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TEXASNURSING M A G A Z I N E
Changing THE CULTURE How Nursing Reflects Societal Paradigm Shifts
T N A : E m p o w e r i n g Te x a s N u r s e s t o a d v a n c e t h e p r o f e s s i o n | I s s u e 3 , 2 0 2 0
ISSUE 3, 2020 Volume 94, Number 3 EDITOR IN CHIEF: Cindy Zolnierek, PhD, RN, CAE MANAGING EDITOR: Kanaka Sathasivan, MPH 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648 tna@texasnurses.org | texasnurses.org
MISSION Empowering Texas Nurses to advance the profession
BOARD OF DIRECTORS OFFICERS: Tamara “Tammy” Eades, DNP, MSN, RN, President Jeff Watson, DNP, RN, NEA-BC, Past President Amy McCarthy, MSN, RNC-MNN, NE-BC, Secretary Gayle Dasher, PhD, RN, ANP-BC, Treasurer DIRECTORS: Melinda Hester, DNP, RN-BC Donna Wallis, MBA, MSN, RN Patricia Freier, MSN, RN-BC, CPHQ Ernestine "Tina" Cuellar, PhD, RN, PMHCNS-BC Lucindra Campbell-Law, PhD, APRN, ANP, PMHNP-BC EXECUTIVE DIRECTOR: Cindy Zolnierek, PhD, RN, CAE
VISION Nurses transforming health
TNA DISTRICT AND PRESIDENT Dist.1:
Clarissa Silva, PhD, MSN, BSN, RN clarissa.silva@ttuhsc.edu
Dist. 3:
Margie Dorman-O’Donnell, MSN, RN margiedo@sbcglobal.net; District office: Jamie R. Rivera, JamieRivera@texashealth.org
One-year subscriptions: $25 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses), foreign $30; single copy $2.50. Subscription is not available to non-member Texas nurses. Some back issues may be viewed online at texasnurses.org.
Dist. 4:
Natalie D. Garry, MSN, APRN, GNP-BC Ngarry1617@gmail.com, tnad4.nursingnetwork.com
Dist. 5:
Leah Koen May, MSN, RN, NE-BC President.TNAd5@gmail.com, tna5.org
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Dist. 7:
Stacy Cooper, MSN, RN staycoop@yahoo.com, tnadistrict7@gmail.com
Dist. 8:
Patricia E. Alvoet, EdD, MSN, RN-BC pe.alvoet@gmail.com
Dist. 9:
Juliana Brixey, PhD, MPH, MSN, RN jjbrixey@hotmail.com; District office: Melanie Truong, RN, Executive Secretary, tna9@tnadistrict9.com, tnadistrict9.com
TEXAS NURSING (ISSN 0095-36X) is published quarterly— Winter, Spring, Summer, Fall—by the Texas Nurses Association, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 Periodical postage is paid in Austin, Texas.
TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index. 16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044 Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA. POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org. Or mail your new address—at least six weeks prior to your move— to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you.
Dist. 17: Mari Cuellar, NEA-BC, MSN, RN mgrace2329@yahoo.com Dist. 18: Janice L. Miller, MSN, RN, ACM janice.miller@umchealthsystem.com Dist. 19: Anita Lowe, MSN, RN alowe@uttyler.edu Dist. 35: Chrystal G. Brown, MSN, RN At-Large: Contact TNA, 800-862-2022, ext. 129 brichey@texasnurses.org
FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org. Copyright 2020 © Texas Nurses Association
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CHANGE IS INEVITABLE How COVID-19 Accelerated Nursing Change
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“But I’m Not Racist….” The Nurse’s Role IN DISMANTLING Institutionalized Racism
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CHANGING INSIDE AND OUT TPAPN’s Culture Shift
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Contents IN EVERY ISSUE
FEATURES
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12
22
PRESIDENT’S NOTES
TNA 2020 – 2023 STRATEGIC PLAN
THRIVING AFTER GRADUATION
Hindsight Is 2020
TNA's Three-Prong Strategic Direction
Changing the Culture of Nursing and Helping New Graduate Nurses
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Read more stories on culture change and nursing at texasnurses.org. TNA members get stories, news, and practice tips every Tuesday in the Check Up e-newsletter. If you haven't been getting the Check Up, check your email spam filter or contact us at tna@texasnurses.org.
TNA MEMBER NEWS Kudos, COVID-19 Task Force, Obituary
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As of March 1, 2020, all Texas prescribers or their delegates are required by state law to check the Prescription Monitoring Program before prescribing opioids, benzodiazepines, barbiturates, or carisoprodol. Help end this crisis.
Sign on before you sign off.
President’s Notes Tammy Eades, DNP, MSN, RN
HINDSIGHT IS 20/20 2020 is the Year of Nurse Change crisis standards of care. We have the power to reduce racial disparities. We have the power to end workplace violence. We have the power to make nursing more welcoming to new nurses. We just achieved our previous fiveyear strategic goal of reaching 16,000 members. Congratulations to everyone for stepping up, bringing new members to the organization, and becoming the largest nursing association in the country. We look forward to reaching ambitious new strategic goals with the help of all of our members.
Thank you for being the heroes we need. IF YOU LOOK AT THE DEFINITION of this saying it states “the full knowledge and complete understanding that one has about an event only after it has happened.” For example: With 20/20 hindsight we now see where our strategy went wrong. As we enter the second half of 2020, we reflect on the changes that we can now see in hindsight. Culture change occurs when individual and community behavior is influenced by new knowledge or shifts in priority. Culture change has been an important part of nursing since Florence Nightingale. As nurses, we play an integral part in changing the culture. In the past six months, COVID-19 has struck Texas among our friends, families, and loved ones. In direct care, nurses again have answered the call to take care of our patients while facing everchanging guidelines. Even with inadequate PPE, long work hours, furloughs, and overwhelming expectations, we continue our profession. Thank you for being the heroes we need. In education, classes had to shift quickly to virtual models, and nurs-
ing students are having a difficult time obtaining hands-on clinical experiences or placements. Our faculty and students face overwhelming expectations as changes are being made daily. With cooperation between Texas Nurses Association and the Board of Nursing in the first few weeks of the pandemic, students can now finish their education through simulation clinicals. These changes in the work and academic environments reflect a broader cultural shift during this pandemic. And as those shifts happen, TNA wants to help you make a difference. As a member of TNA, your voice matters. Nurses are sitting at the table to voice nursing concerns. We are making a cultural change at the state level concerning all nursing matters. As nurses, we must believe and follow our Nursing Code of Ethics. We must uphold the highest integrity of the nursing profession and by doing so, we understand all lives matter with no discrimination. But it takes cultural change to spread that message. As nurses, we have input on
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You are going hear more in the coming months about these goals and TNA’s 2020-2023 Strategic Plan. The plan has three components: 1. Build Foundations 2. Empower Nurses 3. Shift Culture This strategic plan will need all of your support to accomplish our goals. I am asking you to continue to support TNA and bring as many nurses to our organization so we can become one voice. As we face all the changes of the past year, I ask that you continue to care for your families, loved ones, your neighbors, and yourself. Educate the public on the importance of physical distancing, hand hygiene, and staying safe, healthy, and positive. Let us look hindsight 20/20 in the eye and state that we have learned where we strayed and are willing, ready, and able to adjust our strategy to become better nurses and community leaders. I cannot stress how grateful I am to you for being a nurse and my hero. Stay safe, healthy, and happy, Tammy i
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TNA MEMBER NEWS SPOTLIGHT ON YOU KUDOS
2020 LEADERS AND LEGENDS OF TEXAS NURSING The Leaders and Legends of Texas Nursing banquet was cancelled due to COVID-19. It is tentatively rescheduled for June 11, 2021, the evening prior to Texas Nurses Association’s (TNA) annual House of Delegates in Georgetown. Celebrated award winners include: LIVING LEGENDS Mary Holt Ashley, PhD, RN, CNAA, began her career as a nursing assistant and eventually achieved her PhD in nursing and retired as the Chief Nurse Executive for the Harris County Hospital District. Ashley served as vice president of TNA after stints on various statewide committees and as president of District 9. Michael L. Evans, PhD, RN, NEA-BC, FAAN, is a dean, professor, and Endowed Chair for Excellence in Nursing at the Texas Tech University Health Sciences Center School of Nursing. Evans served as president of TNA, an officer of the American Nurses Association (ANA), and president of the American Nurses Credentialing Center. Lolly Lockhart, PhD, RN, has been actively involved in TNA since 1961. She worked for TNA as assistant director and associate editor in the 1970s. Her work was the impetus for TNA’s Nurses in Office campaign. Lockhart was instrumental in implementing the Nurse Friendly program (the basis for ANA’s Pathway to Excellence Program). K. Lynn Wieck, PhD, RN, FAAN, helped TNA secure safeguards for nurses such as nurse staffing rules and safe harbor. A past TNA president, she is a champion of young nurses, mentoring many to become nurse leaders, and is an expert in multi-generational workforces, recruitment, retention, and emerging workforces.
POSTHUMOUS RECIPIENTS Joyce Adams, PhD, RN, was a nurse educator and retired as the Dean of Program Development, Institutional Effectiveness, and Health Careers at San Jacinto College. She served on many committees with TNA, including with District 9. Adams served on the Board of Vocational Nurse Examiners and was the first representative of Associate Degree Nursing programs to serve on the Board of Nurse Examiners (now the Board of Nursing). Dorothy A. Otto, EdD, RN, ANEF, a member for more than 60 years and past president of TNA, was Associate Professor Emerita at Cizik School of Nursing at UTHealth. She served on the District 9 board, the TNA Council on Education, as faculty liaison to the Texas Peer Assistance Program for Nurses, and on the nursing education policy council. Otto also served on the National League for Nursing on more than 10 committees and task forces.
AMERICAN ACADEMY OF NURSING 2020 CLASS OF FELLOWS Congratulations to the distinguished nurse leaders from Texas who will be inducted into the Class of Fellows in October.
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Hyochol Ahn, PhD, MSN, MS-ECE, MS-CTS, APRN, ANP-BC Amy Anderson, DNP, RN, CNE Lisa Campbell, DNP, RN, PHNA-BC Joyce Dains, DrPH, JD, APRN, FNPBC, FNAP, FAANP James Dickens, DNP, APRN, FNP-BC, FAANP Stacy Drake, PhD, MPH, RN Ashley Henneghan, PhD, RN Eddie Bernice Johnson, MPA, RN Joyce Neumann, PhD, APRN, AOCN, BMTCN Jessica Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP Kavita Radhakrishnan, PhD, RN, MSEE Azizeh Sowan, PhD, RN, MSN,MSDA, MBA
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Nelson Tuazon, DNP, DBA, RN, NEABC, CENP, CPHQ, CPPS, FNAP, FACHE
Michelle Wright, PhD, RN
COVID-19 TASK FORCE TNA announces the new members of the COVID-19 task force, which will be responsible for gathering information, finding opportunities, and producing materials in coordination with staff.
Sheila Brooks, RN, MSN, FNP-C Barbara Chapman, APRN, FNP-C Michelle Gill, BSN, RN Heather Hill, MSN, RN, NE-BC Ron Hilliard, MSN, RN Francis Luna, MSN, RN, NCSN Tammie G. Michael, DNP, APRN, AGPCNP-BC Erin Perez, DNP, APRN, ANP-C, AGNP-C, ACHPN Christine Riley, MSN, RN Steven Powell, MSN, RN-BC Stacy Zipkes, MEd, BS, ADN, RN-BC
They are joined by Edtrina Moss, PhD, RNBC, NE-BC, LSSGB, chair of the Education and Workforce Committee, and Colleen Marzilli, PhD, DNP, MBA, RN-BC, CCM, PHNA-BC, CNE, NEA-BC, chair of the Regulation and Practice Committee.
OBITUARY Edith West Clarkson, 78, passed away July 28, 2020. She was in Refugio, Texas, and obtained both her Bachelor of Science in Nursing in 1965 and her Master of Science in Nursing in 1975 from The University of Texas. She started as head nurse at the University Texas Medical Branch of Galveston 1965-1968 and later was a staff nurse with Dr. Michael DeBakey’s first heart transplant team in the United States. She retired from Methodist Hospital in San Antonio in 1992. Clarkson was a member of institutional review board, ANA Congressional district coordinator, TNA District 17 president, and Sigma Theta Tau president. i
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IN MEMORIAM Nurses remain on the front lines of the fight against COVID-19, risking their own health and lives while helping others. We pay tribute to those Texas nurses tragically lost to COVID-19.
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We honor their lives and mourn their loss alongside their family, friends, and colleagues. Our thoughts are with you. From all of us at Texas Nurses Association
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CHANGE IS INEVITABLE
How COVID-19 Accelerated Nursing Change By Cindy Zolnierek, PhD, RN, CAE
“THE NEW NORMAL” has become common parlance as we reflect on all things pre- and post-COVID-19. Many speculate what, if any, of these changes will persist. The broad expansion of telehealth and telemedicine is likely irrevocable. Virtual gatherings and work-from-home arrangements are likely to continue in some manner. Hopefully, we also see infection control practices of washing hands stick and lessen the impact of the upcoming flu season. For nurses, the new normal has particularly been relevant in two ways: public perception and workplace safety.
PUBLIC PERCEPTION The general public has perhaps never been so aware of nurses’ contributions to health care as they are today. Nurses are being celebrated in every medium. Large corporations, celebrities, and children are all saying “Thank you.” There is interest in nurses’ experiences and stories. There is concern and support for their well-being. There is recognition of
Before the pandemic started, we included the need for strengthened media relations in TNA’s new 20202023 Strategic Plan. We could not have predicted how a global crisis would thrust nurses into the spotlight and create immeasurable opportunities. the sacrifices they are making. Nurses are also becoming respected not just for their giving nature and role in direct care, but for their education, research contributions, and health care expertise. With this heightened awareness of nurses, the new normal for Texas Nurses Association (TNA) has meant almost daily interview requests from reporters for news media: electronic, print, radio, and television. Even documentary producers have reached out, eager to share nurse experiences. The 2017 Woodhull Study—a repeat of a 1998 study—found that nurses and the nursing profession were virtually absent from media stories about health care,
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mentioned in only 13% of articles, with almost no shift between 1998 and 2017.1 When nurses were mentioned, the topic was likely to be labor (57%) or the profession (44%) and rarely research (9%) and policy (4%). However, in this new normal, we have seen nurses asked to comment on policy recommendations to contain the virus as well as policy decisions of state officials. Nurses are asked to educate the public on the science of COVID-19: infection transmission, personal behaviors to reduce risk, types and reliability of testing, and disease progression. Before the pandemic started, we included the need for strengthened
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ment. Many nurses reached out to TNA requesting support and assistance in understanding the basis for the changes in their work environments. The COVID-19 crisis is different from anything previously experienced in many ways, including the length of time we have been and will be in crisis mode. Nurses are tired and traumatized. The unusual infection control practices of reusing PPE have become the new reality. Decisions about rationing, crisis planning, and staffing being made quickly and without nurse input has also become a new reality. This new normal is not welcome. Furthermore, we hope it is not here to stay. While communication is always important in health care, during a crisis it is critical to facilitate the easy, bidirectional flow of information from the bedside to the C-suite and vice versa. Nurse leaders should encourage questions and concerns, and responses must be sincere and timely.
While communication is always important in health care, during a crisis it is critical to facilitate the easy, bidirectional flow of information from the bedside to the C-suite and vice versa. Nurse leaders should encourage questions and concerns, and responses must be sincere and timely.
TOMORROW’S PARADIGM
Nurses: We implore you to speak out, to ask questions, and to state your concerns in a manner that invites a response from those able to take action.
media relations in TNA’s new 2020-2023 Strategic Plan. We could not have predicted how a global crisis would thrust nurses into the spotlight and create immeasurable opportunities for changing the status quo that the Woodhull study describes. Could we have made this shift without COVID-19? Uncertain, but we hope it remains long after the pandemic is contained.
Nurse leaders: We hope you take to heart the need to share rationales, including relevant facts, behind necessary decisions.
TNA members: Take this opportunity to envision and create your own new normal.
WORKPLACE SAFETY The new normal experienced in health care organizations may be less welcomed. As the threat of the pandemic became realized in the United States and Texas, health care organizations needed to quickly respond to preserve resources. In those first few weeks, a crucial component of this response involved conserving personal protective equipment (PPE).
Suddenly, masks, previously available and freely accessible to all, were removed from patient care areas and rationed to staff. Nurses had to wear the same PPE between patients and store masks in bags for reuse. N95s were kept under lock and key and provided only to staff encountering patients undergoing aerosolizing procedures. These new practices were contrary to the evidence-based infection control practices ingrained in nurses. The idea that the resources needed to practice safely might not be available was unthinkable. Confusion and mistrust abounded. Nurses felt betrayed and at risk. They were unassured by new policies that seemed to change daily. They lost confidence in their organization’s leaders. Many organizations experienced a breakdown in communication and struggled to involve nurses in the decisions affecting them, their practice, and their work environ-
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While both public perception and workplace trust have shifted, every crisis offers opportunity.
While each of us individually have little influence on the new normal, TNA is here to help all nurses shift change in the direction they want. We want nurses empowered to speak to the media, empowered to speak up in the workplace, and empowered to build a tomorrow that they are proud to be part of. i ENDNOTES 1. Mason, D. J., Glickstein, B., Nixon, L., Westphaln, K., Han, S., & Acquaviva, K. (2018). Research brief: The Woodhull study revisited: nurses’ representation in health news media. George Washington University Center for Health Policy & Media Engagement.
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TNA 2020 − 2023
STRATEGIC PLAN STRATEGIC DIRECTION
STRATEGIC DIRECTION
STRATEGIC DIRECTION
BUILD FOUNDATION
SHIFT CULTURE
EMPOWER NURSES
Taking risks Building awareness Collaborating for synergy
Celebrating nurses
Leveraging ideas Building knowledge for action
Changing the culture
OBJECTIVE: To demonstrate TNA values and establish our relevance while ensuring our sustainability. IN 2015, TEXAS NURSES ASSOCIATION (TNA) launched a five-year strategic plan focused on organizational renewal. The strategic objective—to position TNA as a vibrant and growing membership organization that provides superior value to its members—was addressed through goals focused on local engagement, membership growth, policy initiatives, and financial stability. Over the past five years, under diverse leadership on the Board of Directors, and with the help of nurses across Texas, TNA accomplished:
Exponential increases in member engagement through committees, events, social media, and other opportunities.
Membership growth by 82%.
Clearly articulated and published policy positions.
Ư Has a valuable, meaningful presence among nurses.
Reduction of the budget deficit every year.
Ư Is a bold political leader.
Last October, the TNA Board initiated its strategic planning work for 2020-2023 by reflecting on TNA’s history. At the January meeting, they fleshed out the new objectives and goals based on what TNA’s future could be by:
Conducting an environmental scan identifying highlights, concerns, hopes, implications, and take-aways.
Discussing nursing trends, political and economic factors, emerging technology, and member needs.
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Envisioning a future in which TNA:
Ư Has strong, powerful, and inclusive membership. Ư Is a trusted authority. Ư Has a progressive framework for governance. Finally, the board identified contradictions or barriers to this vision and proposed strategic directions to remove these barriers. Goals were set for each strategic direction (above), and staff have now undertaken the task to develop action plans for each goal. i
[CAREGIVER ] CARE FOR THE
Nurses are experts are responding to a crisis. To help nurses in crisis situations, Texas Nurses Association and the Texas Organization of Nurse Leaders created Care for the Caregiver, with the support of Johnson & Johnson. These easily viewable webinars and resources can help nurses prepare for crisis situations, build resiliency, and recover after a crisis. As the COVID-19 pandemic continues, nurses need to prioritize self-care and understand the signs of post-traumatic stress disorder.
NURSE DAY AT THE CAPITOL IS GOING VIRTUAL Look for details coming soon.
Join Texas Nurses Association to learn how to advocate for nursing practice, nursing education, and health care, as well as engage with elected officials at the state level. The virtual event will consist of online conversations, learning opportunities, and networking. More details on content, continuing nursing education, and scheduling coming soon at texasnurses.org.
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“But I’m Not Racist….”
“BUT I’M NOT RACIST….” Typically, this declaration is followed by a personal anecdote demonstrating that the speaker could not possibly be racist. “I have Black friends... a Black spouse... I was in the military... I have a mixed family”—these and other statements equate proximity with being “not racist.” These anecdotes, provided as proof of not being a racist, demonstrate a very specific idea of what people in this country consider “racist.”
DEFINING RACISM
The Nurse’s Role
IN DISMANTLING
Institutionalized Racism By Danica Fulbright Sumpter, PhD, RN
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Traditionally, when Americans discuss racism, we conjure images of the KKK, neo-Nazis, or other individuals perpetrating acts of bigotry, violence, and hatred against Black or other Indigenous people of color (BIPOC). To be sure, this personally mediated racism is harmful and continues to plague our society, as evidenced by smartphonedocumented instances of white people calling the police on Black people who are sitting at Starbucks, napping in a common room of their college dormitory, or even birdwatching. However, a more insidious, powerful, and enduring form of racism is institutionalized racism, first discussed by Kwame Touré (Stokely Carmichael) and Charles Hamilton in their 1967 book, Black Power: The Politics of Liberation. These leaders exposed how racism operates in subtle ways through policies and systems, thereby creating a society that upholds white supremacy by precluding the need for individual perpetrators of racism. Acclaimed public health scholar and physician Camara Phyllis Jones defines institutionalized racism as “differential access to the goods, services, and opportunities of society by race.” This disparate access is normalized, legalized, and manifested as inherited disadvantage that has continued to create worse outcomes for generations of BIPOC. As institutionalized racism materializes as “inaction in the face of need,” there is no need for an identifiable perpetrator. In other words, we cannot blame an individual for the fact that Black mothers are three to four times more likely to die in and around childbirth than their white (and even less educated) counterparts; that the lifetime odds of being incarcer-
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These data are shocking to those who believed the U.S. entered a post-racial world with the Civil Rights Act of 1964 and solidified such with our first Black president in 2008. Clearly, however, race still matters in this country. ated are one in 17 for a white man but one in three for a Black man; or that the net wealth of white families is nearly 10 times greater than that of Black families.1,2,3 These data are shocking to those who believed the U.S. entered a post-racial world with the Civil Rights Act of 1964 and solidified such with our first Black president in 2008. Clearly, however, race still matters in this country.
UNDERSTANDING OUTCOMES Maternal and infant health outcomes demonstrate clear differences unexplained by income and education. With an infant mortality rate of 11.4 (per 1,000 live births), Black infants die at a higher rate than all other infants.4 This rate is more than double that of non-white Hispanic and white infants (4.9 and 5.0 respectively). As nurses, we are trained to promote health, and our traditional response to this type of disparity is to counsel Black mothers to eat more nutritious foods, access prenatal care in a timely manner, and educate themselves so they can avoid risk factors. While diet, early prenatal care, and maternal education all positively influence birth outcomes, individual-focused interventions fall short, evidenced by ever-widening racial disparities. In fact, even after controlling for education and socioeconomic factors, Black women and infants still remain at higher risk for maternal and infant mortality.5 I, as a PhD-prepared Black woman, am more likely to have my infant die than a white woman who has not finished high school.6
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As racial equity consultant Joyce James exhorted School of Nursing faculty, staff, and students during her “Groundwater Analysis” training, nurses must shift from asking “What is wrong with these people?” to “What happened to these people?” Initial historical offenses such prejudicial city plans, including redlining or the placement of waste and other toxin-releasing facilities, continue to plague our state and affect many of the social and structural determinants of health for Black Texans.7 We see this playing out in the disproportionate impact of COVID-19 on Black and brown communities across Texas and the nation.8 Learning history, especially the regional history of the communities we serve, is an important part of our learning and unlearning journey. Studies have shown that the stress of perceived discrimination and racism can lead to physiological changes that not only influence birth outcomes but other health outcomes such as obesity, cardiovascular health, and hypertension.9,10 In addition to efforts to increase the numbers of health care providers who are BIPOC and efforts to increase access to care such as Medicaid expansion, it is incumbent on us as frontline health care providers to recognize and appreciate the impact that racism— personally mediated and institutionalized—has on the health of the individuals and communities we serve.
CHANGING THE SYSTEM It has been said that our systems are broken, but in actuality, our systems are operating exactly as they were intended. Our health care system (as other systems) was designed by white people for white people. To illustrate the point, consider another historically marginalized group: people with disabilities (PWD). When many buildings, sidewalks, and homes were initially designed, the needs of PWD were not front of mind. They were designed for able-bodied individuals, so it should not be surprising that PWD have a very different experience and worse outcomes when trying to navigate systems not made with them in mind. However, with careful consideration, deliberate inclusion of PWD, and legislation, physical structures are now more accessible.
It has been said that our systems are broken, but in actuality, our systems are operating exactly as they were intended. Our health care system (as other systems) was designed by white people for white people. Similarly, working toward a more racially inclusive system requires more than being “not racist.” We must be actively antiracist, with careful consideration and deliberate inclusion of BIPOC. As nurses, in order to dismantle institutionalized racism and build more equitable systems, here are five steps we can take. 1.
Begin a journey of learning and unlearning.
2.
Ask whose voice is missing and invite other voices to the table.
3.
Keep talking and become comfortable with discomfort.
4.
Examine data by race and ethnicity.
5.
Examine policies and procedures for disproportionate impact by race
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and ethnicity. One way to begin disrupting institutionalized racism is to start unlearning what we have been socialized to believe is true. Much about the history of this country has been transmitted to us through the lens of white supremacy. How many of us can say that we learned about the period in our country’s history from 1865-1877 known as Reconstruction? How many of us knew that 16 African-Americans served in the U.S. Congress during this time, and that more than 600 were elected to their state legislatures?11 I never learned this history in school. This has been a recent part of my personal learning and unlearning journey.
To be sure, this journey of unlearning and learning will be lifelong. We must continue to talk to become more comfortable saying words such as “racism,” “white supremacy,” and “privilege” if we are ever going to become antiracist. hard look at who is and who is not being served in our organizations. What groups have the best outcomes and why? Who has the worst outcomes and why? We must continually ask ourselves: “How is racism operating here?” We must think about who is missing at “the table” and whose interests are not on the agenda in order to interrupt systems that were designed to help a limited group. I cannot help but wonder why I was not taught about this important period in American history. Then I am reminded of the African proverb, “Don’t let the lion tell the giraffe’s story.” In all of our spaces we must ask ourselves: Whose voice is missing and why? To be sure, this journey of unlearning and learning will be lifelong. We must continue to talk to become more comfortable saying words such as “racism,” “white supremacy,” and “privilege” if we are ever going to become antiracist. We must foster these conversations within our spheres of influence, whether at work, school, home, or church. Wherever we are, we must keep talking because systems of oppression gain their power from our silence. As we continue to increase our consciousness about institutional racism and our capacity to participate in difficult conversations, we must also examine the policies, procedures, and practices that make up our systems. We must look at data within our systems disaggregated by race and ethnicity to take a
5. Novoa, C. & Taylor, J. (2018, February 1). Exploring African Americans’ High Maternal and Infant Death Rates. Center for American Progress. https://www. americanprogress.org/issues/early-childhood/ reports/2018/02/01/445576/exploring-africanamericans-high-maternal-infant-death-rates/ 6. Mathews, T.J. & MacDorman, M.F. (2006, May 3). Infant Mortality Statistics from the 2003 Period Linked Birth/Infant Death Data Set. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/ data/nvsr/nvsr54/nvsr54_16.pdf 7. Foster, K.M. (2019). Destruction of Black Communities in the Name of Progress. The University of Texas at Austin. https://utexas.box.com/s/ eaypqi2ms44e9jdqb20jt018mp0pqyo7 8. Ahmed, A. (2020, April 7). The “Father of Environmental Justice” on Why He Isn’t Surprised by COVID-19 Health Disparities. Texas Monthly. https:// www.texasmonthly.com/news/father-environmentaljustice-coronavirus/ 9. Collins, J.W., David, R.J., Handler, A., Wall, S., & Andes, S., (2004). Very Low Birthweight in African American Infants: The Role of Maternal Exposure to Interpersonal Racial Discrimination. American Journal of Public Health, 94, 2132-2138. https://doi.org/10.2105/ AJPH.94.12.2132 10. Williams, D.R., Lawrence, J.A., & Davis, B.A. (2019). Racism and Health: Evidence and Needed Research. Annual Review of Public Health, 40, 105-125. https:// doi.org/10.1146/annurev-publhealth-040218-043750 11. History.com editors. (2018, August 21). Black Leaders During Reconstruction. History. https://www. history.com/topics/american-civil-war/black-leadersduring-reconstruction
Though race is a social construct and we know there is more genetic variability within races than between them, it remains an important topic of exploration and discussion for nurses and all health care professionals. We must expand our understanding of racism beyond personally mediated acts to look more broadly at institutionalized racism. When we are able to take a systems approach, we will be able to remove the stigma and re-envision organizations that equitably serve everyone. i ENDNOTES 1. Roeder, A. (2019). America Is Failing its Black Mothers. Harvard Public Health. hsph.harvard.edu/ magazine/magazine_article/america-is-failing-itsblack-mothers/ 2. National Association for the Advancement of Colored People. Criminal Justice Fact Sheet. Retrieved July 22, 2020. https://www.naacp.org/ criminal-justice-fact-sheet/ 3. McIntosh, K., Moss, E., Nunn, R., & Shambaugh, J. (2020, February 27). Examining the Black-White Wealth Gap. Brookings. https://www.brookings.edu/ blog/up-front/2020/02/27/examining-the-blackwhite-wealth-gap/ 4. Centers for Disease Control and Prevention. Infant Mortality. Retrieved July 22, 2020. https://www.cdc. gov/reproductivehealth/maternalinfanthealth/ infantmortality.htm
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CHANGING INSIDE AND OUT How TPAPN’s Internal Culture Shift Led to Better Participant Experiences By Dawn Webb, MSN, RN-BC
CULTURE IS COMPLEX. Culture carries a lot of history, and a workplace can easily fall into saying “we have always done it this way.” Even simple change such as implementing a new policy is difficult, but changing an entire culture is daunting. Culture change is multifaceted and requires creativity and the willingness to lead by example. When I started my position as director of the Texas Peer Assistance Program for Nurses (TPAPN) in 2019, I knew the program faced several challenges, all of which were influenced by culture: the culture for participants and the culture for staff. Participants viewed the program as disciplinary, and the team worked independently of one another instead of embracing interdisciplinary cooperation. The two were unquestionably linked.
A HESITANT START I noticed every team member was eager to make changes to the program but were leery of me and had not had the support they needed in the past. Despite a new treatment model that individualized participant plans and streamlined the program, staff turnover had been high, and staff struggled to manage their high caseloads. Doing work to create a new TPAPN culture seemed like an additional burden, and I believe some staff thought my vision for the TPAPN program was far-fetched.
While staff worked hard to change their own perspectives, so much more than that changed, and it became noticeable! TPAPN participants were receiving a different type of support. They were finding their own motivation, and interactions with their case managers became more meaningful. I started off by getting to know everyone, building rapport, and making myself vulnerable. I told stories about past experiences, mentioned my likes and dislikes, shared my sense of humor, and did everything I could to just be myself. Slowly, our staff strengthened in their trust with each other. They opened up and were more willing to work together. I explained my leadership style and asked them to give me a chance to show them what we were capable of together. And finally, the guards came down.
A PARADIGM SHIFT With the team more receptive to change, my priority was to transition
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TPAPN into a person-centered program. This started with embracing new language and changing the way we speak, write, and present ourselves. After an initial person-first language training, I began to point out when I said something that was not person-centered and corrected my language in front of the team. They followed suit. What I didn’t realize initially is how much they would love and embrace it. Each team member would bring things to my attention; the language on our website and outreach material needed to be updated, as well as our forms and polices, the participant agreements— the list goes on.
As we continued to become personcentered, I added in team-building activities: the ones that force you to get to know one another. Though the process had growing pains, we persevered. I met individually with everyone as often as I could, and we teamed up on outreach activities so I could watch and learn from them. We received training on motivational interviewing, traumainformed care, and cultural awareness. We also participated in the NAMIWalks event together and made a commitment to reducing mental health stigma, especially in nursing.
In a fulfilling thrilling environment
A NEW TYPE OF SUPPORT While staff worked hard to change their own perspectives, so much more than that changed, and it became noticeable that TPAPN participants were receiving a different type of support. They were finding their own motivation, and interactions with their case managers became more meaningful. We have had many remarkable moments in the last 15 months, and the best ones include laughter and tears. I found that the most important part of building a strong, happy team is to stay human. I shared my fears of public speaking and being intimidated in some meetings; I asked for and gave support. Our team now participates in a weekly staff meeting where each of us brings our expertise to discuss challenging cases and give TPAPN participants the best possible care. Having eight licensed professionals provide input, with their many years of experience and education, and diverse perspectives and insight, means participants get better assistance in the end. It’s incredible to witness. And participants have found the new program more beneficial. Culture is hard to change, but when you have an extraordinary group of people who believe in what they do, anything is possible. No longer does the vision seem far-fetched. Now it’s just what we do every day. i Learn more about the Texas Peer Assistance Program for Nurses at tpapn.org.
Kristin, Family Birth Center RN
Granite Basin Recreation Area, Prescott, AZ
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Unlimited Courses for $29.99 a Year! Any Time, Any Place Get the info you need online through the TNA Learning Curve. New courses are added every month! Some of our recent offerings include: » Get Your Message Out: Media and Social Media for Nurses
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Th ri vin g AFTER GRADUATION Changing the Culture of Nursing and Helping New Graduate Nurses By Li-Chen Lin, PhD, RN
NURSING CULTURE is based on the philosophy of nursing. Nurses are expected to be knowledgeable, accountable, and compassionate while providing holistic care. Nurses are great at advocating for others but historically have not been good at advocating for themselves or their fellow nurses. Unfortunately, we have also fostered a nursing culture that allows hostility toward new nurses. New graduate nurses face difficulty transitioning to practice in these environments. They may lack role models or accessible resources. They may perceive a lack of support from their peers and nurse leaders. Almost one in five nurses leaves the profession in their first year.1 Incivility, bullying, exclusion, and workplace violence all contribute to this high attrition. It is imperative that we foster positive nursing work environments in all aspects. Changing nursing culture—essential to attracting and retaining new nurses— will be challenging and take time. Professional nurses and educators are in pivotal positions to create a welcoming environment that is nurturing to new nurses.
CREATING A POSITIVE WORK ENVIRONMENT The work environment includes physical, socio-cultural, and psychological aspects, as well as the culture of the workplace. A socio-cultural component that contributes to a positive work environment is inclusiveness, whereas isolation may contribute to a negative work environment. Unsupportive workplace
culture such as workplace violence and bullying can be detrimental to new nurses, patient safety, the organization, and the profession.2 Every nurse contributes to the nursing work environment. Nurses can create a positive impact by fostering self-respect and respect for each other as health care professionals. By joining or creating committees, such as a unit-based council or safety committee, nurses can provide valuable input to decision makers.
health and respect the dignity of patients and populations. The nurses’ ethical duty is to the practice environment.3 However, suboptimal nurse performance related to incivility can negatively affect patient safety.4 We need to help pave the way for our future nurses and encourage them to follow the same journey. We must hold ourselves and each other accountable in cultivating the culture of nursing.
Nurse residency programs, which help nurse graduates transition to practice, may integrate ways to create respectful, supportive environments. Some employers include mentoring programs to help new nurses adjust to a challenging new career and work setting. Nurse leaders should encourage nurses to be mentors, for instance by providing mentors with tools and preparation to become role models for their mentees.
It takes a collective, dedicated commitment to make this vision a reality. If you observe or experience a toxic work environment, be an advocate, speak up, and address the problem. Call “time-out” on bullying when you see it. Support new nurses as they transition to practice. Be aware of how a toxic environment can affect emotional and mental well-being. When you no longer find joy in your work, identify why and address it if possible.
HOLDING EACH OTHER ACCOUNTABLE
EMBRACING THE DIFFERENCES
Nursing is and should continue to be a rewarding career, regardless of nursing specialty. Our calling is to promote
Unlike many other professions, nurses come from a wide range of generations, different levels of education, and scopes
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of practice. Some nurses join the nursing profession as their second or third career. These differences—along with nurses being the largest health professional group—make it even more challenging to set clear expectations. Communicating with people from different generations or cultural backgrounds can present tension and potential conflicts. Individual perceptions of the appropriateness of behavior differ and may be influenced by cultural background. Clear and honest communication is key to embracing differences. Communication can facilitate understanding and resolve conflicts from differences in perceptions. For example, when working with new graduate nurses, restate expectations to them during orientation and throughout their residency. Whether in clinical decision-making, recognizing deteriorating patient conditions, or time management, new graduate nurses will need help and unambiguous communication to meet the expectations of their peers.5
WELCOMING WITH INTENTION Explicit welcoming allows new nurses to feel their professional development is valued and that they belong in the profession.6 New nurses need a supportive and welcoming culture to develop their nursing careers. We should change the term “nurses eat their young” to “nurses nurture their young.” When nurses practice self-care and self-compassion, they are more likely to have the capacity to be kind to themselves and others around them. We must teach nursing students and new nurses to also practice self-care and self-compassion to build resiliency. By recharging their internal resources, they can better provide compassionate care. Students should be introduced to and shown ways to integrate self-care and kindness into their professional development. Encourage new nurses to find mentors at work and outside of work and build enriching relationships. By surrounding themselves with other successful people, they will find it easier to succeed.
EMPOWERING NEW NURSES Above all, new nurses should feel empowered to communicate their needs at personal and professional levels. They should not feel guilty for saying no politely, for example, when asked to work
overtime that could be detrimental to their health or family life. In a positive work environment, nurses feel confident in advocating for proper orientation and on-site training to do their job safely. Nurse educators are essential to creating resilient future nurses. By providing nursing students with constructive feedback, educators can show student nurses that they are supported. This positive student-teacher relationship can empower students to be confident future nurses who value the nursing profession. Nurses must also support their current peers. For instance, during the pandemic, when nurses are required to float, they should be supported with training to expand their skill set and have support from their peers. We also need nurse leaders to advocate for their staff. A holistically healthier nursing workforce means more competent nurses who can better provide compassionate care. Negative behaviors in the workplace need to be stopped, including incivility toward new graduate nurses. We need to reverse the history of uncivil behaviors in our nursing culture. We need to break the cycle of bullying. We must hold civility as the norm for our nursing work environment and relationships. i ENDNOTES 1. Kovner, C. T., Brewer, C. S., Fatehi, F., & Jun, J. (2014). What does nurse turnover rate mean and what is the rate? Policy, Politics, & Nursing Practice, 15(3-4), 64-71. https://doi.org/10.1177/1527154414547953 2. Hawkins, N., Jeong, S., & Smith, T. (2019). New graduate registered nurses’ exposure to negative workplace behavior in the acute care setting: An integrative review. International Journal of Nursing Studies, 93, 41-54. https://doi-org/10.1016/j. ijnurstu.2018.09.020 3. American Nurses Association (2015). Code of Ethics for Nurses with Interpretive Statements. 4. Rainbow, J. G., Drake, D. A., & Steege, L. M. (2020). Nurse health, work environment, presenteeism and patient safety. Western Journal of Nursing Research, 42(5), 332–339. https://doi. org/10.1177/0193945919863409 5. Freeling, M., & Parker, S. (2015). Exploring experienced nurses’ attitudes, views and expectations of new graduate nurses: A critical review. Nurse Education Today, 35(2), e42–e49. https://doi-org/10.1016/j.nedt.2014.11.011 6. Daws, K., McBrearty, K., & Bell, D. (2020). “If somebody just showed me once how to do it”: How are workplace cultures and practice development conceptualised and operationalised for early career nurses? Nurse Education Today, 85. https:// doi-org/10.1016/j.nedt.2019.104267
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