Kyana Brathwaite, founder and CEO of KB CALS- Caring Advocacy & Liaison Services, worked as a critical care nurse when she hurt her shoulder during a patient transfer.
“Our patient population is getting heavier [and] it is not always realistic to pull colleagues from different areas/departments to help. My true issue was not with the injury—although unfortunate, they do happen—my issue was with how my particular situation was handled after the injury by both management and the entity I worked for,” she explains.
For these reasons, the pain of her injury and the lack of support by management, Brathwaite chose not to stay at the bedside. Would she have stayed had circumstances been different?“Prior to the injury, I was
considering staying at the bedside for at least five more years to give me time to plan the direction in which I wanted to take my nursing career.”Although she did plan to continue her career eventually, she would have given solid years to suffering bedside nursing specialties.
In fact, many nurses run from the bedside as soon as possible because conditions are so deplorable. They look for jobs in advanced practice, teaching, and other non-bedside related areas of nursing, while the number of nurses taking care of the most critical patients continues to dwindle.
Here are four reasons nurses leave the bedside and some ideas as to how to make them stay.
1. New Grad Education
New grads can go into a bedside job and not know exactly what they are in for. In nursing school, clinicals usually don’t go beyond two to three patients per student so they are not exactly exposed to the real-life rigors and stresses that come with the life of a bedside life—and cultural shock is a very real phenomenon.
“Nursing students are constantly told by faculty, peers, mentors, and experienced nurses what bedside nursing is ‘really like,’ says Greg Eagerton, DNP, RN, an associate professor at the University of Alabama at Birmingham School of Nursing. “However, it is like the first time we ride the bike by ourselves…The same is true for new nurses; their hands are held throughout their training and then the day comes when they are ‘alone’ and it’s a little frightening. They now have the sole responsibility for their patient’s care, their patient’s life—and that can be daunting. It’s also the reason we always encourage team support from their mentors, their more experienced peers, and from all members of the health care team, including physicians, therapists, support staff, etc.”
Although this is true, new grads often express intense dislike of their new role as a bedside nurse, and they immediately want to move to another branch of the profession. Is it that the nurse is not prepared or that the job is simply too difficult? It certainly sounds like management is trying to accommodate new nurses, but a quick search of internet nurse boards will reveal new nurses in despair. Perhaps more intensive job shadowing will allow new grads to see what bedside nurses do. Perhaps more realistic teaching would also go a long way toward helping them. Whatever the answer, new grads are a special population that needs attention—though it already gets quite a bit—to keep them safe and happy at the bedside.
2. Staffing Ratios
Another issue that chases nurses from the bedside is poor staffing ratios. It can be overwhelming for one nurse to have eight to ten patients to themselves. Not only is it unsafe, it is also stressful, and many nurses would rather find a new job than to put their licenses and their mental health on the line like that. For this reason, staffing ratios are important to consider when examining the loss of bedside nurses.
“I do not feel staffing ratios is the main driving factor,” argues Ken Shanahan, MSN, RN, CCRN-K, clinical nursing director at Tufts Medical Center. “One of the main reasons I feel this way is because the only state with staffing ratios is California and yet they have the most nurse strikes. These strikes are actually increasing dramatically and are something we will need to address as a profession. The work environment is the most important factor and number of nurses or ratios is only a component of the working environment. There are many other components that we are not hitting the mark on that would help create a healthy work environment.”
Although a large portion of nurses would disagree with Shanahan’s opinion on the importance of staffing ratios, he does have a point: they are not all that is involved here. Getting the floors better staffed is only one part of the puzzle, but addressing pressing issues such as horizontal violence is needed, too. Everyone knows about staffing ratios, but few realize they are only one prop to hold up a very large house meant to keep nurses at the bedside.
3. Compassion Fatigue and Burnout
Compassion fatigue and burnout are the psychological components that keep nurses from staying at the bedside. The two are closely related but are not the same. Burnout, in short, is frustration with the situation and is typified by anger. Compassion fatigue is an exhaustion of the ability to extend oneself emotionally anymore and is typified by depression. Please note, these are very simple definitions and they are not exhaustive. Both of these conditions can occur together, and neither is pleasant. Nurses have had their lives broken over these issues, and no one wants to go through that. How, then, do we solve this problem?
“Burnout and compassion fatigue are concerns for direct care providers in all professions,” explains Eagerton. He suggests the following measures to help support staff:
Leaders should be visible and approachable.
Work schedules should allow adequate time off between shifts.
Adequate breaks should be provided during the work shift so that staff have down time.
Schedule time for staff to have discussions about what stressors they are experiencing that may lead to burnout and fatigue.
Create opportunities for staff to be involved in activities that allow them to do things that are not direct patient care but have meaning to them, such as committee membership, attending professional conferences, and so on.
Have resources available for nursing staff in addition to their managers to discuss their stressors, such as chaplains, mental health professionals, and counselors.
Have dedicated space(s) on or near the units where they work where they can have some quiet time or time to eat their meal or have their break without interruption.
With these ideas in place, nurses can have a better shot at overcoming compassion fatigue and burnout. When these are not a factor or are a mitigated factor, the more a nurse can feel happier staying at the bedside.
4. Injuries
Nursing is definitely a contact sport, as stories like Brathwaite’s prove. Transferring patients is getting more and more difficult with increased body weights. In addition, various specialties are more susceptible to transfer related injury. For instance, operating room nurses are at great risk because they must move patients who are unconscious and essentially dead weight. However, that doesn’t make your typical bedside nurse any less at risk. Moving and lifting are just as much a part of the job, and mechanical equipment is usually not available to help.
“There is only one of you, [and] there will always be more patients,” says Nick Angelis, CRNA, MSN, author of How to Succeed in Anesthesia School (And RN, PA, or Med School) and cofounder of BEHAVE Wellness.“If no one is available to perform a task safely with you, don’t do it. Hospitals always push putting the patients first, but you’re a danger to patients if you give and give until your weekly schedule must also include time for massage and chiropractor appointments. Flu vaccines, unsafe equipment, dangerous staff ratios, risk of physical harm from unruly patients because hospital security resembles nursing home patients—these all require putting yourself first.”
It really does come down to this: Nurses need to learn how to put themselves first. If you can’t lift that 300-pound patient, then don’t even try, no matter how much it needs to be done. Similarly, hospitals need to make allowances for nurse injuries. Providing mechanical lifts, better security, and education about safety could go a long way towards protecting nurses and keeping them at the bedside.
In the end, the question of keeping nurses at the bedside is definitely multifactorial—and controversial. Patients have been cared for all this time with the methods we’ve been using, so why change? The reason to change is that the nursing shortage is real, and it isn’t what you think. It isn’t a lack of trained nurses. It is a lack of trained nurses willing to work. If we can make the bedside more appealing to these nurses who have run for cover, perhaps the nursing shortage wouldn’t really exist at all.
One of the American Nurses Association’s seven Bill of Rights for Registered Nurses is to “freely and openly advocate for themselves and their patients.” Yet, women and minorities may not be as effective advocating because they’re less likely to negotiate. There is a “win-win” negotiating style, developed at Harvard’s famed Negotiation Project, which may be more appealing. Practice them in small ways until they become second nature. Then when it’s necessary to advocate about safety, staffing, workplace violence, etc., you will be ready with a collaborative, problem-solving approach.
But if you don’t negotiate? Nurses who accept poor compensation or working conditions can end up feeling victimized, devalued, and unmotivated. With that attitude, they are less likely to provide excellent patient care and to get promotions. Don’t let that happen to you. Elevating your negotiation skills will lead to better communication, collaboration, and results for you and every other party.
Reframe the Concept of Negotiations
Given the overwhelming percentage of female nurses, it’s important to consider how
gender plays into negotiation. Research shows that women are two and a half times more apprehensive about negotiating, while men are four times more likely to initiate a negotiation. In fact, 20% of women say they don’t ever negotiate, even when the situation necessitates it, according to Linda Babcock and Sara Laschever, authors of Women Don’t Ask: Negotiation and the Gender Divide.
That apprehension keeps many nurses from learning and practicing this important communication competency. “Negotiation is in the top five life skills that everyone should have,” insists Donna Cardillo, RN, author of The Ultimate Career Guide for Nurses.
“We negotiate all the time—with our kids, partners, patients, and coworkers, often without even realizing it. The word can have a negative connotation but only because most people don’t understand what it really is,” explains Cardillo. In health care, there is an additional connotation, and that’s terms of negotiation and union contracts, she adds.
According to Webster’s Dictionary, “negotiation” is defined as “to meet and discuss with another in order to reach an agreement.” But many of us suspect that in order to do that, one party must dominate, trick, or pressure the other into submission.
Sometimes, we have to reframe an uncomfortable concept, like negotiation, and perceive it in a new way, to make it more palatable, notes Cardillo.
“For example, say a nurse wants to attend a national nursing conference, and get paid time off, and expenses covered and so on. I’ll advise explaining the benefit to the hospital and the nurse manager. ‘By going, I’ll be able to bring back information from national speakers and experts to share. I will do an in-service session, or write a paper on it, and I’ll bring back printed materials,’” she explains. Nurses needn’t let a “No” response discourage them, either, adds Cardillo, because it may take repeated requests to get what you want. But if you don’t ask, the answer is always “No.”
Another way to reframe it, Cardillo says, is that by asking you’re planting seeds of change for the future, so you’re advocating for yourself and for your profession.
“Many of us were raised not to ask for what we want and to feel satisfied with whatever we got. I just saw a tweet from a nurse: ‘People say I need this job. I say this job needs me.’ That’s so true. Everyone is entitled to feel valued in the workplace,” she says.
Steven P. Cohen, author of The Practical Negotiator, has trained health care professionals in negotiation skills globally and agrees that nurses must self-advocate. “Your number one job is to look out for your own interests. Self-interest means maximizing circumstances to help you get what you need: good pay and benefits, rewards and resources that let you serve the patient. You must be well served.” He notes that if a nurse is treated badly, then he or she can’t function well, and patients suffer.
There are three kinds of interests to consider and prioritize in a negotiation—in conflict, complementary, or in common, according to Cohen. “If you’re going on vacation with a multigenerational family, how likely is it that you have common interests and all want to do the same things? Not likely. But you may have complementary interests. Your goal could be that everyone in the family will have a good time on the vacation.” He advises nurses to look for where there are complementary interests and no conflict, and to build step-by-step to a win-win solution. “Most anyone in a hospital, from aide to CEO, has similar objectives,” he adds “and is asking the same questions: How can I make the most of my job? How can I take care of the people I need to take care of?”
Negotiate in Your Off-Hours
One of the best ways for nurses to become empowered is for them to learn and practice good negotiation skills, asserts Michelle Podlesni, RN, president of the National Nurses in Business Association. “Why are we having nurses that don’t last two years in a hospital setting? Because they aren’t empowered and negotiation starts with assuming your power. I help nurses to understand their power,” she explains.
Podlesni believes that negotiation skills can be learned, like other important nursing skills. Earlier in her career she read The Power of Nice by Ronald Shapiro and Mark Jankowski, and it made a big impression on her. The book defines negotiation as using knowledge to get what you want, using the “three P’s” of preparing, probing, and proposing.
“Say a new nurse is getting scheduled in a certain way. How do they know it’s fair? You ask: ‘How is the schedule made?’ Nurses don’t always assess their own situation and propose what works better for them. We need to make a paradigm shift—your license is a license to start practicing in your business as a nurse,” Podlesni says.
Negotiate with Coworkers
Whether delivering direct patient care as a manager, researcher, or as an entrepreneur, nurses need effective negotiation skills. Not every nurse is in a role that requires negotiating with patients, students, vendors, clients, or external agencies. But almost universally, nurses must negotiate with colleagues and coworkers.
“I’m a double minority, a male nurse and an ethnic minority,” says Usama Saleh, RN, BSN, MSN, PhD, a nurse educator.
Usama was working as an RN in oncology and often negotiated with colleagues about the assignment of patients, for instance, and to resolve conflict so all parties are satisfied. In addition to ensuring an equitable workload, “it’s important to negotiate with your nurse mates on the team in order to deliver effective care. I always look at it in terms of quality of care,” he explains.
Usama came to the U.S. from the Gaza Strip and also had to become accustomed to the negotiation style of Americans who were born and raised here. “Culture and religion influence the etiquette of negotiation,” he says. “I wasn’t able to be aggressive; I was a soft negotiator. I admired it when negotiators were more assertive, but because of cultural factors I couldn’t do it.”
Usama also taught in China for short while and saw how negotiation is different there, as it is throughout the Middle East. Though he can adjust his individual style to the culture, overall, he’s happy with it. “I believe using a softer negotiating style has given me good results. It’s softer than usual in the U.S., but it is still effective and I’m very satisfied with the outcomes,” he adds.
Now You’re Ready for Salary Negotiations
“When I speak to groups of nurses I have a joke: Everything in life is negotiable except for the salary of a staff nurse,” says Cardillo. Most hospitals have set salary ranges for nurses, sometimes negotiated by unions, until you go on to be a case manager, supervisor, or manager.
If you’re not sure if salary negotiation is appropriate in your role or organization, Cardillo suggests you probe with these phrases:
Is there any way to … ? (Boost salary, add benefits, etc.)
Are any adjustments available?
Is there any room for negotiation?
Where to get salary survey info: professional associations, National Association of Colleges and Employers (NACE), Salary.com, jobstar.org, bls.gov, medzilla.com, career fairs, career development centers, and coworkers.
Even if you can’t negotiate your initial salary, you may be able to negotiate during a wage and performance review or an improvement plan meeting. “Most of the time, nurses are nervous going in to that type of meeting,” says Podlesni. “Take ownership of the discussion and go in prepared with information and knowing your desired outcome.”
For example, in a performance evaluation where a nurse is judged poorly, he or she doesn’t have to accept an unfair assessment. In one such situation, “an emergency room nurse was told she did not have timely emergency room skills such as inserting NG tubes,” Podlesni recounts. “I advised her that evaluations need to be conducted fairly and use consistent criteria across that board…I recommended that she request a video or documentation of someone doing the skill in the timeframe suggested. They were unable to provide this, and as a result, she received her $10,000 annual salary increase.”
During a wage evaluation, you can always negotiate for a higher salary or better benefits package. “Say your salary is $60,000 a year,” Podlesni says. “What stops you from saying ‘I love my job and want to keep working here, but I need to get to $65,000 a year to spend that much time out of my home and to pay childcare expenses’?” You may not get that raise but at least it starts a conversation and then you can decide if you want to stay in the job or if it’s time to find a better paying employer.
Believe in Your Value
Minority nurses bring an extra dimension to their work that they may not recognize and value highly enough. “Being Latina and bilingual, bicultural, we’re typically in a culture that doesn’t boast,” says Adriana Perez, PhD, ANP-BC, FAAN, assistant professor of nursing at the University of Pennsylvania School of Nursing. “We’re taught that you have to be modest, don’t call attention to yourself. It’s about building relationships and taking care of others. We have to balance humility with self-confidence.”
At the National Hartford Centers of Gerontological Nursing Excellence leadership development program, Perez learned the essentials of career success, including salary negotiation.
“AACN publishes mid-to-average salaries for professors that might not factor in additional skills or expertise,” she explains. “I’m bilingual, board-certified adult nurse practitioner, and researcher addressing health equity issues that are national research priorities. There aren’t that many Latina nurse scientists so it puts me in a great bargaining position. I can help the school meet its inclusion and diversity mission. But that’s not enough. I have to produce results and demonstrate a measurable impact.”
Polish Your Negotiating Skills
Many organizations offer professional development workshops that focus on cultural diversity, communication skills, negotiation, and conflict resolution. The leadership program that Perez benefited from included a career-enhancing mentorship relationship.
“We grew from mentor and mentee to now colleagues and friends. I attribute a lot of my growth to that program,” she says. “I recommend finding mentors. Study the leaders in your organization whose style you like and who are well-respected. Ask them for coffee: ‘Can we schedule some time?’ Nurses are giving and want to help. They’ll share lessons learned and will tell you about programs, scholarships, training, and other resources out there.”
It’s true that some nurses will never enjoy advocating for themselves. But it doesn’t have to be that way, with a little practice they can increase their confidence and ability. The end result: Better outcomes for everyone.
