed that RNs with graduate degrees earned an average of at least $20,000 more than RNs with other levels of education. Nurses who graduate with a degree also get into the workforce faster. Data from an August 2013 survey by the AACN revealed that nursing graduates of BSN or master’s programs are much more likely to have a job offer at graduation than graduates in other fields.
And while the higher salary is great, nurses are finding they need a bachelor’s to even get a job. The AACN study showed that 43.7% of hospitals and other health care settings require the degree and that 78.6% of employers prefer to see the BSN on a resume even if they don’t require it.
When you consider how to advance both your professional goals and your personal goals, keep in mind how each job will help you get to where you want to be. “Lots of nurses get a degree and go to work and don’t think about career development and learning how to grow your career,” says Barry. As a new nurse, you must ask yourself whether you are gaining valuable experience that you can put on a resume. And if you have been in nursing for years and are considering a move to academia, you should consider whether a teaching position will offer you needed benefits and retirement.
A Balancing Act
Working and going to school isn’t easy, and adding other obligations, like family, often makes the task overwhelming. But as the demand for nurses with a bachelor’s degree increases, schools are making it easier by offering accessible classes and accelerated degree programs. And Moss advises nurses not to be discouraged by the commitment. “This is a train,” she says. “Jump in when you can.”
In the meantime, anything you can do to make yourself more valuable to an organization will help increase your salary, and often a new degree raises your pay as well. “Provide evidence of how you made a difference,” advises Phillips.
Kirschling suggests talking with your employer about wanting to build on your skill set or your desire to continue your education. “Employers want to retain nurses and create career mobility within the organization,” she adds.
Keep Your Options Open
“People believe the continuing mantra that nurses need to work in traditional venues like hospitals and doctors’ offices,” says Carmen Kosicek, RN, MSN, author of Nurses, Jobs, and Money: A Guide to Advancing Your Nursing Career and Salary. But the pay for those positions doesn’t always match the financial outlay needed to practice there, she continues.
Instead, Kosicek advises nurses, especially those just graduating from nursing school, to look for other opportunities that offer both professional experience and gainful employment. “It’s not all about the money,” says Kosicek, “but they all have bills.”
According to Kosicek, many graduates are not hired for 4 to 18 months, and many of them are competing for med/surg jobs to gain broad experience. She suggests considering other options where you will use all your skills. A position as a school nurse, for example, where you handle hundreds of varied and often complex cases is an excellent way to use your skills and learn new ones. When you apply for a new grad residency program, you are already starting above the rest of the pack, she says.
If you are unsure what your next move should be, Kirschling recommends checking out www.discovernursing.com to explore opportunities.
Approach Your Career as a Business
When you view your career as a business, you give yourself permission to look impersonally at your experience and your credentials. And you treat any potential job offer, salary increase, or career move with the same consideration as you would a major life change.
Just as you would negotiate the price of a house you are buying, you also must learn to negotiate salary offers, argues Kosicek. “It’s not always about your base pay of dollars,” she says. “You can negotiate other ways of compensation.” For example, you can ask for more vacation days, a higher match of your 401(k) plan, or tuition reimbursement for classes.
“No one is teaching that,” says Kosicek, but it is a valuable skill because it will get you closer to your goals. Negotiating shows you are confident and know your worth. “It is a totally different language,” she adds.
Act Like a Leader
Even if you haven’t reached your ultimate career goal, you can act like you have. “You can’t do a BSN [program] and expect to be a manager,” says Barry. “There are lots of little steps.”
Be a leader in your nursing community and make your presence known. One way to help increase your salary potential is to get involved within your state or with national organizations, says Barry. Don’t just become a member. Begin to make a difference by giving your input, showing up at events and meeting others, or volunteering on your state board of nursing, advises Barry. “It increases your ability to network and puts your face out there.”
Don’t overlook the importance of your workplace as well. Barry recommends getting involved with unit-based activities. Join a shared governance committee or work on a quality improvement project. Then give thoughtful input and work hard for the team.
Be More than Just Another Resume
Your resume might be your only shot at a job you want, so make it perfect. Just as nurses need negotiating skills to get ahead, they need a resume that is detailed and exact because it could mean the difference between the slush pile and a job offer.
“Nurses are not going to get in with traditional nursing resumes or traditional interviewing skills,” says Kosicek. “They have to show they are business wise.”
Barry agrees. Your experience, commitment, and education all combine into one package to an employer, but they have to be able to see it. You can do your part with a detailed resume that lists your education and any current classes along with your qualifications.
Become a recognizable name through your professional and appropriate exposure on social media and your networking efforts that bring you in touch with various health care professionals, suggests Barry.
Other Benefits
Of course, taking on a new degree doesn’t work for everyone. You have to consider the financial return on your investment, so you aren’t trading more education for insurmountable debt.
Chart the financial impact of furthering your education. If you want a degree but can’t imagine how you will pay for it, become a sleuth for scholarships or take an alternative path. If your company doesn’t reimburse for tuition, see if your professional organization membership gives you access to scholarships or grants. Can you take one class at a time to chip away at the degree?
A less tangible benefit of continuing your learning is confidence. “It gets you excited and keeps you informed and learning outside your unit,” says Barry. “Certification is important. It shows your commitment to your profession. It also shows your professional role modeling.” When you are learning and advancing by taking classes, even if it’s one at a time, you are demonstrating to your employer that you are actively engaged in your profession, she says.
Phillips knows firsthand the benefits of doing the unexpected. She recently left a faculty job at Rush University and the comforts of family and friends for her current job in a new city. Although the prospect gave her nervous butterflies, Phillips says the job fit perfectly with her career plan, filling a gap in policy experience that Phillips wanted to have. “Sometimes you just have to do it,” she says. “I didn’t want to sit around and not take some risk. Most people who have a well-rounded professional life have taken some risk.”
Have a Plan
Your career will stagnate if you don’t have a solid and ambitious plan to follow. Decide where you want to go and write a plan of action to get there. Put yourself in position to get where you want to be. Do you respect a nurse in a leadership position? Notice how she acts and ask about her volunteer work or about any organizations of which she is a member. “Part of the learning process is going through and collecting along the way,” says Barry. “As you are getting a degree, you are exposed to all those other areas.”
Even if you are not looking for a job, keep accurate records of your career successes, advises Phillips. “We don’t document our outcomes,” she says, so when the time comes to tell potential employees about them, it’s hard to remember the details. Keep a file—“call it a happy file,” suggests Phillips—where you record accurate outcomes and contributions from your job successes. Pay particular attention to relevant numbers and dates, so you can retrieve them when necessary. “Nurses have to be prepared,” she says. “You never know when an opportunity will present itself.”
Does an Advanced Degree Equal Respect?
Like it or not, an advanced degree is the first step toward a leadership position. “It’s very important for nurses to get a nursing degree,” says Barry. For nursing as a profession to advance with respect, getting a degree—particularly a BSN—will also bring more nurses into position to take over as future leaders. “Nursing education has a lot to do with where you go,” says Barry.
Starting with a BSN is the most important goal because it keeps you competitive, argues Barry. But as Kosicek points out, you will have to find your place in the market and actively seek out nursing roles that both pay your bills and satisfy your professional goals. Sometimes, a career move is your chance to advance professionally and personally and will lead to greater rewards, but you have to be willing to take the leap.
“The risk is that we have to be open and willing to leave our comfort zone to experience all nursing has to offer,” says Phillips. “And it’s scary. But I don’t believe anyone should be burned out. You need to find a new perspective.”
Just as each nurse is unique, so is each successful career path, says Phillips. “I’ve been a nurse for 37 years, and I am just as excited today as the day I graduated because I see the possibilities,” she says. “At the end of the day, how do you want to feel about what you want to do and what makes you proud of your profession?”
Julia Quinn-Szcesuil is a freelance writer based in Bolton, Massachusetts.
Every hospital has stories of nurses who thrive by floating. More than likely, they have chosen to be part of the hospital’s float pool. Yet, for floor nurses who must take float assignments when their unit’s census is low or to fill staffing shortages across the hospital due to absences, vacancies, or high-acuity levels, floating can be a major source of job dissatisfaction. In the past decade, hospitals across the country have revamped their float policies to give nurses greater autonomy and agency in deciding whether or not to float.
Risi Bello, RN, has been a float nurse at MedStar Washington Hospital Center in Washington, DC, for 12 years, and for the most part, loves it. The flexible schedule, the variety of clinical experiences, and the constant exposure to new patients and coworkers are what attracted Bello, 49, to floating in the first place. She’s only required to work a total of 48 hours over a six-week period, which she can work in either 8- or 12-hour shifts. Although two of her shifts have to fall on major holidays each year, the schedule has given Bello, a married mom of six, a work-life balance she might not have achieved had she been a floor nurse.
And watching Bello work on two different floors during separate shifts in late December, it was clear that she was comfortable wherever she went in the 926-bed hospital. She confidently cared for four patients she had met only hours before, knew where to access the floor’s medication and supplies, and updated patient records on a hand-held mobile device.
“You get to meet the best people in the hospital,” says Bello, a native of Nigeria. “It’s socially engaging and you learn a lot because you’re not stuck with a particular set of diagnoses.”
Tools for Success
In an essay published last year in MedSurg Nursing, Katie J. Bates, MSN, RN, reflects on recent research gauging nurses’ attitudes towards floating as well as her own experiences with it early in her career. Recent graduates and experienced nurses alike can feel “alone, anxious, and even incompetent when floated to other units,” if they haven’t received proper orientation, she wrote in her piece, “Floating as a Reality: Helping Nursing Staff Keep Their Heads Above Water.”
Nurses who float to unfamiliar units can get stuck either with less challenging patients or with the most difficult cases to give staff nurses a break. They may feel less productive as their time is spent searching for supplies or seeking help from nurses on the unit. These scenarios make the floating nurse feel “undervalued and expendable,” and patient care may suffer as a result, explains Bates, a critical care staff nurse at Good Samaritan Hospital in Puyallup, Washington.
Bates recommends creating tip sheets, informational packets, or pocket guides for float nurses that contain specific information about subspecialties. For example, “an orthopedic tip sheet may describe hip precautions for postoperative patients,” she wrote. Bates also suggests having a dedicated resource nurse in each unit who doesn’t take her own patients, but is there to assist nurses who float to the unit. Finally, Bates says the unit’s charge nurse should check in with the float nurse periodically to ensure she is comfortable with her patient load and responsibilities.
Bates acknowledges that budgetary constraints may preclude efforts to implement these changes. Yet additional resources and staff support are critical to turning floating into a positive experience, she argues.
Float Pools or Resource Nurse Teams
In response to dissatisfaction floor nurses have expressed about mandatory floating, several hospitals have developed dedicated teams of full-time float nurses. At MedStar Washington Hospital Center, the float pool is composed of 91 nurses who are mostly full-time floaters, says Rosemarie Paradis, RN, MS, NEA-BC, CENP, FACHE, the hospital’s vice president of nursing excellence. Additionally, the pool is also staffed by nurses from other hospitals who want to pick up shifts on their off days.
Over time, the float pool has attracted new employees, with 20 nurses being added to the float pool in the past two years, according to Dennis Hoban, the hospital’s senior director of recruitment services. Float pool nurses, Paradis says, are expected to improve their skills and maintain their competencies just as floor nurses are.
While the hospital relies on the float pool first to cover deficiencies in staffing, occasionally staff nurses are called upon to float outside their home units. “As has been our normal practice, nurses float to areas that are similar to their own…and where they have the competency to work,” says Paradis.
In 2006, University of Utah Health Care’s University Hospital in Salt Lake City transformed its resource nursing unit—what the hospital calls its float pool—from an underutilized tool into a highly valued asset. Until that point, the nurses in the unit had been perceived as fill-ins and denied opportunities to take on challenging assignments and complex patients. Now, the 45 nurses in the unit are sought after by other units because the 654-bed hospital decided to invest in training them, explains Karen Nye, BSN, RN, the resource nurse manager.
“We have a timeline of expectations,” says Nye. “We make sure they have training opportunities within a certain date of their hire, and we make sure they adhere to that timeline.”
Now, resource nurses can earn advanced certificates in the ER, ICU, burn, and neurology units. The hospital’s AirMed medical transport team relies heavily on resource nurses since its work requires flexibility and versatility, says Nye. Most recently, a new cardiovascular ICU opened with the assistance of Nye’s resource nurses.
Since there is greater trust and utilization of resource nurses across the hospital, Nye preschedules them in units at risk of paying out too much overtime to staff nurses. The result has been a significant cost savings for the hospital. In five ICUs that accepted pre-scheduled resource nurses in 2010, there was a 62% reduction in overtime hours over a ten-month period, according to a 2011 nursing report published by the health system.
More Options for Staff Nurses who Float
Other hospitals have done away with mandatory floating by floor nurses altogether to boost employee morale and reduce turnover. In 2005, Aultman Hospital in Canton, Ohio, eliminated mandatory floating in response to frustration nurses expressed at being floated from their home units on days when patient volume or acuity was low.
The 808-bed hospital replaced its old float policy with a “Willing to Walk” program, which gives floor nurses the right to decline an offer to float without negative consequences, according to Eileen Good, MSN, MBA, RN, Aultman’s senior vice president for clinical advocacy and business development. Good oversaw the development of the program when she was the hospital’s chief nursing officer.
A floor nurse who declines to float to other units can either take time off without pay or use benefit time. Giving nurses choices and greater autonomy helped Aultman earn Magnet recognition from the American Nurses Credentialing Center in 2006.
Before Good proposed the “Willing to Walk” program, Aultman had developed specialty float pools of nurses trained to work in similar units across the hospital. Good noticed that only a few floor nurses were being floated each day because units were taking advantage of the specialty float pools, composed of 40 to 50 nurses. The rates of floor nurses required to float had decreased significantly. “If we could improve this process with float teams, then why couldn’t we just eliminate [mandatory floating]?” she asks.
As a result of these changes, Aultman reduced its turnover rate from 8.3% in 2007 to 4.3% in 2010. The hospital is in the process of reapplying for Magnet designation, says Good.
While Mercy Hospital, a 175-bed facility in Portland, Maine, hasn’t eliminated floating, it created a tiered system of compensation directly tied to the floating nurse’s competency level in 2007. The new policy was aimed at easing ill will on both sides of the float divide: nurses who floated felt unwelcomed and out of their depth when working in unfamiliar territory, while floor nurses resented the fact that float nurses were getting paid a higher daily rate regardless of their skill level.
Aside from compensation issues, there were also no clear expectations of float nurses or the units that received them, explains Scott Edgecomb, RN, RRT, CCRN, clinical nurse lead in the hospital’s critical care unit. “The expectation was that they would function at a pretty high level when they arrived,” says Edgecomb, a member of a retention and recruitment council that developed the policy. Yet, no structure had been put in place to ensure float nurses received adequate training.
The new policy created four distinct levels of competency for nurses who float, with Level One functioning as little more than “helping hands” on the receiving unit all the way to Level Four, demonstrating the highest level of competency and an ability to take complex cases on specialty floors. Now each level is compensated differently, replacing the across-the-board pay differential float nurses received before.
Edgecomb says the new float policy creates greater incentives for nurses to develop their skills, and that nurses who float now are most likely functioning at a Level Three or Four. Floating is no longer looked upon with dread, but as an opportunity to earn more and develop competencies in specialized units. And the recruitment and retention council has sought to mentor nurses who are proactively seeking floating assignments that expand their skill set.
“People were stepping forward and saying they were interested in assuming those higher level roles,” he says.
Floating as New Nurse Orientation
Advocate Christ Medical Center in Oak Lawn, Illinois, has developed a new program that aims to introduce new nursing graduates to their professions through floating. The program aims to solve two problems: the high number of seasoned float pool nurses who were leaving the pool to take positions as floor nurses and the inability of new nursing graduates in the area—south of Chicago— to find jobs, explains Kristen Brown, MSN, BA, RN, CPN, the hospital’s professional nurse educator and nurse residency coordinator.
Growing out of Brown’s practicum requirements for her master’s degree, the program is starting small but could change the way the 695-bed hospital recruits its nursing staff. In 2013, the program’s pilot year, six nursing graduates were hired from over 100 applicants, and Brown plans to hire at least two more rounds this year.
Nurses in the new graduate float program receive a 12-week orientation and participate in a 12-month nursing residency program, where they receive training with content specialists and have a chance to interact with their peers. Once they start to float, they are sent to specific zones within the hospital—medical-surgical units, orthopedics, surgical trauma, and women’s surgery—where clinical coaches work with them one-on-one over a three-month period.
Brown says the program will enable the hospital to rebuild its float pool with clinically competent nurses. By moving away from hiring to a specific vacancy and capturing strong candidates early in their careers, the hospital can fill vacancies as they occur. It also gave new graduates a chance to learn about the health system and specialties they may want to explore in the future.
“This could be the way new nurses are hired here, potentially,” Brown says. “If you have high quality candidates, you don’t have to worry about finding a spot for them. You’ve got a continuous pipeline of individuals coming in.”
Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.
It’s the experience of a lifetime. After you’ve cleared security to enter Fort Bragg in North Carolina and your vehicle has been searched, you are instantaneously awed by the enormity of this army military post. I am on my way to engage two ranking officers—nurses—in conversation regarding health care in the military. The drive takes you on the four-lane All American Expressway with vehicles whizzing by between 55 and 60 miles per hour. As I slow down to take in this sprawling city, I am reminded that I am no longer in the city of Fayetteville that abuts the post.
But the pièce de résistance was the emotional tremor I felt when the Womack Army Medical Center loomed up at the end of a long entrance way to affirm that this was iconic America. This complex, 1.1-million-square-foot (this is not an error) care facility is not just impressive by its bricks and mortar, but is a care facility providing world-class health care across a compendium of general and specialized medical disciplines to our service men and women, veterans, and the families of those who serve on active military duty. To visually take it all in requires a significant swivel of my head.
The purpose of my visit is to gain some measure of understanding and appreciation of this reputable institution and to tell the story to those who will not have the opportunity I had to visit and see for myself. My host is Lieutenant Colonel Angelo D. Moore, Deputy Chief, Center for Nursing Science and Clinical Inquiry, a native of Queens, New York, and graduate of Goldsboro High School in Goldsboro, North Carolina. Moore holds a PhD from UNC Chapel Hill and was the university’s first African American male awarded a doctorate from the School of Nursing. A scholar, clinician, and practitioner with a passion for attacking health care disparities, Moore knows his way around scholarly journals but is just as comfortable applying a Band-Aid to a 5-year-old with a splinter in his thumb. He leads the effort at Fort Bragg to integrate evidence-based practice (EBP) into all aspects of nursing care.
Moore chose Winston-Salem State University for his undergraduate degree because of the seven-to-one ratio of women to men among the student body—a decision he candidly admits worked out for him because that was where he met his wife, Lee Antoinette, a civilian nurse now on the faculty at Fayetteville Technical Community College. He was posted to Fort Bragg last July from Honolulu, where he had been stationed for six months having initiated and led the EBP process.
For the better part of a day, Moore allowed me to engage him in an in-depth conversation on what happens within the walls of this facility that necessitates a tour by a skilled guide to truly appreciate the delivery of military health care services. I was taken through the “miles” of passageways and corridors, to the service malls and the various departments, as well as the skilled nurses training center to witness the nurses being tested on their competencies on a variety of medical and dispensing procedures; the cafeteria to sample military fare; and, eventually, one of the deputy commanders of the medical center, Colonel Kendra Whyatt, who on this day was in charge.
Too often there is a perception that connects questionable treatment of our military service personnel to the assumption that the health care delivered is similarly questionable. Nothing could be further from the truth. In my conversation with Colonel Whyatt, she very carefully called my attention to the signature difference between a military nurse and a civilian nurse that is invaluable in understanding the dynamism of military health care.
“Military nurses,” Whyatt says, “wear inseparably and simultaneously the role of the soldier and the role of the nurse, and they are expected to provide care for their fellow soldiers and protection for them if necessary, and certainly for themselves at the same level of competence.”
It is this dichotomy—the syringe and the gun—that guides my desire to understand how care is delivered by our nurse soldiers to a military population of 57,000 at Fort Bragg, of which 45,000 are active duty members.
What we know today as Fort Bragg came into effect in September 1922, but its history is attached to a Confederate general, Braxton Bragg, a native of North Carolina. The post occupies 127,000 acres; its population makes it the largest US Army base; and it is the home of the Airborne—the 82nd Airborne Division, referred to as “All-American” because its members represent 48 states. It is also the home of the distinguished Special Operations Force. Among its many amenities are its schools—preschool through high school for nearly 5,000 students, the children of soldiers on active duty.
Womack Army Medical Center opened its doors on March 9, 2000. The center is named for Private First Class Bryant H. Womack, a North Carolina native who was posthumously awarded the Medal of Honor for conspicuous gallantry during the Korean conflict. The center’s mission is succinctly stated: Provide the highest quality care, maximize the medical deployability of the force, ensure the readiness of Womack personnel, and sustain exceptional education and training programs.
The center is 1,020,359 square feet, encompassing six-floor towers and other buildings. It sits on a 163-acre site, has a 153-bed inpatient capacity, and serves the more than 225,000 eligible beneficiaries in the region. It is the largest beneficiary population in the Army.
The building has a state-of-the-art design: The inpatient tower floors have an interstitial space between each floor that allows computers, as well as other technical components, to be repaired without interrupting patient care. The complex is designed to transform many of the administrative areas into service areas providing care if necessary, which would double their inpatient treatment capacity.
Four patient-centered medical homes are located on Fort Bragg, and two community center medical homes are located in the surrounding military community where their beneficiaries live and work. The Womack Army Medical Center was among the first health care providers in the country to seize on the benefits, design, and purpose of the medical home in 2004. The military’s ability to make the medical home work for their patients rests on their enormous electronic records capacity, making it easier for them to implement the benefits from the Electronic Health Records (EHR) system that gives providers worldwide access to comprehensive and timely patient histories. The $1.2 billion medical records system began deployment that year across the entire force and was fully operational by 2007, just as the benefits and necessity of the EHR were dawning on the civilian medical community.
The medical home is best described as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the simplest to the most complex medical conditions.
But there is also the Soldier Centered Medical Home (SCMH). This is a care process with an exclusive and unique focus: the soldier. It includes behavioral health, physical health, and nutrition services; these are significant to soldiers who may be displaying the symptoms of Post-Traumatic Stress Disorder (PTSD). Everyone is screened using a predetermined questionnaire and an initial evaluation that determines whether the soldier is a prime candidate for treatment or follow-up. The Army’s official position is that “80% of all soldier complaints at sick-call are muscular-skeletal,” according to physician Colonel Dallas Homas, the former commander of the Madigan Army Medical Center in Tacoma, Washington, and the originator of the SCMH that became operational in November 2011. The concept grew out of an incident where an exceptional noncommissioned officer lost his knee unnecessarily, according to Homas.
Diagnosis and treatment of PTSD, however, continues to be a contentious issue within the military sector and might have led to Homas’s reassignment from Madigan Army Medical Center. Colonel Ramona Fiorey, a nurse, assumed command of Madigan on August 9, 2013. The Department of Veterans Affairs (VA) has reported that for the last two years PTSD diagnoses are just shy of 30% of the 800,000-plus Iraq and Afghanistan War veterans treated at VA hospitals and clinics.
It is during my conversation with Moore that a picture emerges of how the soldier-nurse threads her way through the system to attain the highest heights of a nursing career. One thing they do have is the role models to motivate them to succeed. You see, the Surgeon General of the US Army is also the Commanding General of the US Army Medical Command. Currently, that person is Lieutenant General Patricia Horoho. She is a nurse. Whyatt, one of Womack’s deputy commanders, is also a nurse. Nurses provide the leadership at the highest level and at base level. This is without precedent, and the profession does take notice.
Horoho has already made significant changes regarding military health care by her emphasis on what she calls, “life space.” She wants providers to address those periods when military personnel are away from a care facility with emphasis on ensuring they are engaged in healthy behavior.
Horoho’s leadership centers around the Army Nurse Corps’ five-point strategy, known as the Patient CaringTouch System or—with the military’s characteristic use of acronyms—PCTS. It has five components: enhanced communication, capability building, evidence-based practices, healthy work environments, and patient advocacy. The PCTS is a patient-centered model for nursing care that was developed to reduce clinical quality variance by adopting a set of internally and externally validated best practices. Additionally, it is an enabler of Army medicine’s culture of trust initiative and the transition from a health care system to a system of health. The plan is elaborately laid out in a campaign document intended to guide the care leadership through 2020, with emphasis on evidence-based decisions, metrics, and best practices that cannot be overemphasized.
As you might expect, the Army takes the issue of leadership very seriously. Army nursing is guided by an Army Nursing Leader Capabilities Map that encompasses a thirty-year journey, and Moore is a good example of how the process has guided his own career. A nurse’s development has three segments, and the progression is tied to seven performance criteria. The three segments are tactical skills, operational and organizational skills, and strategic thinking and execution. The nurse can move along a career path in what is called “duty positions,” beginning as a staff or charge nurse and rising in rank to a section or department chief and then deputy commander for nursing.
During this progression, the Army nurse develops competency in such areas as change and people management, succession planning, and foundation thinking, where he or she is expected to demonstrate unit-level, evidence-based decision making. At this level, “the PhD or the DNP enables and equips a nurse to engage in visionary and strategic thinking,” explains Moore. “After ten years in the military, nurses overwhelmingly have acquired the master’s degree, and this is a distinguishing factor in military nursing culture.”
Lieutenant Colonel Moore (never addressed as “Dr. Moore” but exclusively by his rank, as is the pattern within the military regardless of credentials) actually wanted to be a dentist, but financing that career seemed to be out of reach. He heard about the Army College Fund, so he enlisted in 1989. He was placed in the communications section, but had a strong desire to transfer to the medical field. He was working to complete his associate’s degree at night and heard from a friend about the Army’s Green to Gold program in which, if selected, he could progress over time from an enlistee to an officer. He completed the degree and applied, was accepted, and enrolled in the nursing degree program at Winston-Salem State University, graduating with the BSN in 1995.
As an active duty nurse, Moore’s assignment took him to the Eisenhower Army Medical Center in Georgia as a medical/surgical nurse; later, he chose to be certified as a critical care nurse upon completion of a four-month training program. Moore tells me that this is the normal developmental pattern allowing nurses to be associated with a particular specialty of their choosing.
As a male nurse in the 1990s, Moore was not an oddity because the requirements of war had always allowed the Army to attract males to the military nursing profession. Medics were trained to provide treatment to fellow soldiers on the battlefield, so the transition to formal training to administer generalized or specialized care was natural for many. Today, males’ 30% representation in Army nursing is six times higher than in the civilian nursing population.
“Male nurses,” Moore says, “are usually more prevalent in the areas that are ‘action-packed,’ such as trauma, or the highly technical areas where elaborate technical components are integrated into the patient’s care and in emergency room nursing.”
After several years of praying “Please, Lord, do not let any of my ICU patients die on my shift,” Moore wanted a change out of critical care and chose to work in primary care to reduce the prospect of patients needing critical care in the first place. He applied to the Army’s long-term education and training program and was accepted into the master’s program to become a nurse practitioner.
His next assignment was his appointment in 2007 as a recruiting commander stationed in Brooklyn, New York, with centers in Albany, New York, and New Jersey. Moore and his team of recruiters focused on enticing doctors, dentists, and nurses into the Army as officers by being visible at medical conferences and health forums where these professionals were present. The recruiters championed the experience, benefits, and research engagements that a recent MD graduate, for example, would never get in a hospital or private practice in his or her civilian role. They also targeted students considering careers in the medical profession.
Moore responds to my question regarding minority recruitment within the Army by explaining that there is no program designed to recruit minorities into the health care ranks as a targeted group.
“To the best of my knowledge, we do not look at race in our recruiting efforts,” says Moore. “We make appealing what the Army has to offer and allow the prospect to decide. Because of the culture of the Army, we encourage the prospective recruit to consider carefully the choice of military service.”
There is a well-known, generalized concern, however, about the low minority representation among the officer ranks in the military, which has attracted the attention of the top brass. So it came as no surprise when in March 2011 the Military Leadership Diversity Commission issued a report that included the state of diversity among the leadership ranks of the military.
“The disparity between the numbers of racial and ethnic minorities in the military and their leaders will become starkly obvious without the successful recruitment, promotion, and retention of racial/ethnic minorities among the enlisted force,” the report states. “Without sustained attention, this problem will only become more acute as the … makeup of the United States continues to change.” It’s similar to the state of private sector organizations.
Whether the Army does or does not have a minority recruitment strategy, the fact is that officer and leader representation will not improve unless there is a deliberate pipeline strategy leading from enlistee to officer. However, as I walked the hallways and visited the patient treatment locations at Womack, those at work and those receiving care looked very much like America.
With Moore accompanying me as I toured the facility past the many labs, the enormous back-office function, work stations, administrative functions, physical therapy service areas, and clinical specialties of every description along the long and seemingly interminable walkways, he added to my attempt to grasp the magnitude of what takes place at Womack as a matter of routine, by citing some impressive statistics. While doing so, he emphasized that the active military and the Veterans Healthcare Services are decidedly not affected by the provisions of the Affordable Care Act (ACA).
“There is one provision, however, where we see eye-to-eye with the ACA, and that is in the aspect of prevention as opposed to curative or disease care, because a healthy lifestyle is central to mission readiness,” explains Moore. “The three streams that drive mission readiness within the healthy life space triad are activity, nutrition, and sleep—and we are confident there will be a pay-off down the road.”
In fiscal year 2013, the Womack Army Medical Center had over 12,000 admissions with a 62% average daily bed occupancy rate and average length of stay of 2.6 days, over 3,000 live births, and over one million outpatient appointments. On a daily average, the associated clinics provided over 3,400 outpatient visits, approximately 6,000 outpatient prescriptions, almost 1,000 radiological exams, over 4,000 pathological tests, almost 200 Emergency Department visits, almost 40 surgeries, and at least eight live births. There are two medical residencies (family practice and obstetrics), and 14 other physician or Allied Health educational and training programs. Moore points out that no prosthetic service is provided to the injured soldiers at this facility. He reminds me that the health care staff consists of active duty members, Department of Defense civilians, and contractors who include civilian physicians and nurses. It is easy to identify the civilian medical staff because they are listed on appointment boards by their medical credentials; whereas, the active duty medical staff are listed by their rank, often on the same appointment boards.
Moore guides me along a walkway with photographs of distinguished service members and towards the skilled nursing center where competency tests are taking place. This is a biannual event where nurses are tested and certified to perform certain medical procedures. Womack nurses are required to expose themselves to this process if they are to be allowed to perform certain procedures. It is proctored by senior nurses and other technical staff. My visit to the center as this event was taking place was purely coincidental.
In a room deep inside the complex, nurses were examined on performing catheterizations on a mannequin (part of the infusion therapy procedure) and on their ability to know the difference when it is a pediatric patient compared to an adult; reading and interpreting the ECG tape—a necessary step before referring it to a cardiologist; identifying mental health behavioral issues such as PTSD; and using newly introduced, technologically sophisticated equipment. There are charts and poster boards everywhere. The atmosphere is intensely business-like, presided over by a nurse with the rank of major and dressed in fatigues. Even the test mannequin appears to be aware of the buzz over the event’s significance.
Next, Moore takes me to the pharmacy services mall, which is where the patients have their prescriptions filled. Every aspect of this procedure is very clearly understood as between 25 and 30 patients wait for either a consultation with a pharmacist or watch to see that their prescription is ready. The first served are those requiring immediate and preferential attention: the active duty soldiers. He or she registers as they all do, and the patient’s name lights up on a marquee pallet as an indication that the prescription is ready. The active duty member’s name will supersede all others.
Finally, our walk heads towards the command center where Moore has arranged for me to visit with Colonel Whyatt, Deputy Commander for Nursing and Patient Services, who is acting commander today because Commander Colonel Steven J. Brewster is off the post. This is Whyatt’s first assignment to Fort Bragg. After being cleared to enter the command center, I am seated in what is quite easily comparable to an executive suite in any corporate headquarters. The offices are bright and cheerfully wood-paneled, with each executive officer’s support staff seated within earshot of their work stations. One is dressed in fatigues, as is Colonel Whyatt. She is tall, relaxed, and with a distinctive military bearing that suggests a calm, in-control demeanor. She is a native of Greenwood, Mississippi, and was previously stationed at a military facility in Germany.
With my discussion about minority recruiting still turning over in my mind, I wanted to know her opinion regarding mentoring and coaching. But first she has to be reassured by Moore that I have been cleared to have this conversation with her.
I first want to know what makes for a successful and responsive military health system. “It’s the combination of the military, civilians, and contractors working together,” Whyatt responds.
“What are the two top concerns that occupy your attention?”
Whyatt responds succinctly: “[To stay in mission readiness], I have to recruit staff, retain and train staff, and we are facing challenges in this area; in particular, in the recruiting and retention of staff. Most everyone knows that certain funding is at a standstill.”
“Do you mean the sequester?”
“Yes.”
But a majority of hospital executives believe there is a shortage of physicians and nurses in the US, according to a new survey from American Mobile Nurses Healthcare, a staffing company that recently published its 2013 Clinical Workforce Survey. It found that 78% of hospital execs think there is a shortage of physicians; 66% say there is a shortage of nurses; and 50% report there is a shortage of advanced practitioners. The survey also found that the vacancy rate for physicians in hospitals is nearly 18%, compared to 10.7% in 2009, and nearly 17% for nurses, up from only 5.5% in 2009. The vacancy rate also rose for allied professions, from 4.6% in 2009 to 13.3% in 2013. But Womack is currently under a staff freeze, and the civilian workforce is expected to be reduced sometime during 2014.
Colonel Whyatt owes her military career to her mother. At the end of Whyatt’s sophomore year at Prairie View A & M University, her mother strongly suggested that instead of coming home and looking for a summer job, she visit with the ROTC office on campus and see what they could do for her. Whyatt visited the office, enlisted, and went on to complete her undergraduate degree in nursing with a scholarship from the Army. Her career has taken her to three tours of duty to Germany and several Army posts within the US.
“Are you mentoring and coaching any on active duty at this time?” I ask.
“That is an expectation of this position. Yes, I am,” she responds.
