Why Good Nurses Leave the Profession

Why Good Nurses Leave the Profession

It’s 8:00 a.m. and Christa Thompson, BSN, RN,* is travelling to a local Houston hospital to educate nursing staff on the latest medical device. A typical day is anywhere from two hours up to 12 hours for her, but she’s not unusually tired or stressed by the end of the day. A nurse for over five and a half years, Thompson is a RN by trade and works part-time as an independent clinical consultant training other people on the use of medical devices. She credits her nursing education and curiosity at an international nursing conference for getting her this job.

“I went up to a medical device booth at the conference and asked the representative if they hired nurses, simply out of curiosity,” says Thompson. “I was pretty much hired on the spot.” She loves her consultant job and knows her new career is a dream job for most nurses, but nursing is not where her true passion lies.

Thompson plans on leaving nursing to become a doctor. Nursing has been a rewarding career for her, but she realizes she can’t do nursing forever, even if her intentions weren’t to continue on to medical school. She is not alone in the sentiment that nursing at the bedside is not something that most nurses can do for their entire career. Her path to transition from the bedside is unique but not uncommon to many nurses in the profession.

Of the 3,514,679 nurses in the United States, nearly 63.2% of RNs and 29.3% of LPNs work in a hospital setting. The RN Work Project reports an average of 33.5% of new RNs leave the bedside within the first two years. Leaving the bedside to pursue other nursing positions does not necessarily mean nurses leave the profession, but it is a catalyst to do so. Why do some nurses leave the bedside and eventually the profession? Ask any nurse and the answers are varied, but common themes seem to ring true for most.

Why Nurses Leave the Bedside (and, Ultimately, the Profession)

Poor Management. One of the greatest complaints nurses have is the lack of support from their management team. What makes a poor manager? Some nurses may say it’s one who doesn’t value open-communication and feedback from his or her staff. Some say it’s the management team that plays favorites amongst staff or a particular shift. Yet, other nurses say it’s the manager who is not supportive of a nurse advancing her career. The list could go on forever, but one common frustration among nurses is the overall lack of support for those at the bedside. It seems to some that once nurses become managers, they “forget where they come from” and are oblivious to the struggles a bedside nurse faces on a daily basis.

Management may not even be aware of the stressors their staff encounters working the bedside. It could be that they are so wrapped up with their own job that they can’t focus on what would make life better for their staff. Or it could be that they just don’t care. Whatever the case, nurses do feel strongly about poor management.

Thompson agrees that management sometimes shows little consideration for those working at the bedside: “I feel like the night shift is ignored by management, like they have no voice.” The same sentiment echoes true for many other nurses. They feel as if management does not value them as part of the health care team—just as a docile staff that follows orders without question.
The best form of leadership follows a diplomatic approach; meaning, higher-ups actively engage their employees for input on situations that may arise. The diplomacy allows for everyone to have a voice. This type of management style encourages active participation among all employees and may dissipate some of the negative feelings some nurses feel towards their management team.

Lack of Upward Mobility. Many nurses unhappy with their chosen profession find that job mobility from the bedside is difficult without an additional degree. A nursing degree overqualifies many from other jobs outside of nursing and may not pay the equivalent of a nurse’s current salary. In order to get a job that pays as much or more than the average RN makes, additional years of school are typically required. This is a sacrifice that some may not be able to make, given that going back to school requires time away from work.

For those willing to go the extra mile and complete a higher degree in nursing, many career opportunities abound. Going back for an advanced nursing degree is the way some nurses find personal satisfaction in their career. Although not in a graduate program yet, Brittany Green, BSN, RN, a relatively new nurse of three years, plans on becoming a family nurse practitioner to influence patients in an outpatient setting and prevent some of the morbidity and mortality she sees in her current job as a cardiovascular recovery room nurse.

Green believes nurses leave because they experience burnout. “It’s not a career for everyone. It takes a special type of person to handle the emotional and physical stress that comes along with nursing,” she says. “I know I won’t be able to do bedside nursing forever; the long hours and stress will start to wear more on me.”

Underpayment. A nurse’s job can be physically and emotionally draining. Many nurses feel like they are severely underpaid for the work they do. Twelve-hour shifts can feel more like 16 when you are working the job of four people, but only getting paid for one. Nurses also sacrifice holidays, weekends, and family events because of their long and ever-changing schedule.

On the other hand, one may say a nurse’s schedule is ideal; a three-day work week schedule and having the ability to take long vacations using minimal vacation time sounds appealing to many.
But at what cost?

Nurses are notorious for picking up extra shifts on their day off because they feel like they are being paid not nearly enough for the work they do. Based on the most recent Minority Nurse annual survey results, the average RN salary in the United States is $67,980 per year. This may be considered a solid middle class income for most Americans, but nurses work very hard and feel as though it is not enough most days.

Too Many Tasks. Today’s nurse does it all; you name it, nurses do it. Administer meds? Check. Assist patients with dressing, bathing, and mobility? Check. Perform bedside procedures once done by physicians? Check. Coordinate care between all disciplines of the hospital? Check. The list is endless—and that’s the problem. Nurses are responsible for so many aspects of a patient’s care that it can become overwhelming for one person to manage during a shift.

A typical nurse works a 12-hour shift that translates into much more when the nurse is doing the job of multiple people day in and day out. Sometimes a nurse is so involved in completing everything it becomes difficult to take a much needed and deserved break during her shift. This makes for a very long day. Although the typical nurse’s schedule consists of three 12-hour shifts per week, when the days are packed with multiple tasks and responsibilities each and every day, burnout is inevitable. Studies conducted to rate nurse turnover clearly show that as a nurse’s workload increases, nurse burnout and job dissatisfaction—both precursors of voluntary turnover—also increase.

Nurses performing too many tasks typically boils down to staffing, specifically understaffing, which is also known as short staffing. When nursing units are short-staffed, nurses take on a majority of tasks done by others simply because they know how to do many other people’s jobs, but those people cannot do the job of the nurse. How many nurses have had to cover the front desk because there is not a unit secretary on duty? Or how about the nurse who is behind on her nursing duties just because she is trying to complete activities of daily living for a patient that is usually carried out by a nurse’s aide? Nurses wear the hat of many, but no one can take on the role of the nurse.

Short Staffing. A resounding number of nurses blame short staffing as the most common reason nurses leave the profession. According to a recent poll on Allnurses.com, more than one third of 1,500 nurses polled say that continuous short staffing drives nurses from the bedside and, ultimately, the profession. One of the reasons for short staffing is management cutting costs as much as possible—and what better way to do that than cut staff and work on less than is needed? Nurses are notoriously known to multitask, wearing many hats on a day-to-day basis. Management knows this and may not think it’s a problem to go without a unit secretary or nurse aide on the unit because nurses will pick up the slack. Unfortunately, this unequal distribution of work leads to many unhappy nurses who burn out quickly when doing the job of many people.

Employers can ease the burden on nurses by mandating nurse-patient ratios. Since 2004, California has mandated patient ratios of 1:5 for nurses working in hospital settings. Studies have shown the benefit of such staffing ratios. The Aiken study demonstrated that nurses with California-mandated ratios have less burnout and job dissatisfaction, and the nurses reported consistently better quality of care, leading to decreased turnover.

Decreasing patient-nurse ratios has more benefits than disadvantages that could benefit US hospital systems. The Aiken study followed nurses in three states: Pennsylvania, New Jersey, and California—with California being the only state with mandated nurse-to-patient ratios. Over 22,000 RNs were surveyed, and researchers found:

• RNs in California have more time to spend with patients, and more California hospitals have enough nurses to provide quality patient care;
• In California hospitals with better compliance with the ratios, RNs cite fewer complaints from patients and families;
• Fewer RNs in California miss changes in patient conditions because of their decreased workload than RNs in New Jersey or Pennsylvania;
• If California’s 1:5 ratios on surgical units were matched, New Jersey hospitals would have 14% fewer patient deaths and Pennsylvania hospitals would have 11% fewer deaths;
• Nurses in California are far more likely to stay at the bedside and less likely to report burnout than nurses in New Jersey or Pennsylvania.

Maybe other states should follow California’s lead and mandate nurse-patient staffing ratios. What will it take to get the message across to industry leaders and make a change in how staffing levels are managed across the United States?

To Stay or Go?
The nursing profession isn’t completely lost on Thompson. She still works occasionally at the bedside on an intermediate care unit simply because of the one-on-one interaction she has with her patients. Many nurses reflect that they love nursing and enjoy spending time with their patients—something that is becoming more and more difficult with everything nurses are expected to do in this day and age.

The decision to leave the bedside affects not only the nurse contemplating such a transition but also the facility and patients who may be taken care of in a facility that is short-staffed. Replacing a nurse is costly. The RN Work Project cites the average cost to replace an RN who leaves the bedside ranges from $10,098 to $88,000 per nurse. What’s more astonishing is total RN turnover costs range from approximately $5.9 million to $6.4 million per year at an acute care hospital with more than 600 beds.

There are nurses who love their career and wouldn’t ever think of leaving. Kim Hatter, MSN, RN, is one of them. Drawn to the profession because of her mother, she was inspired by her compassion at an early age: “[My mother] was actually one of the first African Americans to graduate from Southern Arkansas University as a registered nurse.”

When questioned whether or not she had plans on leaving the profession, Hatter says no. “I’ve never thought of leaving the nursing profession, but I have sought a higher level of education in nursing recently.” Like Green, Hatter is completing her goal of becoming a nurse practitioner. She recently graduated from an adult–gerontology program and will soon leave the bedside to work at an outpatient clinic.
Because the bedside can be brutal on the body, many nurses like Green and Hatter choose to pursue nursing higher education to move from the bedside instead of leaving the profession completely. “I’ve heard of a lot of nurses with back and knee injuries,” says Hatter. “Nursing is a physically taxing job and does take a toll on your body.”

What is the Answer?
Nurses face a variety of challenges in the workplace that makes their job difficult. Based on the most prevalent and distressing issues identified by nurses, what is the overall answer to keep nurses at the bedside and, ultimately, in the profession? The RN Work Project reported when RNs leave their job, most go to another health care job not necessarily in a hospital. This is great for the general community, but it leaves a gap in coverage in hospitals where most acutely ill patients go. Where does that leave patients who need care in a hospital setting?

Green doesn’t think there is any one solution to the problem. “Burnout will always be an issue in the nursing profession,” she explains. “I think one of the most important things is for nurses to feel appreciated—by employers, coworkers, physicians, and hopefully patients.”

Hatter has a different prospective on potential solutions to this monumental problem: “I think paying nurses a higher rate of pay is always an incentive to stay. I also think nurses should receive more recognition for the valuable role they play in society.” The common denominator between Hatter and Green is that they both believe the nursing profession deserves more credit than it currently receives—and maybe this is the first step in keeping nurses happy and in the profession for the long haul.

Sexual Orientation and Gender Identity in Nursing

Sexual Orientation and Gender Identity in Nursing

It’s been said that lesbian, gay, bisexual, and transgender (LGBT) nurses form one of the largest minorities within the profession, and yet they are hardly recognized as a subgroup. To date, limited data are available to determine just how many nurses identify as LGBT (or some variation of those letters, such as LGBTQ, in which the “Q” stands for questioning or queer). But according to a 2013 Gallup poll, approximately 3.5% of the US general population identifies as LGBT; so whether or not you identify as LGBT, it’s likely that you will have to treat patients who do at some point during your nursing career. As patient advocates first and foremost, nurses must strive to provide culturally competent care for all, regardless of gender or sexual orientation.

LGBT nurses and patients alike face a unique set of challenges in the health care system: hostile personnel, lack of insurance, and higher rates of certain disorders, such as substance abuse. Yet both seek to make the health care system more supportive and equitable through changes in policy, education, and advocacy. Their aim: to raise cultural competence of health care professionals and lower the health disparities and barriers to care affecting LGBT individuals, families, and couples. Here are the profiles of five professionals committed to leading the charge for an open and accepting health care environment.

Austin Nation, RN, PHN, MSN 

PhD Student at University of California – San Francisco (UCSF)

Veteran nurse Austin Nation has over 30 years of nursing experience to his credit, including stints in hospital supervision and providing AIDS services, before heading back for a PhD program. His aim is to teach nursing, which he is now undertaking as an adjunct professor at San Francisco State University.

He says he’s faced a “triple-whammy” of discrimination—surprising in a city like San Francisco, where he expected more cultural competency around these issues.

“I thought this was the gay mecca, with open, liberal thinkers, but that hasn’t been the case,” he says. “I’ve experienced racism, sexism, and homophobia. I’m a black male in nursing. I’ve been blatantly subjected to all this stress while embarking on a PhD journey, which is already stressful enough.”

Nation wonders why the UCSF system, which dominates the city and cares for a larger LGBT population than any other, is “so provincial when it comes to addressing issues closest to the heart of that community.”

“We have beautiful diversity banners, photos of different kinds of people together all getting along, but it isn’t like that,” he says. “In an academic setting, change happens so slow—it’s like turning the Titanic.”

Nation takes every opportunity to raise consciousness in class. “I’m trying to provide education in real time as it happens.” For example, if a nurse refers to gay patients in a distant or disrespectful way, he’ll step in: “Hey, that’s us you’re talking about—we’re not those people.” In addition, Nation leads a Men in Nursing group and is spearheading an LGBT Cultural Competency for Healthcare Providers workshop that has generated overwhelming interest.

One part of the problem, Nation suggests, is that “the health care community tends to be conservative. We come from a paradigm of heterosexuality.” It wasn’t too long ago that homosexuality was considered a psychological aberration, he adds.

Nurses are often uncomfortable with the subject of sexuality and reluctant to talk to patients about sexual health, Nation has observed. He suggests that discomfort first crops up during physical assessment class as undergraduates.

“We learn about the human sexual reproduction system. Then, during a head-to-toe assessment of a patient, you pull the covers up and look. But what are you looking for?” What happens if a nurse pulls up the gown of a male and sees female sexual organs, say? “That’s a good opportunity to have a conversation about gender variances,” he says.

“There have been many people that didn’t accept me,” explains Nation. “I’m the kid from the ghetto who made good. For me, the saving grace is that I’ve had women who’ve taken me under their wings. They watched over me and protected me in difficult or sensitive situations. I try to create that same sense of belonging for my students.”


Riikka Salonen, MA

Manager, Workforce Equity and Inclusion, Oregon Health & Science University (OHSU)

A bi-national native of Finland, Riikka Salonen leads diversity and inclusion strategy efforts at OHSU in Portland, Oregon. “Our intention is to provide an environment of care which is welcoming and inclusive,” she says, “as well as protective of patient and employee rights and benefits. For instance, we’ve had same-sex partner benefits since 1998, and offered transgender health-specific benefits for employees for over a year.”

Family inclusion is one topic that OHSU focuses on—and for patients, that means visitation is a given for everyone, including same-sex couples or a child who has two mothers. “Family inclusion also means that if a gay employee wants to put out family photos, they feel they can without there being whispering about it.”

OHSU Pride, an employee resource group for LGBTQ employees and allies, was started in 2007 to ensure an inclusive environment. “OHSU Pride has created a significant difference in our campus, which has become very LGBTQ-affirming,” says Salonen.

LGBTQ education and consciousness-raising at OHSU is an ongoing effort, Salonen notes, starting with new employee orientation. From there, it proceeds on an as-needed basis, depending on a nurse’s specialty. For example, Salonen says, OHSU provides “a specific session for pediatric nurses that focuses on providing care for transgender or gender-nonconforming youth.”

Parents worried about a 5-year-old boy who insists he’s a girl, for example, can be referred to TransActive Gender Center (www.TransActiveOnline.org), a national nonprofit with low-cost services for youth and families. (For those living outside Portland, Skype counseling sessions are an option.)


Mary Bylone, RN, MSM, CNML

Regional Vice President, Patient Care Services, Hartford HealthCare, East Region, and Director, American Association of Critical-Care Nurses National Board of Directors 

“I’m 58 and didn’t figure out my lesbian orientation until later in life,” says Mary Bylone. “My brother is gay and so is my son. I didn’t come out at first because of the prejudice and abuse my brother experienced. As a manager, I’m now out; [but] as a staff nurse, I wasn’t.”

Bylone says her sexual orientation doesn’t totally define her: “It’s part of me, not all of me.” She has noticed that fellow employees and patients gravitate toward her to talk about gay issues. Possibly, she suspects, they do it “because I’m an out person in a responsible position. One day, a mother started crying when she told me her son was gay. I was able to comfort her as the mother of a gay son.”

Bylone has experienced situations where patients have discriminated against gay nurses. “I remember a patient who asked to see me when I was a head nurse,” Bylone recalls. “She didn’t want to see her nurse that day. ‘Why? Is it because he’s a man?’ ‘No, that’s just the problem. He’s no man,’ is what she answered. Unfortunately, the nurse was standing outside the door and heard her cruel complaint.”

Bylone adds that managers sometimes treat out nurses differently. “You may be assigned a gay patient when people know you’re gay, misunderstanding that someone’s sexual orientation does not define her or his entire person,” she explains. “I’m a nurse who happens to be lesbian, not a lesbian nurse.”


Emily Pittman Newberry

Trans Woman and Recent Surgical Patient in Portland, Oregon

Emily Pittman Newberry says she lived life for 55 years “pretending to be a man,” before embracing her gender identity as woman and transitioning over a period of five years. “People often ask me, ‘When did you decide you were a woman?’ The question should be: ‘When did you acknowledge it to yourself and choose to live openly?’” Every transgender person Newberry has met or read about says they always knew.

Newberry maintains that health care personnel have been universally professional and even kind to her during this process, though she had trouble with her insurance company. They wouldn’t cover the cost of surgical gender-confirming surgery.

She has some advice for nurses, such as not taking it for granted that you know a patient’s gender. “Ask them to self-identify and tell you what gender pronoun they prefer you use in referring to them,” says Newberry, though she understands that “asking is a tender place for a nurse and a transgender person.”

“Sometimes I see someone who is clearly struggling with it—getting pronouns wrong, getting uptight [such as the time she asked a clerk to change her gender in the clinic patient record system],” says Newberry. “I want to say, ‘This is new for everybody.’ It’s my job to educate people, be kind and humane even when I feel angry. It’s a dance, and we’re all learning the steps.”

Another piece of advice is to not get thrown if a transsexual patient has a health condition that doesn’t match their gender as your records show it. “If you see a prostate problem in a woman, for instance, act like it’s no big deal,” Newberry suggests.

Many health care IT systems only offer “male” or “female” as gender choices, which is limiting and potentially hazardous. Binary options are also being challenged by popular culture. Facebook now allows users to self-select from 56 gender options, such as “transgender” and “intersex” and “Female to Male/FTM.”

There are bound to be many uncertainties and uncomfortable moments for Trans patients and their nurses as we travel this unmarked path. “Do your best to carry on in a professional way,” says Newberry. “Ask yourself: ‘Am I being tender or am I being rational?’ You can be both at all times, of course, but sometimes more on the compassionate side and other times the scientific. Both are a part of every health care professional—you can emphasize one or the other, depending on the situation.”


Desiray Bailey, MD

Hospital Chief of Staff, Central Hospital, Group Health Cooperative, Seattle, WA, and immediate past president of GLMA: Health Professionals Advancing LGBT Equality (formerly known as the Gay and Lesbian Medical Association)

“GLMA was a physician-oriented organization originally, but we decided to be more inclusive and include the whole health care team,” says Desiray Bailey. “We work to provide opportunities to practice openly and more compassionately.”

Nurses are now an active part of the group, as evidenced by GLMA’s annual conference and nursing summit, scheduled for September 10-13, 2014, in Baltimore, Maryland.

One of the aims of GLMA is to improve education and awareness of gay and transgender issues among health care personnel. “It’s a very rare nursing program that provides LGBT education,” says Bailey. “We’d like to see it as part of the curriculum for all health professionals—physicians, nurses, physician assistants, and people in behavioral health training.”

At Group Health, Bailey has been an advocate for equal treatment of LGBT staff and patients for many years, facilitating changes in policy, employee benefits, patient and family visitation, consumer rights, and community outreach.

Additionally, she advocates for equal treatment so that “any professional in a hospital or medical center who is gay, lesbian, bisexual, or transgender won’t experience discrimination as an employee because they can’t be out, or their organization doesn’t provide benefits that are equitable with straight employees.”

In many states where LGBT employees aren’t a protected class, it’s possible to be discriminated against or fired for being gay. Even worse, a few states have “anti-gay laws—where certain sexual acts are illegal—or there aren’t specific protections,” Bailey says. “I’m fortunate to live in Washington State—we’ve had domestic partnerships for a few years and now marriage equality.”

According to Bailey, the Affordable Care Act has benefited the LGBT community. “Insurance plans can’t discriminate based on sexual orientation or gender identity. Legally married couples are still recognized, even if they live in a state that doesn’t recognize their union, and there aren’t lifetime limits for AIDS patients,” she adds.

Among the tools available to improve LGBT equality in a health care setting is the Healthcare Equality Index of the Human Rights Campaign, a civil rights organization. “This is a tool that really changes the atmosphere for employees and patients,” says Bailey. Once a decision has been made to participate, “there’s an organizational will to want to score well. They want to put in place the right policies and training for staff,” she adds.

Seeking out legitimate information about LGBT issues is very important “if you want to take care of all your patients,” Bailey says.


Jebra Turner is a freelance health and business writer based in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at www.jebra.com. 


Achieving Salary and Career Satisfaction

Achieving Salary and Career Satisfaction

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. 


Advanced Degrees and Certifications: What You Need to Succeed

Advanced Degrees and Certifications: What You Need to Succeed

Advanced education and specialty certifications can help minority nurses take their careers—and their ability to improve health outcomes—to a whole new level.

Carmen Paniagua has so many educational and professional credentials after her name that she practically needs an oversized business card to fit them all. In addition to being an RN, she is an ANP (Adult Nurse Practitioner), a board-certified ACNP (Acute Care Nurse Practitioner) and AGACNP (Adult-Gerontology Acute Care Nurse Practitioner), an APNG-BC (Advanced Practice Nurse in Genetics), and a FAANP (Fellow of the American Academy of Nurse Practitioners). She’s also a CPC (Certified Procedural Coder) and a CMI (Certified Medical Interpreter), and she holds MSN and EdD (Doctor of Education) degrees.

“Some people probably look at my CV and think this is just a lot of ‘alphabet soup,’” says Paniagua, a faculty member at the University of Arkansas for Medical Sciences College of Medicine in Little Rock. “But advanced degrees and certifications are more than just a collection of letters. They’re the evidence and recognition of your competence and clinical expertise. They enable nurses to take pride in the accomplishment of advanced practice knowledge and to demonstrate their specialty expertise to both employers and patients.”

Jose Alejandro, president of the National Association of Hispanic Nurses and corporate director of case management at Cornerstone Healthcare Group in Dallas, agrees that it’s what those abbreviations really stand for that counts.

“You can have all the degrees and certifications you want, but it’s the tools you learn from having them that’s the biggest benefit,” says Alejandro, an RN-BC (Registered Nurse-Board Certified), CCM (Certified Case Manager), FACHE (Fellow of the American College of Healthcare Executives), and a MBA who recently earned his PhD. “They give you additional skills and what I call your ‘chops.’ That’s primarily what has enabled me to move up in my career, because I can accomplish things based on more than just having experience.”

Graduation Books

Opening Doors

There are many compelling reasons for minority nurses to pursue graduate education and specialty nursing certifications. Acquiring these credentials opens the door to a wide new horizon of rewarding advanced practice careers and leadership roles—from nursing professor and nurse scientist to nurse practitioner, nurse anesthetist, nurse executive, and more. Furthermore, the Institute of Medicine’s (IOM’s) landmark 2010 report The Future of Nursing: Leading Change, Advancing Health calls for all nurses to “achieve higher levels of education and training” and “attain competency in specific content areas” in order to respond more effectively in today’s rapidly evolving health care environment.

But the IOM report also underscores an even more persuasive reason. Advanced degrees and certifications—or more precisely, the specialized knowledge and skills nurses gain from them—are linked to improved patient outcomes and better nurse-led interventions for eliminating minority health disparities.

“This is a wonderful time for all nurses, and particularly nurses of color, to seriously look at graduate education, because of the millions of uninsured and underinsured people who will now be coming into the health care system as a result of the Affordable Care Act,” says Kem Louie, PhD, RN, PMHCNS-BC, APN, CNE, FAAN, professor and director of the graduate nursing program at William Paterson University in Wayne, New Jersey. “Many of these new patients will be members of medically underserved minority populations. The other issue is that there’s a shortage of primary care physicians. So there’s a tremendous need to increase the number of culturally competent advanced practice nurses who can meet these patients’ primary health care needs.”

Of course, it’s also hard to ignore the “what’s in it for me?” benefits. Becoming certified in an in-demand specialty—for example, emergency nursing, perioperative nursing, critical care, or pediatrics—increases your value to employers. Plus, it’s no secret that many advanced practice (APRN) specialties that require a master’s degree and board certification—such as Certified Registered Nurse Anesthetist (CRNA) and Certified Nurse-Midwife (CNM)—pay substantially higher salaries than the typical staff RN position (see sidebar). In fact, according to the most recent (2008) Health Resources and Services Administration (HRSA) National Sample Survey of Registered Nurses, RNs with graduate degrees earn an average of at least $20,000 more per year than nurses with lower education levels.

But it’s not just about the money, argues Henry Talley V, PhD, CRNA, MSN, MS, director of the nurse anesthesia program at Michigan State University College of Nursing in East Lansing and treasurer of the American Association of Nurse Anesthetists. “Advanced degrees and specialty certifications do increase your earning powers,” he says. “But they also increase your ability to make change happen in health care. They make you an expert in your particular field, and they put nurses on an equal footing with other health professionals.”

Breaking Down Barriers

Minority enrollments in graduate nursing programs have nearly doubled over the past decade, according to the American Association of Colleges of Nursing (AACN). Yet racial, ethnic, and gender minority nurses continue to be underrepresented among the ranks of APRNs and certified RNs—primarily because they’re still underrepresented in the nursing population as a whole. Fortunately, numerous nursing organizations, from AACN to the American Board of Nursing Specialties, are recognizing the need to identify and remove barriers that may prevent nurses from diverse backgrounds from earning the advanced credentials they need to succeed.

Traditionally, one of the biggest challenges in going back to school—for majority and minority nurses alike—is finding the funds to pay for it. And thanks to the current economy, with its skyrocketing tuition rates and burgeoning student loan debt, figuring out how to afford graduate school can be a trickier task than ever. Then there’s the cost of certification examinations, which in some cases can range from about $300–$400 to as high as $725 for the CRNA exam. But even though finances can be a formidable obstacle, they’re not an insurmountable one.

“What I have personally observed is that our potential minority nursing students are much more hesitant to take out loans and incur debt than majority students,” says Courtney Lyder, ND, ScD(Hon), GNP, FAAN, dean and professor at UCLA School of Nursing. “And what I tell them is: Nurses make good salaries. Compared with other academic disciplines, the compensation in nursing makes it one of the few professions in which you can actually pay off student debt in a timely manner.”

“One of the benefits of coming to graduate school now is that there are still scholarships and federal financial assistance programs available,” adds Louie, who is also the founding president of the Asian American/Pacific Islander Nurses Association. She cites HRSA programs like the National Health Service Corps, which provides scholarships for nurse practitioner and nurse-midwife students in return for a commitment to practice in a medically underserved area for at least two years after graduation, and the Nurse Faculty Loan Program, which forgives 85% of student loan debt for RNs who complete a graduate degree at a participating school and agree to serve as full-time nursing faculty.

Talley and his wife, a Clinical Nurse Specialist (CNS), recently conducted research examining some of the other factors that impede minority nurses from pursuing advanced degrees in general and nurse anesthesia degrees in particular. Lack of knowledge about APRN and specialty nursing career paths is another big barrier, he says.

“There are still people of color out there who have just not had the exposure to these career options,” Talley explains. “Nursing specialties have to get the message out to them about these opportunities and what the requirements are. Nurses need to know early on that they will want an advanced degree, because the key to opening that door will be how well they do in their undergraduate studies. Otherwise, they’ll find out about advanced practice specialties later in their BSN programs and decide ‘I want to do that’ when their GPAs will not support it.”

But Alejandro believes that perhaps the hardest hurdle for minority nurses to clear is the surprisingly common “fear factor.”

“It’s the fear of failure, fear of the unknown, fear of whatever,” he says. “I tell all the students I mentor: ‘The very first barrier you have to overcome in pursuing any advanced education or any certification is removing that fear.’ In my case, once I was over that fear, I was able to ask questions. If I didn’t understand something in a particular class, I went ahead and asked classmates who understood it a little better.”

Starting the Journey

So you’ve decided it’s the right time to return to school, earn an advanced degree, and chart your course toward a fulfilling specialty nursing career. Congratulations! But where do you start? How do you choose which graduate program to apply to? And what type of degree should you go after? Is a terminal master’s enough or will you need a doctorate?

Lyder, who made history by becoming the first male minority dean of a school of nursing in the United States, as well as the first African American dean at UCLA, says it all boils down to answering one basic question: What do you want to do?

“Find your bliss,” he advises. “Is it pediatrics, geriatrics, psych/mental health, administration, nurse-midwifery, nurse anesthesia? Once you’ve figured that out, the next step is to identify schools in your community that may have those programs. Then, contact those schools and schedule a time to talk with the admissions counselors—and I don’t mean an e-mail—to see if this is something you really want to pursue. Also, try to find an opportunity to shadow someone who’s in that role. Identify that CRNA or that psychiatric nurse practitioner and say, ‘Can I shadow you for a day to get a sense of whether this is what I want to do?’”

Getting over the fear of speaking directly with admissions officers or the graduate program director to get the facts you need to make well-informed decisions about a school is key, Louie emphasizes.

“You have to tell yourself, ‘Just pick up the phone,’” she says. “Graduate programs in nursing are competitive and some of them can be very daunting. But I find that I have to invite students to talk to me, to ask me, ‘What support services are available? Tell me about the admission requirements. Help me through the application process.’”

As for what kind of advanced degree to get, once again it all depends on your goals.

“Some nurses are confused about advancing their education. They think they all have to be PhDs,” says Paniagua. “Well, if you’d like to be a nurse researcher, then a PhD is fine, because it’s primarily a research-focused doctorate. But then there are other avenues. You can get a doctorate in nursing practice (DNP), which is a professional practice degree, or you can get an EdD, which is an education-focused doctorate. So if you’re planning to have a career in academia, you should pursue either an EdD or a PhD. If you’re planning to practice or to work in the clinical setting, you should get your DNP. Or you can just get a master’s degree [in your specialty area of interest, such as an MBA or an MSN in nursing informatics].”

Above all, the most important thing to consider when shopping around for a graduate program is finding one that’s the right fit for your specific needs—both academic and personal.

“You need to make sure that your value system is in sync with the mission and vision of the institution,” Lyder says. “For example, here at UCLA we are a research-intensive school of nursing. Our professors infuse research and evidence-based practice into every course, every lecture, everything they do. If that’s not the type of learning environment you want, then this isn’t going to be a good match for you.”

Louie recommends investigating different program formats to find options that will accommodate what she calls “your life needs.” For instance, if you have to keep working at your job while going to school, or you have young children or other family obligations, the traditional full-time, brick-and-mortar campus model may not work for you. “You need to know that there are online programs, there are blended online/on-campus programs, there are part-time and weekend programs,” she says.

Another alternative worth exploring is the accelerated (fast track) format. These programs include RN-to-MSN—also known as a Master’s Entry Program in Nursing (MEPN)—which bypasses the traditional BSN degree, and BSN-to-PhD, which bypasses the master’s. Their greatest advantage is that they enable nurses to earn graduate degrees more quickly and earlier in their careers. However, because the accelerated time frame makes the academic workload extremely intensive, these programs aren’t for everybody.

Taking the Plunge

Achieving the advanced degrees and certifications that will boost your career to a higher level can be an arduous process. But all the nurse leaders interviewed for this article agree that the rewards are worth it. In fact, with the right preparation, the right program, and strong support networks (family, friends, faith, colleagues, mentors, and minority nursing associations), it might just be easier than you think.

Talley offers this advice: “Don’t be afraid to take the plunge. I think sometimes we [minority nurses] doubt ourselves, and there’s no reason to. Believe in yourself, have faith in yourself, and don’t let anyone interfere with your dreams.”

Honesty and Ethics in Nursing

Honesty and Ethics in Nursing

The latest Gallup Poll of Honesty/Ethics in Professions says the most trusted profession (for an astounding 13 out of the last 14 years) is—drumroll, please—nursing. When random Americans were asked to “please tell me how you would rate the honesty and ethical standards of people in these different fields,” more than 85% gave nurses “high” or “very high” marks.

Caring Nurse

This year’s rating is the highest since 1999 when the profession was first included in the poll. The one year nurses didn’t top the list? It was 2001, after the terrorist attacks of 9/11, when firefighters were included for the first and only time and scored higher. Gallup conducts the telephone survey in late November each year.

Health care professions dominated the top five most trusted groups: pharmacists came in next at 75%, medical doctors rated 70% (tied with the oddballs in this cohort—engineers), and dentists earned 62%. The lowest rankings go to car salespeople (8%) and, sadly, members of Congress (10%).

What is it that makes nurses so trustworthy? There are as many theories as respondents. Some say intimacy. After all, we stand naked—both literally and metaphorically—before nurses. But would the ratings be similar for massage therapists, say? Not likely. The Gallup data suggest that women—on the whole and on average—are seen as more trustworthy than men.

So would male nurses earn the same trust ranking as female nurses? Most likely.

But can nurses count on garnering trust automatically? Definitely not.

In the end, trust is personal. Some minority nurses especially feel that they must battle for respect. Here are a few ways to enjoy high regard in this very special profession—one that for many nurses is more of a “calling” than an occupation.

Embrace your role as a caregiver and patient advocate. “One reason for trust is that nurses have what I call the home-court advantage,” says Ramón Lavandero, RN, MA, MSN, FAAN, senior director of the American Association of Critical-Care Nurses. “They’re with patients and their families more than any other professionals. In the hospital, it’s 24/7; even with home care, nurses still have more patient and family contact than anyone else.”

Lavandero says another factor is that above all else, nurses keep their patients’ needs in mind. “They see nurses going to bat for them when there are rules or systems in a health care setting that aren’t effective.” For example, it doesn’t serve end-of-life patients, he says, when hospital regulations don’t allow visits from a lifelong pet.

Turn up the volume with stellar communication skills. “One of the things I learned as a man and a nurse and as a native Puerto Rican is that if I was comfortable in a situation, the patient was comfortable,” says Lavandero. “Ninety-nine percent of my experience was without problem, and that includes the year I worked in a labor and delivery unit.”

Strong communication skills become even more important when there is perceived bias, such as a patient who believes a minority nurse may be less competent or have a substandard education. “That’s when your communication needs to shine,” he says, “perhaps by addressing the unasked question with a comment like ‘Did you know, when I was a student at Columbia University …’” A skilled communicator learns that direct confrontation is only one way to address barriers such as mistrust, he adds.

Nurses must communicate with many parties besides patients, including families, administration, and other health care staff members. It’s not easy to speak to (and on behalf of) multiple constituencies, especially when a nurse isn’t familiar with a patient’s desires, circumstances, or cultural background. “That’s why we need to learn all we can about a patient and have to determine how to be honest without creating or introducing more difficulties,” says Lavandero.

Recognize that ethical issues are a cornerstone of nursing. “Nurses are also trusted because their Code of Ethics is grounded in fairness and respect for all people,” says Cynda Hylton Rushton, RN, PhD, FAAN, the Anne and George L. Bunting professor of clinical ethics at Johns Hopkins University in Baltimore. Ethical training is part of every nursing school curriculum, and a code of ethics guides all nurses as they care for patients, she says. This is not a profession that only pays lip service to a moral ideal.

Some common ethical questions that nurses must consider, according to Rushton, are: “How do we balance what patients or families want with what’s available? (Often there are limits.) Also, how do we balance quality care with safety and efficiency?” One element of quality care is relationships, she says, but the “health care system is relationally depleted” and devalues relationships in favor of efficiency.

Also, our American society and health care system “would like to pretend that death is optional,” she explains. “There is such fear and despair around aging, illness, disability, and death. Sometimes we feel that we’re doing things that are harmful or disrespectful to patients. That’s not what we’re called to do as nurses.” Nurses are often at the center of trying to navigate a broken system that causes them much distress, she adds.

Moral distress is a term Rushton uses to describe when a nurse knows the moral thing to do, but feels powerless to act on it. It’s paramount that nurses become knowledgeable about ethical issues and effective ways to address quandaries, she says.

The future can be brighter, though, if nurses realize the public’s trust in nurses is “sacred” and “hard won.” She implores nurses to “make sure, first of all, that we’re deserving of it. And second of all, uphold that trust.”