EMPOWERING. UNITING. ADVANCING.
Winter 2019
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Nursing’s Evolution Through the Years
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EMPOWERING. UNITING. ADVANCING.
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EDITORS / CONTRIBUTING WRITERS Mary Watts, BSN, RN Judi Dansizen, MSN, APRN Beth Hawkes, MSN, RN-BC Joy Eastridge, BSN, RN Melissa Mills, RN, BSN, CCM, MHA Maureen Bonatch, MSN, BSN, RN Lorie Brown, RN, MN, JD Brian Sorenson
allnurses is published quarterly by allnurses.com, Inc., 7900 International Dr., Suite 300, Bloomington, MN 55425 All rights reserved. Reproduction in whole or part without written permission of the publisher is prohibited. The opinions of contributing writers to this publication do not necessarily reflect the views of allnurses.com, Inc. Copyright © 2019 by allnurses.com. All rights reserved.
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Contents
Nursing As a Profession: Changes Through the Years By Joy Eastridge
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Nursing Uniforms: From Skirts to Scrubs and Beyond By Melissa Mills 38
34
The Evolution of Nursing Education By Beth Hawkes
Departments
Current Issues in the Nursing Profession and Resolutions for Future Change
6 Editor’s Note
Nursing Career Adventures
11 Calendar
24 By Maureen Bonatch
By Judi Dansizen
10 The Best of...
12 Career Tips 44 Trending Products
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The Good, The Bad, and The Ugly By Mary Watts 14
7 Nursing News Briefs
46 Get Social 47 LOL 54 Expert’s Corner
Editor’s Note While reading through this issue’s articles in their raw form, there was certainly a common thread that I picked up on. No, it wasn’t the fact that I should turn the heat up in the office a couple degrees. It was the passion that our writers have not only for their nursing jobs but also for telling the stories of those who they are writing about.
Connect
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allnurses Magazine is both simple and complex. The countless hours behind the scenes that our dedicated staff put into discussing potential stories, crafting a framework for these potential stories, and finally putting together a cohesive theme for each issue. All told, it’s no small feat to accomplish these tasks. But in the end it’s the writers whose passion for nursing – and writing – truly shines in the often lengthy and always informative articles within
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Contact us
We welcome your story ideas. Reach us at magazine@allnurses.com
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“They may forget your name, but they will NEVER forget how you made them feel”– Maya Angelou
the pages of this magazine. The simple part is feeling the appreciation from our readers about how we have taken a new approach to telling the stories of nurses and helping to empower, unite, and advance the nursing profession. With the common thread of the Winter 2019 issue of allnurses Magazine being the past, present, and future of nursing; the timing couldn’t be better. When much of the world is reflecting on the past year or years and simulataneously looking forward to the new year that is already well upon us, we’re proud to have a wealth of information in the next 50 or so pages which manages to look at where nursing has come from and how we must tackle the pressing issues as nurses to elevate the profession. Here’s to 2019!
Nursing News Briefs
Cleveland Clinic Unveils Top 10 Medical Innovations for 2019 ohio
texas Affordable Care Act Struck Down by Texas Judge
Cleveland Clinic takes progress seriously. They recently compiled a list of the top 10 Innovations for 2019. Their top innovation is pharmacogenomic testing, which uses a patient’s genetic makeup to predict an individual’s metabolism of drugs, including some opiate-based drug. This can result in a more individualized approach to pain relief which will also result in improved pain relief. While some patients have a genetic makeup that makes them metabolize medications faster than others, it will allow providers to tailor prescription ordering to an individual’s genes.
The federal individual mandate penalty was repealed in 2017. Recently, the state of Texas along with 19 other states sought to have the Affordable Care Act (ACA) repealed as the individual health care mandate was the cornerstone of the ACA and without it, the law is no longer valid. So what does this mean to most of us? The American Medical Society weighed in on this decision via AMA president Barbara McAneny, MD. She stated, “The AMA will work with the patient and other health stakeholder groups in pursuing an appeal and reversal of this unfortunate decision at the district court level.” Additional concerns were raised by other healthcare agencies that this could result in 20% of Americans that could end up without affordable health insurance. Read More...
Artificial intelligence (AI) is another innovation that will come to forefront of healthcare in 2019. For instance, machine learning algorithms have the ability to highlight problem areas on images, aiding in the screening process and quickly making sense of the mountains of data within a physician’s EMR system. Read More...
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Nursing News Briefs
Assessment of Risk Factors and Bio-Markers Associated with Cardiovascular Disease Among Women Consuming a Mediterranean Diet A recent study published in the Journal of the American Medical Association (JAMA) explored the link between a Mediterranean diet and lower cardiovascular risk in women. This survey included more than
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25,000 US women and the conclusion was that the higher Med diet resulted in a decreased cardiovascular risk of 28%. The article compares other earlier studies conducted in Europe as well. The conclusion was that “a
sizeable proportion of the potential benefit of MED intake with CVD risk reduction remains unexplained and requires future investigation into additional mechanisms�. Read More
Fentanyl is the Deadliest Drug in America, CDC Confirms According to the CDC, Fentanyl is now the most-oft used drug that results in an overdose. Fentanyl was involved in nearly 29% of all US overdose deaths in 2016. In 2011, fentanyl was involved in just 4% of all drug fatalities. At the time, oxycodone was the most commonly involved drug, representing 13% of all fatal drug overdoses, Many overdoses involve more than one drug, either intentional ingestion of multiple substances or accidental ingestion of multiple drugs. Fentanyl is often laced into heroin and cocaine. Read More... Winter 2019
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The Best of allnurses.com Each quarter, hundreds of amazing articles are published on allnurses.com, below are those deemed the best by our readers!
Nurse Gives Lethal Dose of Vecuronium Instead of Versed On December 26, 2017, a tragic and preventable death occurred when a patient at Vanderbilt Hospital was sent for a Positron Emission Tomography (PET) scan and received a lethal dose of Vecuronium instead of Versed. The Department of Health and Human Services Centers for Medicare and Medicaid (CMS) did not investigate the event until October, 2018 as the death was not reported to them at the time.
Nurse Salaries Versus Executive Administrative Salaries: A Chasm Worth Crossing
The gap between nurse salaries and those of healthcare executives rose from 23:1 to 44:1 in 10 short years. Our healthcare system is strapped, we are in the midst of a nursing shortage, and it seems there is a chasm be between caregivers and administration when it comes to wages. Learn about this pay chasm and how you can help.
The Bravest Thing I’ve Ever Done
October is Breast Cancer month. It is also Domestic Violence Awareness month. I’ve been through both, and breast cancer is not the hardest thing I’ve ever done.
Jewish Nurses Take Care of Synagogue Shooter
After the shooting at the Pittsburgh synagogue, nurses, some of the Jewish, took care of the perpetrator. This article discusses our Code of Ethics and our professional care of all people.
Terror at the Boston Marathon Finish Line - An interview with Jessica Kensky, RN
The morning of April 15, 2013, began as a normal day. The third Monday in April has been celebrated as Patriots Day and the day for the running of the world’s oldest annual marathon for 117 years - the Boston Marathon. But this day would soon be known forever as a very dark day in American history. In an interview, Jessica Kensky shares memories of that day and how she and her husband’s lives were forever changed.
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Calendar of Events A brief and informative overview of events, conferences and special promotions for the nursing community.
AANA Mid-Year Conference Washington, DC APRIL
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April 6-10, 2019 Washington, DC
The AANA Mid-Year Assembly is designed to prepare nurse anesthetists to effectively advocate on Capitol Hill for protecting and advancing CRNA practice and reimbursement.
AORN 2019 Global Surgical Conference and Expo Nashville, TN APRIL
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April 6 - 10, 2019 Early Bird Rates Available until Feb 15, 2019
ANNA National Symposium Dallas, TX APRIL
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April 14-17, 2019 Hilton Anatole Save by registering by Feb. 25, 2019
64th ACNM Annual Meeting Washington, DC MAY
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May 18-22, 2019 The largest gathering of midwives in the United States.
LNC Retreat Indianapolis, IN APRIL
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April 13-14, 2019 A Retreat With LNC Mentor, Lorie Brown
Are You Ready To Take Your LNC Business To A New Level –Way Beyond Your Current Expectations?
AACN – NTI 2019 Orlando, FL MAY
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May 20-23, 2019 Registration fees increase after April 3, 2019
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Career Tips
How Often Do Nursing Managers Ask Clinical and Medication Questions During Interviews? by Beth Hawkes MSN, RN-BC, HACP
Beth Hawkes (Nurse Beth) is an accomplished nurse working in Acute Care as a Staff Development Professional Specialist. She is also an accomplished author, blogger and columnist. As Nurse Beth, she regularly answers career-related questions at allnurses.com.
Dear Nurse Beth, I have been a Cardiothoracic Surgery Stepdown Nurse for almost 2 years now. My hospital is currently restructuring and eliminating the Stepdown phase of care. Because of this change, I am currently looking for new positions in the CTICU. I recently interviewed for a CTICU position and the nurse manager seemed to be very critical of my work experience and my knowledge of the field. He asked me if I started drips on my floor and if so what are the side effects of Neo and Amnio? It completely caught me off guard because I had walked in ready to
Click here to submit your career-related question to Nurse Beth today or visit https://allnurses.wufoo.com/ forms/z1j8p9o81puszdb/
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talk about my work experience. I just wanted to inquire about how often nursing managers ask clinical and medication questions during interviews. Dear Caught Off Guard, It really depends. If a manager is looking for a nurse with equivalent experience to jump right in with minimal orientation, they may ask about particular drugs, drips and device management. For example, a manager interviewing an ICU traveler may want to make sure they’ve had recent and like experience.
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In your case, you are a Stepdown nurse and it’s expected that Stepdown has a different level of intensity and interventions than ICU. The questions sound more like quizzing than interviewing. You are right, you should expect to talk about your skills and experience and be evaluated for a good fit for the unit. A good response would be “While those drips were not administered in Stepdown, I prioritize patient safety above all else. I always make sure I’m familiar with drugs and side effects before I administer them. I look forward to learning new skills and advancing my practice.” I would say that either the manager was evaluating you for your learning needs, or perhaps was just an inexperienced interviewer. Sometimes new nurse managers, having just come from the bedside, focus overly much on clinical tasks and skills, because it’s all they know until they gain experience. Managing a patient on an Amiodarone drip can easily be taught. Aptitude and teachability, not so much. Best Wishes, Nurse Beth Author, “Your Last Nursing Class: How to Land Your First Nursing Job”...and your next!
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THE GOOD, THE BAD, AND THE UGLY What are some of the biggest changes you have seen in nursing and medical technology, for better or worse? Seasoned nurses are special, not only because of the knowledge they possess and the skills they have mastered but also for the many changes and advances in medical technology they have seen over the years. We polled our readers about what changes they have seen in nursing‌ for better or worse. Here is a sampling of what they had to say.
Responses from allnurses seasoned nurses
“Goodbye paper charting, hello EMR.” Pixie.RN, MSN, RN, EMT-P
“Advances that are used to decrease staffing which only increases nurse stress levels such as getting rid of telemonitor techs and putting out lots of telemonitors and loud alarms everywhere so you are basically tortured by alarms for the entire 12 hour shift and adding tele alarms onto a phone so even when you get a call from a Dr you can’t hear because the alarms are ringing, 90% false while you are trying to listen! Likewise getting rid of sitters for video monitors with cameras and a remote person that is supposed to watch your confused problem patients and tell them not to get out of bed and call you and/or ring an alarm if they start getting up or pulling at their IV or essential equipment. Again another blaring alarm to torment us. I’m giving report and hearing a loud alarm and asking where is it coming from it sounded like a code alarm, oh that’s the video monitor. Wow! And let’s not forget the BIPAP’s that are being frequently used to prevent intubation and many times the patients kept on the floor even over 40% when they are supposed to be in ICU and their very loud disruptive alarms! I hate the alarms! On the other hand, I like the lift equipment like sit to stands and hover mats that help us safely move patients where before we had to hoist them with our bare hands and back. Ceilings lifts would be even better but we don’t have them, not in the budget.” brandy1017
“We know what we know because we did it....there is a devolution on clinical in today’s nursing education .... of course, I’m coming from a ‘72 diploma program...... our critical thinking skills were developed in our 70% clinical” sallyrnrrt, RN Winter 2019
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“I LOVE HoverMatts. I really think that was the best invention ever. And self-turning bariatric beds!!! Those are sooooooo awesome. I also think there has been a lot of advancement in home chest tubes like pleurx drains. I love pleurx drains! But yes, the reduction of actual monitors to watch your tele patients and visual hubs for sitters are very unsafe in my opinion. Reduction of phlebotomists has been the next big thing I’ve started to notice and that makes me angry, “please draw all your own labs on your 6 heme/onc patient’s between 5-6 and then pass meds between 6-7 and be ready for report at 7.” One thing I kinda wish could come back is a hospital ward instead of rooms, HIPAA be damned. Can you imagine how cool it would be to see all 6-7 of your patients at all times! I worked in a tiny ER that was still set up this way, so cool!” KalipsoRed21, BSN, RN 1. Robotic surgery 2. Encrypted text messaging/paging 3. Self-scheduling 4. Tele-health 5. Remote monitoring of home patients 6. Urgent Cares 7. Free-standing EDs 8. Simulation labs with robotic patients traumaRUs, MSN, APRN, CNS “I would love to see visiting hours brought back and/ or enforced. In my experience it causes more harm than good to have visitors (and sometimes many at one time) in at all times including spending the night. Also agree that nursing education has not kept up with reality. Even when I went to school (20 yrs ago) we were taught the correct way and then told “in the real world you would do this/that..”, and it is even worse now.” Daisy4RN, ADN
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“I love wound vacs. These wounds heal so much better. Dressing changes used to mean deep packing wet to dry dressings every shift. We still do the occasional wet to dry, but there are some really effective newer products for wound care that didn’t exist twenty years ago.” RNperdiem
“The ongoing fight of ADN/Diploma vs BSN. We aren’t using common sense, nor are our employers. The “magnet status” has created monsters and pushed for “higher education” that in truth has very little to do with critical thinking skills of a bedside nurse. I am an ADN. I once had a BSN tell me that she would never allow an ADN or Diploma nurse care for her when she delivered her child. Funny how that changed when she arrived to deliver and the only BSN was a new grad. We are cheating potential future nurses out of fabulous careers (for those that can only afford in time and money the ADN program), we are not supporting local community colleges and we are pitting one nurse against another. We are also forcing ourselves into a true nursing shortage when we no longer accept ADN’s and the BSN’s chose to move away from the bedside. While I personally have not experienced the “nurses eating their own”, I certainly see it now. It has become more of a popularity contest than what is truly valuable for our patients and their safety. It’s difficult to work as a team when a young BSN tells me it’s “proven” that he has better critical
thinking skills than my 20+ years of experience in acute care, let alone the Diploma nurses that truly had the most intense training. For those of us that choose to stay at the bedside, in acute care, with national certification and educational credentials specific to our field, what in the world is the point. And please, don’t reference a study by a BSN program. Those are tainted at best and anyone can cite a “study”. I want a nurse, ADN, Diploma, BSN - that has the common sense, great judgment, and critical thinking skills to save my life. Not a degree on a wall, or title on a badge. After our BSN nurses were given special embroidered scrub jackets with their BSN titles, I chose to purchase my own scrub jacket, with my title, ADN. I was promptly told it did not meet dress code........ And what do I love about nursing? That our patients still need human interaction, education, and compassion. That for the most part, they still appreciate and respect nurses. And I would say even more so as every aspect of our job becomes electronic.” butterball1980
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“I worry that there will be no one left that remembers how to do things without a computer. How to organize all the paper, how to communicate between floors. It’s a skill we should maintain, but unless we’re doing it daily, it’s going to be lost. That’s too bad. The patient satisfaction push. Yes, we needed to be more responsive to patient input and keep them as part of the health team, but once they choose to endanger their own health, we shouldn’t be a party to it. Yes, I want to control pain, but I want the patient to be able to do PT. Yes, I want to encourage a patient’s making their own choices, but that fifth tub of ice cream...they need to walk to the kitchen and get it themselves. I’ know my fellow nurses get this, but the suits seem oblivious.” canoehead, BSN
“EMR- love /hate relationship, older programs with redundant, outdated systems, or lack of physician compliance- ease of access and patient safety check a plus, not having to play guess that word as much for written orders. Pyxis- wonders over a med cart. Medical information access- easier to find relevant patient education information but also harder for patient care when. Dr. Google diagnosis cancer not there. Work phones- direct number to reach for needs or paging doctor: awful when also ringing for random crud all shift long. Insulin pumps and glucose monitoring systems. Cardiac devices that monitor pt in outpt setting sending data to phone program or Dr. office. Internet forums for advice, education, social interaction, and venting.” Kallie3006, ADN 18 Winter 2019
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“I love all the new technologies in IV Therapy. The use of Tip Confirmation Sytems to verify tip PICC placement lessens treatment delays and saves nursing time and money. Also the use of Ultrasound to get that PICC well above the ACF in the Basilic or Brachial vein. The use of Ultrasound to start a PIV is a different matter. While still good, it’s not as easy as many portray it to be and they have a much greater propensity to infiltrate than the standard method to start an IV. Do I use it.....yes...but only if I have to if other options do not exist. It does buy some time though to get IV therapies started while you work on central line access. It’s also annoying that nurses fail to learn how to start an IV by palpation or visualization and want to go straight to technology. They pick these superficial veins with a vein light that last a few hours or fail multiple times with the US and fail to see or palpate the good veins right in front of them. I see this every day. Technology is only as good as the hands it is in”. Iluvit
“Moving from paper to electronic charting, cracking down on opiates. When I was in school, they said “the risk of becoming addicted is about 0.12%”- we used to hand them out like candy! The market seems to have changed in my career, I came through when it was flooded and hard to get a job but I think it’s easier now as many nurses move away from the bedside, it gives new grads more of a chance to get a hospital job. There is also more work from home/ remote telehealth jobs.” anewsns, ASN, RN
Did our members capture some of your thoughts on changes over the years? If you have others, click here to add your comments.
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Nursing Career
s e r u t n e v d A An interview with ENA past president Karen Wiley
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Nursing continues to evolve and change. We all remember to some extent the way it was “when I graduated from nursing school.” Change occurs at different rates and for different reasons. Allnurses.com staff were recently able to interview several nurses in various stages of their careers .
K
aren K. Wiley, MSN, RN, CEN is the immediate past president of the Emergency Nurses Association (ENA). We recently spoke with her about the changes that have occurred in nursing over the years. Ms Wiley introduced herself:
Intensive Care. In 1993 I transferred to the emergency department where I worked until December of 2017. I consider myself semi-retired. Currently, I am the 2018 Immediate Past President for the Emergency Nurses Association. My master’s degree in nursing was in Nursing Administration.” There are many reasons for choosing nursing as a career. “I chose nursing for a career because it is what I always wanted to do. However, I did not go into nursing until after I was married and had 3 children. When I graduated from high school I did not want to go back to school, at least not right away. I worked in an office.” We have all faced hurdles in nursing too. “My biggest hurdle during my nursing career was working in the emergency department and keeping everyone safe. Patients as well as nurses. Often you work short staffed and you are caring for psychiatric patients and medical patient who remain in the emergency room because there are no beds in the hospital or no staffing on the psychiatric floor.”
“I have been in nursing for 40 years. My first job was on a 55-bed orthopedic floor where I worked for 8 years. I then worked in various positions including the Intensive Care, Coronary Care Unit and Post
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Nursing continues to change and evolve as our patients become more complex. “The biggest changes that I have seen in the nursing scope of practice include standardized nursing protocols for stroke, chest pain, and sepsis, In addition, we now have Nurse Practitioners, and Physician Assistants.” She went on to dis-
“I chose nursing for a career because it is what I always wanted to do” cuss that team nursing was the approach to care when she first started in 1978. This consisted of her responsibility of 21 patients along with 2 nursing assistants and 1 RN who cared for the more acute post-operative patient. While working in the emergency department, acuity needed to be considered as the usual workload was 4 patients While that number seems desirable, 4 very ill patients (think diabetic ketoacidosis) are quite labor intensive versus 4 relatively stable patients (think sore throat, well baby checks). Ms Wiley has experienced many changes over the past 40 years. “The changes I have seen in my career that have impacted the profession include computers, (order entry, nurse and physician documentation, medication, any surgical and x-ray reports) The benefit is that nurses and physicians can work in the patient chart at the same time. The negative aspect is when entering the information live, patients do not feel you are talking or listening to them, but the computer. Legal issues have occurred when important information is not documented or the supporting documentation is not there. Another change is 12-hour shifts. Patient satisfaction surveys, and violence in the work setting are others.” Media portrayal of nursing has changed over the years too. It was common to see “physician defibrillating the patient or doing CPR but now we do defibrillation hands-free. The media also portrays nurse and physicians in a steamy love affair. Our international nurses watch American TV programs and they do not have a very honest view of how we truly practice. The physician, nurse practice as partners in providing care for patients.” She experienced nursing care overseas via an exchange program sponsored by ENA. Ms Wiley
visited Norway and Poland and made the following observations: • In Poland, EMS has more control of care. It is very unusual for patients to come by themselves to seek care in the ED. This only occurs when a physician has called ahead to inform the ED that the patient is coming. EMS is the usual mode of arrival even though the patients are triaged upon arrival and may still sit in a waiting room. • In Norway, she noted that care was very physician-driven and nurses lacked autonomy. However, they are starting nurse practitioners and are working to integrate this into practice. We ended our discussion about how to feel valued at your job. Her words echo many of us; “I feel valued in my job when patients tell me thank you. Also when I walk out the door, I know that I did my best.”
Have something to say? Click here to comment!
by Judi Dansizen MSN, APRN, CNS Judi is an advanced practice nurse in the Midwest. She has over 25 years experience in various nursing roles. Judi is also the allnurses.com Assistant Community Manager.
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Current Issues in the Nursing Profession
and
Resolutions for Future Change Maureen Bonatch MSN, BSN, RN Maureen draws from years of experience in nursing administration, leadership and psychiatric nursing to write healthcare content. Her work has appeared in numerous health system websites and healthcare journals. Her experience as a fiction author helps her craft engaging and creative content. Learn more about her freelance writing at CharmedType.com and her fiction books at MaureenBonatch. com 24 Winter 2019
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N
urses work at the frontline of patient care. We collaborate and work with other healthcare professionals, but usually provide the most direct patient care. This extra time spent serving as an advocate, resource, and educator, while helping patients facilitate their healthcare journey has prompted the nursing profession to sometimes be thought of as the heart of healthcare. It’s also contributed to nurses earning the honor of being voted the most trusted profession for the 16th consecutive year in the Gallup honesty and ethics polls. Although, the nursing profession isn’t without its challenges.
Insufficient staffing can contribute to additional issues that affect job satisfaction and the provision of quality care. As one of the fastest growing healthcare fields, nursing is anticipated to grow by 15 percent from 2016 through 2026. This is faster than average according to the Bureau of Labor and Statistics. This age-old staffing problem, and present nursing shortage, challenges us to meet this need due to a combination of factors that are increasing the demand for nursing staff. These include: The Affordable Care Act (ACA) has enabled more patients to acquire access to healthcare. Some patients may have never had healthcare before, and many patients may be more diverse, or have complex healthcare needs. The nursing shortage is aggravated by several. With an aging nursing workforce, and the pending retirement of baby boomers combined with an inadequate nursing faculty to educate future nurses, recruiting and retaining an adequate supply of nurses is even more challenging.
The shift toward quality, value-based patient care with a heightened emphasis on population care that focuses on increased health promotion and holistic patient-centered care, requires a larger, more diverse, and highly educated nursing workforce. To continue to support patients, and manage their care, nurses must resolve to seek solutions for current issues within the nursing profession. Nurses are rising to the challenge, and efforts have already begun to tackle current issues and implement positive changes for the future of the nursing profession.
Issue: Nurse Staffing and Recruitment
Nurse staffing shortages are not a new issue. The challenge of maintaining adequate staffing to meet the increased demand for nurses remains ongoing.
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A shortage of nursing faculty. The wide gap between clinical and academic salaries, and the need for additional experience and education, may have contributed to the lack of adequate nursing faculty. The nursing faculty shortage has forced some universities to limit the student capacity for their nursing programs.
Make a Resolution to Seek a Staffing Solution
Nurses are unique in that they can choose multiple education pathways. Although it’s felt that additional education can help nurses successfully navigate increasingly complex patient needs. Advanced education can also allow nurses to take on additional roles and responsibilities within the nursing profession. The Affordable Care Act (ACA) was one of the prompts to inspire The Robert Wood Johnson Foundation and the Institute of Medicine (IOM) to begin working toward making nursing education a seamless academic progression with a goal of having 80% of nurses obtain a Bachelor of Science (BSN) by 2020. They recognized the need to rethink some of the roles
• Nurse bullying or incivility
of the nursing profession, and increase their education, to meet the needs of an aging, more diverse, patient population. This progress to transform the nursing profession continues, with the intent to improve effective care for the changing patient population. Having more BSN prepared nurses can also result in shorter hospital stays, lower healthcare costs, reduced patient mortality rates, and improved patient outcomes.
• Fear of workplace violence
• Inability to achieve a satisfactory work and life balance • Lack of opportunities for advancement
Resolve to Work to Retain the Nursing Staff Gained
Poor retention affects more than the organization. Inadequate staffing can disrupt productivity, impact patient care, and decrease job satisfaction. Patient satisfaction is often linked to the quality and contentment of the nursing staff, so neglecting issues within the nursing environment can spur a vicious cycle of patient dissatisfaction and nurse turnover. Issue- Overwhelming Stressors in the Workplace
Issue: Struggling with Nurse Retention
Although once nurses obtain a position, the environment and culture of the organization must provide positive benefits to encourage them to stay. Organizations that focus more on recruiting nurses, and then not making efforts to make positive changes to retain them, often endure ongoing struggles to retain nurses and maintain adequate staffing levels. Retention issues that may occur due to the facility environment and culture can include: • Excessive overtime • Inadequate staffing levels • Nurse burnout • High staff turnover • Scheduling dissatisfaction • A wage or benefit package that isn’t competitive • Inadequate time to provide patient care
The healthcare environment may be fast paced and ever changing, but it’s not normal for nurses to be constantly overwhelmed and exhausted. Passion isn’t always enough to sustain nurses through the physical and mental demands of the job, yet many neglect their own mental health and wellness. Some may even feel as if it’s a sign of weakness to admit to these feelings, or as if they should be able to handle everything on their own, get over it, or that it’s part of the job. But long shifts, working extended days in a row along with conflicting demands can lead to fatigue and burnout. Many nurses overlook the signs to slow down, implement personal preventative care measures, or seek treatment. A negative or toxic work environment may be related to some of these issues. This can result in other mental or physical issues overlooked or unnoticed such as: • Burnout- The cause and the way the symptoms of burnout manifest can vary. This can lead to an increased risk of medical errors, may affect patient care, impact job satisfaction, and increase turnover. • Post-Traumatic Stress Disorder (PTSD)–Intense, ongoing stressors combined with staffing issues may leave little to no time to process a distressing event at work.
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• Bullying, harassment, and incivility- The RNnetwork survey indicates that 45 percent of nurses report being harassed or bullied by peers. Repeated, unwanted harmful actions intended to humiliate or offend the recipient can infect staff with fear and humiliation, decrease productivity, increase absenteeism and increase turnover. • Alarm fatigue- The multitude of devices meant to assist and alert staff to patient needs can result in sensory overload and desensitization. Their purpose is defeated when nurses ignore, overlook, or are unable to differentiate critical or routine alarms. Alarm fatigue can become counteractive to enhancing patient safety.
Resolve to Commit to a Supportive Environment
The way we treat each other is as important as the care provided. Nurses should respectfully support each other as professionals and encourage others to adhere to the advice they give to their patients, and realize that mental health can be just as important as physical health to provide safe care. Nurses are less likely to encourage others to enter the nursing field if they aren’t engaged, or don’t feel supported, or appreciated, in the workforce.
Promote a professional environment that realizes value and shares goals and success to attract and maintain the best employees by: • Recognize and hold people accountable by rejecting negative behavior and reinforcing what behaviors are unacceptable and detrimental • Align a positive atmosphere to patient outcomes to attract and retain staff who support each other and the organization • Encourage and model clear, calm communication that’s mindful of volume and body language • Nurture a culture of mental and physical wellness and invest in individual health needs • Seek evidenced-based practice to develop an approach for alarms to perform appropriately and reduce false alarms and risks accompanying alarm fatigue
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Issue- Increased Risks of Workplace Violence & Job Hazards
Performing procedures which can cause discomfort or pain for patients that may be fearful or confused can put nurses at risk for workplace violence. The risk of physical or verbal abuse from patients, or family members, can be exacerbated by inadequate staffing and can contribute to an undesirable, unsafe, work environment. The Occupational Safety and Health Administration (OSHA) states that from 2002-2013 the rate of serious workplace violence was 4 times greater in healthcare than private industry. This may be even higher since many may not report because they don’t want to lose time, think reporting won’t make a difference, or that violence is part of the job. The highest rates of violence usually occur in the emergency room and psychiatric units due to substance abuse, cognitive impairment, waking from anesthesia, fear or frustration. This risk for violence for nurses is in addition to the environmental and physical risks associated with the job due to injuries from patient care, exposure to bloodborne pathogens or needle sticks. The increased age of much of the nursing workforce, inadequate staffing hectic pace, fatigue and long hours, can result in decreased alertness and awareness and increase the risk for injury.
Resolve to Reduce the Risk
Education and awareness of situations with increased risk and incorporating a zero tolerance for violence can assist with proactively addressing these issues. Other methods to work to decrease the risk for
violence and injury include: • Emphasize the importance of reporting and documenting • Report and gather data regarding incidents and risks • Set a zero-tolerance policy standard • Develop an expected code of conduct • Build awareness on the importance of ergonomics to reduce injuries • Educate on awareness and how to identify and address if there is a risk for performing safe care • Remove items in the patient care areas that could be used as a weapon • Ensure there is adequate lighting, and an awareness of available exits in a crisis • Encourage clear patient communication on what to expect for their treatment, and wait times • Alert staff if patients have a history of violence
differences, expectations and how to identify personal assumptions, can assist nurses to reduce communication and cultural barriers to care. This could potentially lead to better patient compliance and outcomes. Many patients are reassured to have a caregiver from the same ethnic or racial background. They may be able to better understand cultural preferences, communicate more effectively and appreciate the patient’s perspective. This can help in gaining patient trust and confidence in care and increase patient satisfaction.
Resolve to Educate and Incorporate Cultural Awareness
Patients depend on nurses to adhere to their professional obligation to make healthcare decisions that balance treatment options and patient wishes.The nurse may not agree with the patient’s beliefs, or may struggle with conflicting personal values, but should still strive to provide care in the client’s best interest. Cultural awareness can help the nurse understand and support the patient’s unique care needs even if they conflict with the nurse’s personal beliefs. • Education and understanding on cultural diversity can increase awareness of personal attitudes, and beliefs, and allow nurses to provide fair treatment to patients regardless of their economic status, race, religion, ethnicity or gender identification.
Issue: Meeting the Needs of Diverse Patient Populations
The patient population is becoming increasingly diverse. Striving to increase diversity in nursing staff, and education on cultural awareness, can assist with improving cultural competency. Knowledge of cultural
• Factors such as the changes in the economic environment, stable employment options, and the variety of settings and opportunities for advancement have played a role in increasing diversity in nursing: This has also influenced males and other minority groups to pursue nursing. This may help ensure the nursing profession can be sensitive to cultural specific needs while providing care for diverse populations. • Developing and supporting a more diverse, culturally aware, ethical environment may increase the nurse’s comfort in speaking up to act as a patient advocate and provide culturally appropriate care.
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• Desire, and preferred method, to be recognized for work performance • Preferred management style Don’t Overlook Technological Challenges Today’s nursing workforce must be both clinically skilled and technologically perceptive by balancing hands-on patient care with technology. This can prove challenging with blended workforce generations. Each generation, and individual, may have varied comfort levels, and views, regarding technology. Some may be challenged to learn new processes, while others harbor fear and uncertainty.
Resolve to Work to Embrace Generational Differences
Incorporating technology into the workplace can provide opportunities for education and reverse mentoring between generations. If effective methods of learning are considered, opportunities can be created to develop leadership skills for new nurses.
Issue: Blending Generations in the Workforce
Nurses delaying retirement, and an influx of new nurses, has resulted in blended nursing generations in the workforce. Generational differences, and efforts to work coordinately, can result in conflict and job dissatisfaction. Although individuals can’t be classified by their generation, since each person may have their own unique characteristics and expectations, most are influenced by the period they grew up in and experiences they’ve encountered. Generational differences can affect thoughts and perspectives and impact the ability to work coordinately. The generation we grew up in can also influence: • How we interact • Preferred work and life balance • Methods of communication • Values and beliefs • Significance of education and training
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New generations may be more accustomed to utilizing technology, while other generations may be accustomed to relying heavily on touch, sight and smell to gauge the patient’s medical condition. Both methods of patient care have positive benefits. The challenge is to create a balance that doesn’t completely rely on technology while maintaining the human element in nursing care. Ways to strive to embrace generational differences include: • Recognize the unique characteristics and expectations of each generation • Identify traits shared between nurses of all generations to foster teamwork and collaboration • Work toward a sense of purpose and overall goals • Focus on expectations, rather than outcomes, when approaching tasks Technology, and scheduling software, can be beneficial to reduce paperwork, and to work toward a better work life balance, reduce overtime and the risk of short staffing. But quality, knowledgeable nursing staff must be available for technology to be effective.
veys, incorporated research and data collection to work toward positive legislative changes. This exploration of optimal staffing levels hopes to emphasize the importance of nurse and patio ratios and the effect on patient outcomes. Hospital patient levels are constantly fluctuating. Staffing levels are dependent on patient acuity, complexity of care, the number of admissions, discharges, transfers, and the skill level and expertise required. Nurses have the best judgement on staffing levels and how to best manage flexible staffing while supporting each other. Working toward mandated staffing levels may help reduce the risk of patient harm and improve nurse job satisfaction.
Find Our Voice for Ourselves and Our Patients Issue: Striving for Safe Staffing Levels
Staffing is one common element that can affect multiple nursing issues. Inadequate staffing contributes to more than nursing retention. As patients shift out of hospitals for better reimbursement, it can mean shorter stays with patients with more complex needs. Mandatory overtime, long shifts, or extended workday stretches can affect the ability to provide safe patient care. It can also contribute to: • Increased fatigue and rate of injury • Medication errors • Length of patient stay • Patient mortality • Nurse burnout • Patient dissatisfaction
Resolve to Seek and Support Staffing Solutions Staffing issues have not gone unrecognized. The American Nurses Association (ANA) recognizes the significance of safe staffing and has implemented sur-
The role of the nurse continues to grow to meet the complex demands of the healthcare system. Nurses need to become change agents and have a voice for themselves, and their patients, to work toward being full partners in redesigning healthcare. Nurse’s voices are important and can contribute the expertise acquired from education and experience across many healthcare settings and specialties. Nurses Can Get Involved by: • Volunteering and participating in committees • Continuing with personal and professional growth and education • Becoming a mentor to:
• Appreciate, and explain, the history of why tasks are done the way they are, and to take a critical look for areas for improvement • Share expertise, guide and educate • Inspire and empower future nurses and nurse leaders • Gain a feeling of ownership in the success of the organization • Bridge generational gaps by comprehending the strengths of different generations • Contribute toward a positive workplace culture
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• Display a willingness to embrace change • Acquire a fresh perspective on the newest and latest trends
Nurses Voices Carry
Nurses can make a difference by taking ownership of the nursing profession and committing to change the culture and status quo by getting involved within their organization, their community and contributing their voice to public policy. Nurses are generally underrepresented when major healthcare decisions occur. The Nurses on Boards Coalition is making strides to correct that with a goal of having 10,000 nurses on boards by 2020. To begin acquiring a broader strategic mindset nurses can: • Start prepping mid-career to prepare • Work with a mentor, or other members of the board • Take courses on presentation skills and public speaking to build confidence • Recognize that nurses have valuable contributions Serving on a board can be personally and professionally rewarding. It may also provide opportunities to enhance professional networks, impact public and community health, and be on the forefront of strategic planning. If nurses become a voting member in decision-making roles in healthcare they can: • Have a seat in decision making • Lead conversations • Hold other board members accountable for decisions • Be the voice for nurses and patients • Bring the patient perspective
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Resolutions for Future change
The Robert Wood Johnson Foundation(RWJF) initiative, The Future of Nursing: Campaign for Action, emphasized improving access to care, collaboration, diversity, healthier communities, nurse leadership and education. We’ve made great strides toward these goals, but continue to have more work to do. Many of the issues in nursing are interrelated and ongoing. But by making small steps, and increasing involvement within, and outside, organizations, nurses can work to find their voice to make a better future for our patients and ourselves. The public continues to place their trust in the nursing profession to provide compassionate, honest and ethical care, and nurses are honored to provide it.
Recognizing the contributions and impact of nurses can help us realize that together we can lead positive changes for the nursing profession and lift each other up for future success. Article Sources
5 of the Biggest Issues Nurses Face Today Current Issues in Nursing and Healthcare
Focus on Self-Care Could Help Prevent Nurse Burnout HealthLeaders Top 10 Nursing Stories of 2018
Low Nurse Staffing Increases Risk for Inpatient Death Our Nation Needs More Nurses on Boards Ready to Serve
The Case for a Nurse Trustee
Update on Future of Nursing Report: Are We There Yet?
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The Evolution of Nursing
Is Today’s Education Preparing Tomorrow’s Growing Health C By Beth Hawkes MSN, RN-BC, HACP
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g Education
g Nurses for Challenges?
S
ince nursing education and training began 150 years ago, it has undergone many changes. Nursing education has evolved from hospital-based apprenticeships to college and university-based programs. Along the way, there has been much debate about the best way to prepare nurses. Hospital setting or academic setting? ADN or BSN? Today multiple educational pathways for entry into nursing exist. Nurses can receive their education and training in nursing education programs at the diploma, ADN, baccalaureate or even master’s level.
NCLEX
One thing that is agreed upon is that, regardless of educational preparation, all eligible graduates take the same licensing exam, called the National Council Licensure Examination (NCLEX). Prior to the NCLEX, nurses took the State Board Test Pool Examination. The National Council of State Boards of Nursing (NCSBN) renamed the test to the NCLEX in 1982. The first version was a paper and pencil-proctored test. Candidates had to wait months to take it, as it was only offered twice a year. Nurses from that time recall traveling to huge testing centers where they would hear “Pencils down. Booklets closed” and test for two days. Under the direction of the NCSBN, the exam has since evolved to computerized adaptive testing.
Diploma Programs
In the year 1873 three nursing educational programs—the New York Training School at Bellevue Hospital, the Connecticut Training School at the State Hospital (later renamed New Haven Hospital) and
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the Boston Training School at Massachusetts General Hospital—began operations. It’s generally acknowledged that organized, professional nurse education in the United States began with these 3 programs. Diploma programs all, they were called “Nightingale” programs because they were based on Florence Nightingale’s teachings. Aspiring nurses trained in hospitals under an apprentice-like system. Graduates of diploma programs recall being trained to stand up and offer their chair whenever a doctor came into the nurse’s station.
HIGHEST NURSING DEGREE Highest nursing degree as reported in the 2018 allnurses.com Nursing Salary Survey .45% DNP 7.90% MSN
45.16% BSN
5.72%
.22% PhD Diploma
40.47% Associate (ADN, ASN)
Labor was exchanged for training, room, and board. Student nurses provided the patient care, sometimes supervised, sometimes not. Hospital servitude was the first priority and education was secondary. In time, it was realized that the needs of the hospital trumped the needs of the nursing students. In other words, if patient care was needed on a surgical unit, the student nurses would forfeit their planned Peds training to provide care where it was needed, on the surgical unit. Likewise, classes were canceled if nurses were
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needed on the floors. Diploma programs still exist but are far less common than ADN or BSN programs.
BSN Programs
After WWII some forward-thinking leaders began to promote moving nursing education from hospitals and into universities. Nurse leaders argued for an educated workforce that would adhere to practice standards. Hospitals opposed the change, fearing the loss of free labor. At the same time, patient care was becoming more complex. Intensive care units became more common in hospitals, requiring greater nursing expertise. Nurses now needed a theoretical base to their practice. However, the four-year nursing programs were not able to turn out enough nurses to meet the nation’s demand.
ADN Programs and Role Differentiation
Meanwhile, as an economic fix, community college programs began offering ADN programs in the 1950’s, which seemed a happy compromise and became a popular track. ADN programs supplied large numbers of nurses, relieving the nursing shortage. Students without access to four-year educations could still earn a nursing degree. It was originally thought that ADN nurses would be “technical” nurses working under the supervision of BSN or “professional” nurses but hospitals never differentiated practice based on educational preparation. As a result, Diploma, ADN, and BSN prepared nurses all have the same role and responsibilities in clinical practice. The RN license, and not educational preparation, drives the practice role of the RN.
BSN vs. ADN Entry Level Degree
In 1964 the American Nurses Association stated that nurses should all be prepared at the baccalaureate level. This began a deep and bitter divide within the profession between ADN and BSN prepared nurses that continues to this day.
In 1982, the National League in Nursing (NLN) supported the BSN as the minimum educational level for entry-level nurses. With much debate, many other organizations adopted the same position over the next 3 decades. However, in the 1990s, concerns over a nursing shortage pushed the argument to the background. In 2010, the Institute for Medicine (IOM) issued a statement that 80% of all nurses should hold a BSN by 2020. New York and New Jersey followed with a “BSN in 10” law requiring nurses to obtain their BSN within 10 years of licensure, but to date, there is still not a national, standard educational entry level. In most recent years, employers themselves have begun to require BSN prepared nurses, taking the debate out of the hands of nurses and nursing organizations and into the marketplace. Magnet hospitals employ a higher percentage of BSN nurses.
Advanced Practice
Today there are a number of masters level programs including clinical nurse specialists, nurse practitioners, midwives, anesthetists, clinical nurse leaders (CNL). In addition, there are doctoral programs that prepare nurses to influence healthcare policy and assume advanced leadership roles.
Accreditation
Established in 1893 and called the American Society of Superintendents of Training Schools for Nurses until 1912, the National League for Nursing Education was one of the first professional nursing organizations. The purpose of the National League for Nursing Education was to establish and maintain a universal standard of training for nursing, released as the first Standard Curriculum for Schools of Nursing in 1917. Accreditation is a voluntary, self-regulatory process. The Accreditation Commissions for Education in Nursing (ACEN) accredits diploma, associates, bachelors, and master’s nursing education programs. The Commission on Collegiate Nursing Education (CCNE) accredits only bachelor and master’s level nursing education programs In 1952 the National League for Nursing Education
and the Association for Collegiate Schools of Nursing joined together to become what is now known as the National League for Nursing (NLN). Accreditation of nursing schools was the purpose of the newly formed NLN.
Challenges
The primary problem with nursing education now is the gap between school and practice. Nursing students lack sufficient clinical experience to function independently. Residency programs help to close the gap, but residency programs are not mandated or regulated. One hospital might orient its new grads for 4 weeks, another for 16 weeks. Residency programs follow a quasi-medical model where new grads are supervised and supported for a period of time before practicing independently. Career advancement requires a BSN or higher degree. Universities and colleges must work together for a seamless transition to academically higher education. Mobility programs facilitate articulation and transition from one nursing degree to a higher nursing degree, in which ADN prepared nurses return to school and obtain their BSN or masters degrees. Fortunately, many online programs provide easy access for the adult learner.
Future
It’s interesting to see where the next 150 or even just 50 years will take us. Will educational preparation drive practice differentiation? Will nursing adopt a formalized and standard residency status for new graduates? What is known is that healthcare is changing rapidly and nursing operates in a contextual environment of society, regulations, and reimbursement. Nurses will be an important part of the change and assume new roles in managing and providing our nation’s care. Education must prepare nurses who can practice effectively and lead effectively.
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by Melissa Mills RN, BSN, CCM, MHA
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Melissa is a Quality Assurance Nurse, professor, writer, and business owner. She enjoys empowering other nurses to find their passions and create a unique nursing career that fits their passions, desires, and gifts. She is owner of www.makingspace.company, a website dedicated to helping women find their creative passions through writing and co-owner of enursingresources.com, a start-up Nursing CE company that will offer online courses soon.
Left top: Long skirts and wide brimmed hats were typical for nurses in this 1916 photo depicting nurses serving in World War I. Left bottom: By 1939, nurses serving in the Red Cross had transitioned to capes and white nursing caps as part of their war-time uniform. Above: In this war-time propaganda poster for the Army Nurse Corps, a nurse is depicted wearing the typical “nursing cap� of the time.
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A
sick patient enters the emergency department. Feeling faint, he looks for a nurse. As he scans the room, he notices men and women in colored scrubs. He looks again, trying to find a female in headto-toe-white. This is his image of nursing. Many years ago, this might have been a logical place to begin when looking for a nursing professional. However, today you might find nurses in solid or patterned scrubs, street clothes, or in a lab coat that looks more like the traditional physician attire.
Nursing uniforms don’t end with clothing. It used to be understood that nurses had no visible tattoos, piercings only in their ears and that naturally colored hair would be pulled back or kept short. Hospitals have become more lenient on the clothing nurses wear and these other aspects of their attire, too. Have you ever wondered how we made it to this point? Whether you feel that your body is not your resume or that the way you dress as a nurse is linked to professionalism, here is a historical view of nursing uniforms from the past to the present.
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Florence Nightingale Had a Vision
Uniforms from the 1800s looked similar to a nun’s habit, consisting of floor-length dresses in drab colors with white aprons over the front. Many of the first people to care for the ill were nuns, which is why the uniforms were similar. In the 19th century, Florence Nightingale revolutionized nursing. She entered the profession against her family’s wishes because nursing was not seen as a worthy career choice at that time. Florence is known for molding nursing into a respected discipline, writing multiple books, and establishing the Nightingale Training School at St. Thomas Hospital. Florence had a vision for herself and those she trained. She understood the importance of creating a professional image that also served a purpose. She created uniforms to separate nurses from those still This photo from 1918 shows a in nursing school, and that nurse wearing the typicallong, protected them from illness, white uniform of the times. (Photo weather elements, and the via Minnesota Historical Society) advances of male patients. The first recognizable nursing uniform included a long dress, apron, and frilly cap.
War-Time Changes
During World War I the nursing uniform underwent some of the first changes. Working on battlefields become difficult in long dresses. Nurses needed to be efficient and move quickly to assist the wounded. The aprons disappeared, and hemlines shortened. Tippets - short, cape-like garments - were added to the war uniforms. Nurses began displaying badges on their tippets to show rank.
Uniform Changes with Popularity
As nursing became a popular career choice in the 1950s, attire needed to be easier to clean and produced in large quantities. Skirts and caps remained a staple of the standard dress code. But, the need for more flexibility caused hemlines and shirt sleeve length to shorten. Many nurses wore starched white dresses with white hose and shoes as the standard hospital uniform.
Capping it Off
It’s possible that the most recognizable part of a nurses uniform was the crisp white cap that was worn up until the late twentieth century. An article on Medscape Nurses reports that this change brought about changes from patients who said they could no longer tell the nurse from other hospital staff.
Above: This black wool uniform cape was worn by a nursing student at what was known until 1970 as Northwestern Hospital in Minneapolis, Minnesota. The Rosalia brand black wool cape is lined in red wool and has a standing collar. Hook and eye closure at neck and two self-fabric frogs with black buttons provide closure at center front. Below: This photo from 1960 shows a nursing instructor and nursing students discussing the day’s lessons. (Photos via Minnesota Historical Society)
Caps were worn to show dignity and pride in the nursing profession. Many nursing schools ended with capping ceremonies to celebrate the induction of new nurses into the trade. However, lacking practicality was likely the main reason for the demise of the nursing cap, which was no longer required by most hospitals by the 1970s.
Emergence of Scrubs
Scrubs began in the operating room. In the 1940s physicians started wearing white uniforms rather than their own clothing. By the 1960’s surgical scrubs changed to the traditional green that you see today to lessen eye strain experienced by surgical staff from white uniforms and bright operating room lights. As nurses became responsible for the cost and care of their uniforms, they also started to request more comfortable options from manufacturers. This prompted the modern day scrub. By the 1980s and 90s the traditional nursing uniform was replaced with scrubs in most healthcare facilities across the U.S. Scrubs are easy-to-care-for, come in a variety of styles and colors, and offer nurses comfort and mobility during long workdays. You can choose styles with multiple pockets, elastic waistbands, drawstrings, and
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Left: A nursing home demonstration at the 1916 Minnesota State Fair. Above: A nurse in 1925 poses for a photo. (Photos via Minnesota Historical Society)
other options and still meet most hospital policies. Some facilities might require nurses to wear a specific color or pattern to help distinguish them from other clinicians. Other employers such as home care, hospice, or other community health providers may wear a combination of scrubs and street clothes to care for patients in their homes.
Men in Uniforms
Not only has the appearance of the nursing uniform changed over the years, but the look of the workforce has changed, too. Finding images of men in traditional nursing uniforms is difficult. Many nursing schools provided men with a shirt made of the same dense fabric that women wore, and no caps were required. Some hospitals required men to wear uniforms worn by physicians or dentists because there wasn’t a standard male attire. As scrubs became acceptable, men followed suit, choosing scrubs in multiple colors and patterns.
Hair Color, Piercings, and Tattoos
For years, many nurses have covered tattoos and refrained from coloring their hair in unnatural colors to conform with facility policies across the U.S. A 2015 article in Minority Nurse even reported hospitals and nursing schools banning all nail polish colors, unusual hairstyles, and earlobe gauges.
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In recent years, many facilities have started to change their policies on nursing dress codes. Indiana University Health, the state’s largest health system adopted a relaxed policy on tattoos and hair color in 2018. The hospital reported that the changes were made to reflect “authenticity” of their staff. A Becker’s Hospital Review article from December 15, 2017, stated that the Mayo Clinic changed their policy on showing tattoos for both nurses and doctors in January 2018. This came just three years after the hospital ended a rule that required female employees to wear pantyhose. These rules, lodged in societal norms, continue to change and evolve. However, some feel that the uniform is more than just functional attire. It’s part of the nurse’s expression of self, and it’s also one component of the patient experience.
Function versus Expression
The nursing uniform has long been positioned as a way to keep nurses safe. The functionality of the first long-sleeved and floor-length frocks met the safety standards of the day. As the need to become more mobile emerged, changes began to happen that made the uniform more functional. With the emergency of infection control practices, other equipment was added to the attire that is now considered standard, such as gloves, masks, and even isolation gowns, when needed. As nursing gained popularity, nurses found their voice and demanded respect in many forms. The choice
Pierre Cardin’s nurse uniforms of the future as seen in 1950 (Popperfoto/Getty Images)
of wearing a uniform, changing their hair color and even showing their ink is a part of self-expression and acceptance that many nurses have welcomed with open arms.
The Future of Nursing Uniforms
Where do we go from here? Will nurses one day be roaming the halls of hospitals in street clothes while they care for patients? Or, will nursing “whites” come back into style either on their own or at the requirements of employers? It’s hard to tell what’s next for nursing uniforms. We have come a long way indeed. How do you feel about your current nursing uniform policy? Do you want more leniency or do you think that we’ve gone too far?
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Get Social A glimpse at some of the most popular comments from our various Facebook channels... Be sure to click the headlines to add your comment!
The Value of Joy: Why Feeling Good is Good for You I was honored to be asked to speak on the value of joy at the pinning ceremony at which I recently received my doctorate in nursing. I discovered research about how positive emotions contribute to resilience, wellbeing and health. Though we can’t all feel joyful all the time, it is important to understand the value of joy and how to support this emotion in our patients and ourselves to promote healing.
Are Patients Cared for Equally? Challenges of the VIP Patient
I work in the OR, and when we’re told that it’s a VIP, I usually say “I guess we’ll use the sterile instruments today.” All patients are treated like VIPs by us.
Patient brings own urine sample for preoperative pregnancy testing Yes. Even more so, many people hear a snippet of conversation, jump to conclusions, and run to HR. Get the facts before conclusions are drawn...
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LOL
The look on this patient’s face as he sees the stereotypical nurse of the past on one side and what may be the nurse of today on the other. Is he in a time warp or experiencing a flashback? You decide!!!
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Nursing As a Profession: Changes Through the Years 48 Winter 2019
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Reflections from Rosalee Sites, RN, BSN, MA as told to Joy Eastridge, BSN, RN
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Memories of Early Days
C
leaning our own bedpans in the soiled utility room…steaming needles and syringes after checking the needles for burrs…no IV meds…1 nurse and 3 aides on a 52-bed unit…no critical care units…no recovery room after daytime hours…smoking on the wards…doctors smoking!… Growing up in Elkins, West Virginia in the 1940’s, Rosalee Sites remembers wanting to be a doctor. Interested in all things medical, she knew from an early age that medicine was her destiny; but because of financial considerations in her family and some of the limitations of the time, she instead applied for, and received, a nursing scholarship to the Davis Memorial Hospital Program. After 3 years of rigorous studies in the classroom and on the job training which involved staffing the floor, she was awarded the coveted black stripe on her nursing cap along with her pin and headed to work in 1965.
need something right away. One particular night stands out in her mind because it highlighted the importance of her role as a nurse and how the patient perceived her as being someone they could count on. While rounding, she came into one lady’s room and the patient said, “You are here. I’ve been waiting for you.” She asked, “Is something wrong?” The woman went on to say that in the daytime she had family around and there were lots of employees working but at night “It is you and me. That is the reason I wanted to meet you.” Her statement stamped itself in Sites’ mind, helping her clearly understand how important she was to her patients—they trusted her and counted on her honesty and care; she felt a sense of responsibility for their successful treatment and recovery and her role in it.
Nursing Assessment Skills… Important Then, Important Now
“Nursing assessment skills are the most important tools we have even now. But back in the early days, they were some of the only tools we could employ: skin color, temperature, respiratory rate, nail bed color, clamminess, pupillary response—all of this nursing observation had to take the place of non-existent monitors.” Sites says she can remember rolling a patient’s bed into the nursing station with her so that she could watch them while she charted. “There was just so much less that we could do for people during those times. Medications were limited as were tests. We had to do the best with could with limited resources.”
“As a nurse, I have been privileged to share very special moments in patients’ and families’ lives” Graduating from a degree program during that time, meant that she had to work hard, repeating a good deal of her initial training, to finally get her BSN 8 years later from East Tennessee State University.
“Nursing has been a wonderful profession for me, and I would do it all over again if I could.”
Working the night shifts on the wards meant that she was responsible for as many as 52 patients a night. She remembers making her rounds early in the shift and taking special note of those that might
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“Me, God, and the Telephone”
Early on, Sites recognized her special skills in administration, and after a few years of general nursing, she began to specialize in administration as house supervisor with coverage of the emergency room, a small 4-bed unit at the time. As house super she
had to do bed placement, deliver antibiotics to the floors on her rounds, and cover the ER. “It was me, God, and the telephone,” she remembers. Making necessary calls to physicians at home and running the ER which would be considered primitive by our standards today, was all in a day’s work. “As a nurse, I have been privileged to share very special moments in patients’ and families’ lives: being with them as their loved one takes their last breath, bringing a smile to a critically ill child, listening to an elderly lady talk about her family, helping a family member get their father who had dementia on his knees as was his nightly custom for prayer…”
kept coming, I always realized that the role of the nurse remained central in all of the care we provided. Our patients continued to count on us.” Sites went on to clarify, “Your patients will remember you giving them medication for pain, for starting their IV, for inserting their NG tube but more importantly, they will remember you for listening to them; we used to have a physician on staff who said, ‘If you listen to your patients they will tell you what is wrong with them.’” The advent of CPR and Life Support provided new ways to intervene at the end of life. “The first person I did CPR on was my own dad in 1965. Because he didn’t survive, I worried that I had done something wrong, but later I realized that he had a long cardi-
After getting her Master’s in Organizational Management, Sites continued to make important pioneering differences at Holston Valley Hospital in Kingsport, Tennessee where she continues to practice today. She started “As professionals, we owe it to our the first state-of-the-art Emergency Department, beginning patients to learn all we can and to push with 23 beds. To really underourselves to reach out for more.” stand what was needed and what was available in terms of design and functional capability, she and a team of other employees visited EDs around the country to borrow ac history and there was nothing that I could have the best ideas from the all, eventually making the ED done.” With CPR came ventilation, ICU care and at HVH one of the premier in East Tennessee. She increasingly interventional medical care. also headed up a group needed to obtain a Trauma “Continued Education Level 1 designation and worked hard to make that is Critical” hallmark of advanced technology and ultimate care A lifelong learner, Sites revels in tackling new in trauma part of her local hospital. topics and continues to be a focused student. As a “The Changes nursing leader at her institution, she took to heart Kept Coming” the major importance of encouraging her staff and others to continue learning. She pushed LPNs to get As the years rolled by, intravenous antibiotics their RNs, made ACLS mandatory for ED nurses (to became commonplace; roller clamps and marked loud outcries of protest!), prodded along the process bottles morphed into bags of fluid which gave way of obtaining certifications in ED nursing. Along with to machines that counted the drops and delivered all of this, she was visionary in understanding the the necessary medications in the right quantities critical importance of working with and training the to patients. Scans, CTs, MRIs, EKGs, ultrasounds, EMS staff so that the pre-hospital care maximized robotic surgery, all become part of the daily routine the patient’s chance of survival. for a changing profession. “Even though the changes
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“As professionals, we owe it to our patients to learn all we can and to push ourselves to reach out for more.” She objects to ever hearing the phrase, “I’m just a nurse,” and emphasizes the unique and special role that we enjoy as nurses who often are the ones seeing the bigger picture, the ones who are able to bring different disciplines together, the ones who translate what is in the EMR to both the physicians and the family. Our role has always been important but never more than now.
Nurses as Leaders
“Being a nurse has responsibilities and requires leadership.” Throughout her career, Sites has taken seriously the role of mentor to other nurses, and finds it deeply disturbing to hear nurses complain about the profession she loves. “Maybe you have not thought of yourself as a leader but that is exactly what you are. You are a professional nurse and you will be a leader in whatever area you may find yourself.” As her career progressed, Sites sought out ways to
Sites remembers, “We polished our shoes, ironed pleats in our aprons and looked forward to the day when we could earn the right to wear the black stripe on our caps.” She laughs to think that they were also required to wear girdles so that there would not be any distracting “jiggles!” Sites states, “What we wear can help inspire confidence in our patients, because if we dress well for our role, it can help us and it can help them. Appearances do matter.” Nurses in most areas were not allowed to wear pant suit uniforms until the mid-70’s. Scrubs came out in the mid 80’s and a general loosening of uniform standards continued until recent times when many hospitals have adopted new, more consistent uniforms, including the requirements that all RNs (and other professionals) wear a certain color scrubs so that patients and families can have an easier time distinguishing between providers.
Career Changes and New Challenges
Most nurses would readily agree that being able to change positions within the nursing profession is one of the great benefits of our training. Sites is no exception. After spending many years in the ED, Sites wrote a grant to the Robert Wood Johnson Foundation and was approved to start a Parish Nurse (also known as Faith Community Nurse) Program in her community. Now, 20+ years later, she continues on as the director of the program, faithfully administering the growth from a start of a handful of nurses and churches to two different programs with almost 50 nurses total.
“What we wear can help inspire confidence in our patients ... appearances do matter.” not only improve conditions within her hospital but also in her area. Helping to start a local medical clinic for the working uninsured and serving on a number of boards and committees, Rosalee continues to see part of her role in nursing as someone who takes on community issues as well. She has been known to quote Sir Winston Churchill, “We make a living by what we get, but we make a life by what we give.”
Evolving Uniforms and Lack of Uniformity
In the early days of nursing, compliance with uniform standards was strict and adhered to stringently.
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“Our hospital system wanted to find a way to engage with older adults and I saw Parish Nursing as a great way to do this.” After receiving the grant and getting the program started, Sites pursued innovations, continuing education for the group, and diligently encouraged all the FCNs under her leadership to meet and exceed expectations.
“One of the primary roles of Parish Nurses is advocacy. They need to be informed, knowledgeable and caring. Sometimes, the nurse if the only person who really cares; is there anything more important than that?” she asks.
Looking Ahead
“We have come from a time when we could do very little for our patients to a technology-heavy environment that threatens to distance us from those we care for.” Sites goes on to say that the very technology that improves patient care can also cause us to lose perspective in our personal lives, over-focus us on screen time and diminish the necessary personal interaction. “You must work on being healthy in mind, body and spirit, modeling a healthy lifestyle for others, refueling and renewing your strength so that you can continue to give.” When asked about the future of nursing and ways that we may need to improve, Sites goes back to the basics: education. There she sees systems that are producing new nurses with good textbook knowledge but less practical training; nurses who are equipped to pass the NCLEX but who are less equipped to do basic bedside procedures. “What happens, when we have graduate nurses that are not fully prepared is that they end up leaving the profession. They feel dissatisfied with their jobs and they change jobs, experiencing less support from their peers. “As mentors and nursing educators, we must pursue avenues to do a better job with training so that when nurses hit the floor they are at least able to have some level of proficiency so that they are assets and feel reasonably comfortable in their rolls.”
Parting Words of Wisdom
Through a long career in nursing, Sites has seen a lot: evolving from when we could do very little to extend or improve life to an almost hyper-interventional care time, she sees the need for balance, gratitude and grace. She continues to see nursing as one of the most relevant professions in existence, but one that
cries out for its nurses to get back to their roots of truly caring for one another, both our patients and our fellow employees. “We have all been warmed by fires that we did not build. I encourage nurses everywhere to look for opportunities to make things better for those who
“As mentors and nursing educators, we must pursue avenues to do a better job...” follow you. Take time to mentor the new student nurse or the new employee just joining your team; encourage others, love, touch others’ lives, know that you have made at least one life breathe easier because you have lived.”
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by Joy Eastridge BSN, RN, FCN, Certified Lay Minister Parish Nurse United Methodist Church Joy is a Faith Community Nurse who also enjoys writing. Besides nursing articles, she works on Bible Studies and has recently published a children’s book, Bennie Goes Up! Up! Up! as her way to connect with children, especially her young grandchildren. As a long time nurse, Joy has been privileged to work in a variety of settings in nursing including hospice, medical office work and home health.
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Expert’s Corner
The Dilemma of Multiple Licenses Some think that by refusing to renew their license in another state, no action will be taken. This is incorrect. Actions even can be taken against an expired license because the public has a right to know that action was taken against you in another state. Should you choose to reactivate that license, that state for that license wants to have a record of actions in any other state. Once an action is taken against your license, no matter where, it is on your record forever and available to the public for all to see at http://www.nursys.com.
Dear Lorie: I have a license in Indiana for which I have received a reprimand. I just got a complaint filed in Ohio where I also have a license. Can Ohio also take action against my license? Dear License Dilemma, If you have multiple licenses, you are subject to multiple actions against it for the same thing.
by Lorie Brown RN, MN, JD
Lorie A. Brown is a Nurse Attorney representing nurses before the licensing board and founder of EmpoweredNurses. org. Empowering Nurses at the bedside and in business.
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It’s as if you have a suspended driver’s license in Indiana for driving under the influence. Ohio would not want you driving in their state so Ohio has a right to know about the status of your driver’s license. The same is true with your nursing license as Ohio has a right to know about your Indiana nursing license status and possibly could take action on your Buckeye State license in response to issues attached to your Hoosier license.
It can also take many years for action to be taken against a nurse’s license. The American Association of Nurse Attorneys has published a position paper on the statute of limitations and retained jurisdiction. The paper’s purpose is to create awareness and, hopefully, states will do something about how long it takes for charges to be filed against your license. When it takes so long for actions to be filed, it can be difficult to remember what happened years ago, memory fades and witnesses become unavailable. The paper also discusses retained jurisdiction, the state’s ability to file charges against your license when you no longer have a license. The paper is a valuable reference but, unfortunately, should you have multiple licenses, I call it the “domino effect” because action can be taken against all of those licenses. Lorie
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