Week 7: The U.S. Healthcare System
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The initial movement to bring health insurance to the U.S. in the 1880’s was
modeled from Europe (social and progressive movements) and varied from
compulsory national systems to industry-based requirements. The private sector
insurance arose in absence of government-sponsored health insurance.
o Blue Cross 1929 – Hospital-based plan
o Blue Shield 1939 – Physician-based plan Healthcare Finance
World War II saw a rapid growth in employer-sponsored health insurance, but after
WWII private insurance became the primary form of health insurance.
Federal government enters in as major player in health insurance with passage of
Medicaid and Medicare in 1965.
o Today, Medicare pays for nearly half of home health and hospice care.
During the 1970s, healthcare costs began to rise and gain national attention.
Healthcare expenditures exceed 10% of gross domestic product for the first time in
the 1980s, and by the 1990s managed care is the dominant factor affecting
healthcare delivery.
o Hospitals are no longer the revenue generators they once were, but instead
have become cost centers.
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Today, most people in this country obtain health insurance through employersponsored plans.
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Ownership:
o Not-for-profit is a tax designation. Non-profits need to make money to
support their mission.
▪ Profits are used to pay personnel, improve services, and support the
mission.
Profit is the difference between revenue (amount taken in) minus
expenses.
▪ Most healthcare delivery organizations are organized as not-forprofits.
▪ States regulate hospital ownership status.
▪ In 2014 NYU Langone made $1.67 billion in revenue
o For-profit occurs when investors own a part of the business. Profits are
distributed to the investors or shareholders.
▪ Shareholders own stock in the company. Stocks are traded on the
stock exchange (Wall Street).
▪ Growth in for-profit ownership of healthcare organizations such as
hospitals, nursing homes, hospices, and ambulatory surgery centers.
Levels of Care:
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Current trends in the U.S. Health Sector:
o Aging population and growing burden of chronic illness, leading to an
increased need for nursing care.
o An aging nursing workforce with an accompanying wave of retirement.
o Questions surrounding the survival of the ACA to extend health insurance
benefits to previously uninsured or underinsured individuals.
o An evolving quality, safety and consumer-focused care movement.
o Emerging models that establish primary, ambulatory and community based
care as the appropriate point of service.
o New technology – EMRs, telemedicine, drugs, devices, and new services.
A health disparity is “a particular type of difference in health (or in the most
important influences on health that could potentially be shaped by policies); it is a
difference in which disadvantaged social groups—such as poor, racial/ethnic
minorities, women, or other groups who have persistently experienced social
disadvantage or discrimination—systematically experience worse health or greater
health risks than more advantaged social groups.”
Sources of inequality in health:
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Females have traditionally been diagnosed and treated as if their bodies
were the same as males. Women are often excluded from clinical trials. Less
than 1/3 of uninsured pregnant women get proper prenatal care, while wellinsured pregnant women undergo many unnecessary interventions, such as
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cesarean sections, episiotomies, labor inductions and continuous electronic
fetal monitoring.
o The prevalence of cardiovascular disease and diabetes is substantially
higher in the African-American population than among the majority
population, as well. Furthermore, African-American women are far more
likely than women of the general population to be infected with HIV (about
64% of all women with new HIV infections in a given year are African
American.)
o Overweight and obesity are common in some Hispanic groups (overweight
and obesity are found among 63.9% of Mexican-American men and 65.9% of
Mexican-American women).
o Invasive cancer rates are much higher among Southeast Asian women in
general than in the majority US population.
Health system interventions to reduce disparities:
o Promote the consistency and equity of care through the use of evidencebased guidelines.
o Structure payment systems to ensure an adequate supply of services to
minority patients, and limit provider incentives that may promote
disparities.
o Enhance patient-provided communication and trust by providing financial
incentives for practices that reduce barriers and encourage evidence-based
practice.
o Support the use of interpretation services where community need exists.
Health literacy involves people’s knowledge, motivation, and competence to access,
understand, appraise and apply health information to make decisions in everyday
life concerning healthcare, disease prevention and health promotion. It’s a
constellation of skills:
o Print literacy: locate, read, understand, interpret written information
o Numeracy: use quantities information
o Oral literacy: speak and listen effectively
The best predictor of a client’s health literacy is asking your patient “how confident
are you filling out forms by yourself?”
The best predictor of a client’s health literacy is asking your patient “how confident
are you filling out forms by yourself?”
Health equity is when everyone has the opportunity to “attain their full health
potential” and no one is “disadvantaged from achieving this potential because of
their social position or other socially determined circumstance.
Week 8: The Client-Nurse Relationship
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The patient is a respected and autonomous individual. Patient-centered care (PCC)
addresses a patient’s physical and emotional needs. Plan of care is based on
patient’s individual needs and values.
PCC implies patient involvement in their care. There is a relationship between PCC
and consumerism. Patients as consumers want more information on:
o Price
o Proof of value
o Excellence in the actual delivery of care, not just the outcome
Article: Consumerism Hits Healthcare (Butcher, 2015)
As Americans take more control of their health care spending, they are demanding
straightforward information on prices, proof of value and excellent customer service. When
people are asked to rank their experience with their health care system, it’s not a high
outcome. To learn more about what consumers want from St. Luke's, the health system got
feedback from more than 1,000 patients. For one thing, consumers expect a level of serviceon-demand and an ease-of-access experience that many traditional health care
organizations currently are not prepared to deliver. For another, consumers expect to have
access to information, be able to understand information provided and use that information
to make decisions. “When we survey consumers, they really don’t know the benefits and
risks of the health care they’re getting. They don’t know about how health care
organizations are performing [in comparison with one another], and they don’t know what
anything costs… The industry has kept them, frankly, at a child or adolescent stage.”
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The cost of healthcare has gotten so expensive, people want more value for their
dollar.
To stay competitive, healthcare delivery systems must:
o Be innovative in how to connect with patients
o Respond to the demands
o Rethink affiliations and opportunities
o Be more transparent
o Revise payments systems
o Disclose prices and costs
Nursing focuses on wider system, patients’ values and beliefs, while medicine
focuses on the informed decision-making between physician and patient.
The relationship between the patient and the nurse involves open communication,
including that the health professional has the appropriate skills and knowledge.
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Essential elements of the nurse-patient relationship involve 3 phases of care:
o Orientation phase:
▪ Patient and nurse develop trust to carry out work
▪ Both see each other as individuals
▪ Agreement on working together
▪ Discuss termination
▪ Initial therapeutic contact
o Working phase:
▪ Mutuality of goals
▪ Awareness of differences
▪ Periods of conflict, frustration, and disagreement in varying degrees
▪ Development of trust
▪ Facilitate behavior change
▪ Provide for independence and self-care
o Termination phase:
▪ Establish separation
▪ Review goals and progress
▪ Formulate plans for the future
▪ De-brief on feelings and concerns
▪ Explore apprehensions
The nursing code of ethics serves as a social contract and guidelines for professional
self-regulation:
o The nurse practices with compassion and respect for the inherent dignity,
worth, and unique attributes of every person
o The nurse’s primary commitment is to the patient, whether an individual,
family, group, community, or population.
o The nurse promotes, advocates for, and protects the rights, health, and safety
of the patient.
o The nurse has authority, accountability, and responsibility for nursing
practice; makes decisions; and takes action consistent with the obligation to
promote health and to provide optimal care.
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The nurse owes the same duties to self as to others, including the responsibility
to promote health and safety, preserve wholeness of character and integrity,
maintain competence, and continue personal and professional growth.
The nurse, through individual and collective effort, establishes, maintains, and
improves the ethical environment of the work setting and conditions of
employment that are conducive to safe, quality health care.
The nurse collaborates with other health professionals and the public to
protect human rights, promote health diplomacy, and reduce health
disparities.
The profession of nursing, collectively through its professional organizations,
must articulate nursing values, maintain integrity of the profession, and
integrate principles of social justice into nursing and health policy.
Article: Dying with a Stage IV Pressure Ulcer (Kaiser-Jones, 2009)
This case study of the care received by a terminally ill nursing home resident in his late 80s describes
the many organizational and clinical factors that led to the progression of his pressure ulcer from
stage II to stage IV. The patient suffered weight loss, an increase in tissue load, and deterioration of
the wound and finally died in pain with a large stage IV pressure ulcer that exposed his coccyx. The
authors examine the ethical aspects of the case and explore the ways in which inadequate staffing,
staff education, and supervision contributed to insufficient help with meals, infrequent and improper
repositioning, and unrelieved pain.
Mr. Daly’s care lacked compassion and respect. Someone reading this case study could conclude that
no single person or group of people is entirely responsible. After all, many actions and inactions
contributed to the outcomes of pain, weight loss, loss of dignity, worsening pressure ulcer, and death.
The nurses didn’t promote and protect Mr. Daly’s health, safety, or right to pain relief. We need to
ask whether the ANA’s code of ethics for nurses is a part of every nursing student’s curriculum and
taught in a way that makes it relevant to everyday patient care.
Article: Guidelines for Using Electronic and Social Media (Spector & Kappel, 2015)
Social media can be a highly effective mechanism that allows for the cultivation of professional
connections; promotes timely communication with patients and family members; and educates and
informs consumers and health care professionals. Nurses who use blogs, social networking sites,
video sites, online chat rooms, and forums to communicate both personally and professionally with
other nurses can positively use social media in a responsible manner that fosters congenial interface
with other professionals. An outlet where nurses can share workplace experiences, particularly
those events that are challenging, can be as invaluable as journaling and reflective practice, which
have been identified as effective tools in nursing practice. Participating in social media is not a
problem as long as nurses always remain cognizant of their professional obligations. Nurses must
always be aware of potential consequences of disclosing patient-related information via social media
and mindful of employer policies; relevant state and federal laws; and professional standards
regarding patient privacy and confidentiality. Patients should expect a nurse to act in their best
interests and to respect their dignity. Inadvertent or intentional breaches of patient privacy and
confidentiality have potential to cause harm and erode the crucial nurse-patient relationship, as the
following actual scenarios clearly illustrate.
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Social media encompasses all internet based services that allow registered users to
construct a profile (public or semi-public) and articulate a list of other users with
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whom they share a social networking connection. There are advantages (e.g. media
and education) and disadvantages of social media in nursing.
We often use the terms "confidentiality" and "privacy" interchangeably in our
everyday lives, however they mean distinctly different things from a legal
standpoint. Confidentiality refers to personal information shared with an attorney,
physician, therapist, or other individual that generally cannot be divulged to third
parties without the express consent of the client; safeguarding patient information.
Privacy refers to the freedom from intrusion into one's personal matters, and
personal information; patients have the right to be treated with respect and dignity.
While confidentiality is an ethical duty, privacy is a right rooted in common law.
o The doctor-patient relationship establishes an implied contract of
confidentiality, since the doctor is in a position to help you by collecting and
analyzing otherwise private information. If the doctor asks a pharmacist to
fill a prescription for a drug known to treat a serious form of cancer, for
example, it would not be a breach of confidentiality. But if the doctor were
to tell your boss that you are terminally ill, that most certainly would
constitute a breach of their ethical duty to keep your information private.
Nurses have a legal obligation to maintain patient privacy and confidentiality at all
times, are prohibited form transmitting by way of any electronic media ANY patient
image, and are restricted from transmitting any information that may violate
patient’s rights to privacy or lead to ridicule or embarrassment. They need to
remember that the information they receive is privileged.
The Board of Nursing Disciplinary Action deals with intentional or inadvertent
breaches by reprimand, sanction, censure, placing conditions on a nurse’s license, or
suspension of license.
Violations of state and federal laws can result in civil and criminal penalties such as
fines and possible jail time.
o A nurse may be individually sued for defamation, invasion of privacy, or
harassment.
Breaches can damage the reputation of the health care organization, and can result
in termination of the nurse by their employer.
o Know the employer policy and promptly report any breach.
o Ensure the use of secure devices.
o Do not speak on behalf of the employer unless authorized to do so.
Week 9: Health Insurance and Healthcare Financing
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Benefits of health insurance include peace of mind, security, access, and better
health outcomes.
o The #1 reason people go into bankruptcy is medical debt!
A premium is the amount paid regularly (monthly or quarterly or deducted from a
paycheck) to purchase insurance coverage. A deductible is the money you must
pay yourself for health services before your health insurance plan begins to pay for
costs. High premium plans equal low deductibles.
Though many costs are shared between you and the insurance company, a co-pay is
the money you will pay out of pocket for services. It’s designed to deter you from
going to the doctor (i.e. using your insurance).
o The insurance plan will set a maximum limit on how much you could have to
pay out of your own pocket for services, called an out of pocket maximum.
After that, 100% of the fees for co-insurance are paid by insurance (though
you are still responsible for paying co-pays).
Lifetime Maximum Benefit is the maximum amount of money an insurance
company will pay for your care. The Affordable Care Act prohibits health plans from
putting a lifetime dollar limit on most benefits you receive.
Insurance companies used to be able to deny coverage for health services related to
a health condition the person had before they bought insurance (a pre-existing
condition). The Affordable Care Acts prohibits this and now all people are eligible to
get health insurance.
Actuaries apply probability, risk, life expectancy, and costs of mortality and
morbidity to predict and evaluate financial impact of future events and decide what
amount of money policyholders should pay as premium and co-pay.
o Risk aversion is the degree to which a certain income is preferred to a risky
alternative with the same expected income.
Cycle without health insurance:
There are 3 main types of Health Care Insurance Programs:
o Social Insurance Programs (Medicare)
o Means-tested Programs (Medicaid)
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o Private Health Insurance
Medicare was created by Congress in 1965 and is now the nation’s largest health
insurance program, currently covering about 43 million Americans. It is a health
insurance program for:
o People age 65 and older (i.e. it’s an entitlement)
o People under age 65 with disabilities who have been receiving Social
Security disability benefits for a set amount of time (24 months in most
cases)
o People of any age with End-Stage Renal Disease (ESRD) (permanent kidney
failure requiring dialysis or a kidney transplant)
Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut
hole"), meaning there's a temporary limit on what the drug plan will cover for drugs.
Since the ACA’s enactment, an estimated 37 million Medicare beneficiaries received
free preventative services in 2013, including flu shots and screenings for cancer,
diabetes, and other chronic disease, and 8 million beneficiaries saved over $11.5
billion since 2010 from discounts and gradual elimination of the “donut hole.”
Medicaid is a health insurance program (paid for and managed by federal and state
governments jointly) for individuals and families with low income and limited
resources. It pays for most acute (physician, lab and x-ray, pharmacy, etc.) and longterm (e.g. chronic health conditions) care, and is the payer of last resort.
o Financial eligibility for Medicaid and many other social programs is based on
a family’s income level compared to the Federal Poverty Level (FPL).
o To qualify for most Medicaid programs, a person must be a U.S. citizen or
“qualified non-citizen.”
Patient Protection and Affordable Care Act (PPACA/Affordable Care
Act/Obamacare) was signed on March 31, 2010. The ACA intended to expand access
to health insurance, increase consumer protection, emphasize prevention and
wellness; improve quality of care and system performance; expand the health
workforce; curb rising healthcare costs. The goal was to extend coverage to
approximately 32 million uninsured Americans by expanding both private and
public insurance.
10 essential health benefit categories:
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The ACA Individual Mandate requires all citizens and legal residents (there are
some exceptions) to have health coverage in March 2014. Beginning in 2014, any
person without qualifying health care coverage must pay a tax penalty, either a flat
rate or a share of household income, whichever amount is greater. The mandate is
satisfied when you were insured for a whole year through a combination of any of
the following sources:
o Medicare
o TRICARE
o The veteran’s health program
o A plan offered by an employer
o Medicaid or the Children’s Health Insurance Program (CHIP)
o Insurance bought on your own that is at least at the Bronze level
o A grandfathered health plan in existence before the health reform law was
enacted
The ACA Medicaid Expansion expanded the adult Medicaid program for individuals
age 19-64 who did not qualify for existing Medicaid programs.
There is little transparency for consumers to know the costs or quality of health
care.
Types of commercial health insurance:
o Health Maintenance (HMOs): individuals must seek care for in-network
providers only but have lower out of pocket expenses
o Preferred Provider Organizations (PPOs): contracted preferred provider
list means more choice of providers and higher costs for using nonpreferred providers
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Fee-for-service (FFS) payment is the dominant payment model in the U.S.
healthcare system, offering providers a specific amount of compensation in
exchange for providing a patient with a specific service. FFS payment is inherently
inflationary, rewarding volume and not quality (i.e. physicians get paid the same
amount for one patient regardless of whether they provide excellent care or terrible
care). Providers may actually be paid more for poor quality due to the need to
“rework.”
o FFS payment provides a financial incentive to provide more of those services
that are paid most handsomely (e.g., cardiology, orthopedics) and introduce
new services that generate higher fees than longer-standing services.
o FFS payment provides a financial disincentive to deliver services that
generate comparatively lower remuneration (e.g., primary care, psychiatry)
and provide services for which there is no FFS compensation (e.g., patient
outreach, care coordination, treatment plan development, web visits)
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Payment reform means moving away from FFS and towards other ways of paying
that financially incentivize provision of high quality, efficient care. The goal is high
quality, low-cost care.
The demand for Registered Nurses is expected to increase 26% by 2020 which
translates into 3.5 million nursing jobs. RN employment is expected to grow rapidly
in outpatient settings, particularly physician offices and home health care as more
people are able to access care with new insurance coverage.
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Week 10: Occupational Hazards and Self-Care
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At the federal level, the Occupational Safety and Health Act of 1970 (OSHA)
established the general duty clause, mandating employers to “furnish to each
employee a place of employment free from recognized hazards that are causing or
are likely to cause death or serious physical harm to employees.”
U.S hospitals recorded 58,860 work-related injuries and illnesses that caused
employees to miss work. Furthermore, each year 385,000 needle stick injuries and
other sharps-related injuries are sustained by hospital-based healthcare personnel
in the U.S. (approximately 1000 sharps injuries per day).
The top five causes of healthcare worker injury are:
1. Overextension (45%)
2. Slips, Trips, Falls (25%)
3. Contact with objects (13%)
4. Violence (9%)
5. Toxic exposure (4%)
Putting this into perspective, of all the work hazards in the U.S. per 10,000 cases:
o 157.5 were hospitals
o 147.4 were construction
o 111.8 were manufacturing
o 105.2 was the U.S. average
24% of nurses and nursing assistants changed shifts or took sick leave to recover
from an unreported injury.
o $15,860 = the average workers’ compensation claim for a hospital injury
o $27,000 to $103,000 = cost of replacing a nurse, including separation,
recruiting, hiring, orientation, and training.
Back pain is the leading cause of disability in those under age 45.
o 52% of nurses complain of chronic back pain
o 12% leave nursing because of back pain
o 20% transfer to different units because back pain
o 80% of nurses say they frequently work with musculoskeletal pain
The risk of getting injured is increasing as the workforce ages and patients are
becoming more obese.
New nurses are more at risk for workplace injuries.
Working night shift is associated with a 16% increased risk for a sprain or strain
injuries. To avoid sprains and strains:
o Use proper body mechanics
o Use lift equipment/ lift-teams
o Follow no-lift/minimal-lift policies
o Enlist the help of a colleague
o Request peer-leader teams to promote surveillance/teamwork
o After incident root-cause analyses to promote system change
Working weekly overtime is associated with a 32% increased risk for needle sticks.
Needle stick injuries can expose workers to a number of bloodborne pathogens that
can cause serious or fatal infections; the pathogens that pose the most serious
health risks are Hepatitis B virus (HBV), Hepatitis C virus (HCV), and HIV. To avoid
needlestick injury:
o Promptly dispose of used needles in appropriate sharps disposal containers.
Report all needle stick and sharps-related injuries promptly to ensure that
you receive appropriate follow up care.
o Tell your employer about any needle stick hazards you observe.
o Participate in training related to infection prevention.
o Get a hepatitis B vaccination.
o Avoid the use of needles where safe and effective alternatives are available
o Help your employer select and evaluate devices with safety features that
reduce the risk of needle stick injury
o Use devices with safety features provided by your employer
o Avoid recapping needles
o Plan for safe handling and disposal of needles before using them
The average adult needs 7-9 hours of sleep per day in order to allow our body to
recuperate, both physically and mentally.
o An accumulated loss of 1 hour of sleep per night can decrease concentration
o < 5 hours of sleep in 24 hours causes a decline in cognitive abilities
o Being awake for 17 hours is equivalent to a Blood Alcohol Content (BAC) of
0.05%, and being awake for 24 hours is equivalent to having a BAC of 0.10%.
o Exercise (at least 30 minutes 3x/week) improves sleep.
Fatigue-related medical errors cost about $100 million per year.
Inadequate sleep/long work hours is associated with higher rates of
musculoskeletal injuries, cardiovascular disease, and poor perceived health, as well
as 100,000 car crashes, 40,000 injuries, and 1,550 fatalities each year due to
“drowsy driving.”
Voluntary and mandatory overtime is common due to patient care demands and
staff shortages.
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Article: Fatigue and recovery in 12-hour dayshift hospital nurses (Chen, 2014)
While the 12-hour shift has been a widely accepted staffing solution in hospitals, the fatigue-recovery
process in nurses working 12-hour shifts remains unclear. The study investigated the status of acute
fatigue, chronic fatigue and intershift recovery among 12-hour shift nurses and how they differed by
organisational and individual factors. A cross-sectional survey was completed by 130 full-time
nurses working 12-hour dayshifts in three hospitals to assess the perceived levels of acute fatigue,
etc. Nurses experienced a moderate to high level of acute fatigue and moderate levels of chronic
fatigue and inter-shift recovery. Fatigue and recovery levels differed by the interaction between
hospital and unit after controlling for individual factors. Lack of regular exercise and older age were
associated with higher acute fatigue.
They concluded that an unhealthy fatigue-recovery process was found for nurses working a 12-hour
shift during the day. There appears to be a need to establish fatigue intervention programs for 12hour shift nurses in hospitals.
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Compassion fatigue is a combination of physical, emotional, and spiritual depletion
associated with caring for patients in significant emotional pain and physical
distress. Traumatic stress leads to inadequate self-care behaviors and increased
self-sacrifice in the helper role. Symptoms of compassion fatigue include:
o Work: avoidance or dread of working with certain patients, reduced ability
to feel empathy towards patients or families, frequent use of sick days, lack
of joyfulness
o Physical: headaches, digestive problems, muscle tension, sleep disturbances,
fatigue, cardiac symptoms
Emotional: mood swings, restlessness, irritability, oversensitivity, anxiety,
excessive use of substances, depression, anger and resentment, loss of
objectivity, memory issues, poor concentration, focus, and judgment
Compassion fatigue interventions:
o Take advantage of Employee Assistance Programs (EAP)
o Seeking out a mentor, supervisor, experienced nurse, or a charge nurse who
understands the norms and expectations of one's unit
o Ask for a new work assignment or shift rotation; go to a conference; work on
a special project
o Seek out Pastoral Care or Bereavement services as appropriate
o Develop positive self-care strategies and healthy rituals to recover from
compassion fatigue
As nurses begin meeting the needs of others, they often neglect their own needs. A
commitment to taking care of one's self includes:
o Eat properly
o Drink water and find the right caffeine balance
o Sleep / Use sleep strategies for night shift work
o Exercise regularly/Try relaxation practices
o Cultivate friendships/Family activities
o Engage in hobbies/extra curricular activities to promote work-life balance
having adequate nutrition
In terms of workplace safety, nurses have the right to:
1. Get training from your employer
2. Request information from your employer
3. Request action from your employer to correct hazards or violations
4. File a complaint with OSHA
5. Be involved in OSHA’s inspection of your workplace.
6. Find out results of an OSHA inspection
7. Get involved
8. File a formal appeal
9. File a discrimination complaint
10. Request a research investigation on possible workplace hazards.
11. Provide comments and testimony to OSHA.
Conflict is tension or struggle arising from mutually exclusive or opposing actions,
thoughts, opinions or a feeling, and is a normal occurrence; it can ultimately
improve patient care because of the combined perspectives.
Performance feedback is critique of technique or process of care with a defined
plan for improvement and/or remediation. This occurs in a safe place.
Bullying is repeated, unreasonable actions of individuals (or a group) directed
towards an employee (or a groups of employees) which are intended to intimidate,
degrade, humiliate or undermine, or which create a risk to the health or safety of the
employees; this is a form of abuse. Examples include:
o Unwarranted and invalid criticism
o Unjustified blame
o Unequal treatment
o Exclusion
o Social isolation
o Humiliation
o Unreasonable demands
o Verbal abuse
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o Denied opportunities
Bullying can be in the form of a personal attack (isolation, intimidation,
degradation), erosion of personal competence (damaging professional identity and
affecting care options), or attacks through work orders and tasks (obstructing work
and denying due process).
Article: Ethical and Legal Issues Associated with Bullying in the Nursing
Profession (Matt, 2012)
With the explosion of bullying in the workplace over the last several years, and the recent
increase in cases of bullying in the nursing profession, it is important to understand the ethical
and legal issues associated with these behaviors. The nursing profession has enjoyed more than
a decade of recognition as the most ethical profession. Indeed, the profession is guided by
detailed codes of ethics that provide a foundation for the extraordinary moral character expected
for nurses. Yet, despite these clear ethical expectations, there are nurses who have engaged in
bullying behaviors targeting their subordinates as well as their peers. In addition to ethical
codes, there are laws that are violated when individuals engage in bullying behaviors in any
workplace. This article explores the ethical and legal factors associated with bullying in nursing
and suggests that education about the issues should be initiated to eliminate these destructive
behaviors.
Bullying is a serious workplace hazard that has been known to result in health consequences for
nurses who are its victims. Nurses—whether managers, administrators, or staff nurses—who
engage in bullying behaviors are in violation of general ethical principles as well as ethical codes,
including the ICN and ANA codes of ethics for nurses. Depending on the specific bullying
behaviors, perpetrators may also be in violation of civil or criminal laws. Furthermore,
employers who are aware of bullying activities are in violation of OSHA regulations or state
administered occupational safety and health laws.
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Depending on the specific bullying behaviors, perpetrators may also be in
violation of civil or criminal laws. Employers who are aware of bullying
activities are in violation of OSHA regulations or state administered
occupational safety and health laws.
ANA Best Practices to Promote Civility:
1. Use clear communication verbally, nonverbally, and in writing (including
social media).
2. Treat others with respect, dignity, collegiality, and kindness.
3. Consider how personal words and actions affect others.
4. Avoid gossip and spreading rumors.
5. Rely on facts and not conjecture.
6. Collaborate and share information where appropriate.
7. Take responsibility or be accountable for one’s own actions.
8. Recognize that abuse of power or authority is never acceptable.
9. Speak directly to the person with whom one has an issue.
10. Demonstrate openness to other points of view, perspectives, experiences,
and ideas.
11. Be polite and respectful, and apologize when indicated.
12. Encourage, support, and mentor others, including new nurses and
experienced nurses.
13. Listen to others with interest and respect.
Week 11: Power, Politics, and Policy
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Nurses create value and make important contributions to the profession and to
healthcare.
Male registered nurses (RNs) make more than $5,000 per year than their female
counterparts across most settings. The salary gap occurs in most specialty areas
and positions and has not improved since 1988. Orthopedics is the only specialty
without a pay gap between men and women.
o Salary differences exist by position, ranging from $3,956 for middle
managers to $17,290 for nurse anesthetists.
o Over the course of a 30-year career, female RNs will have earned about
$155,000 less than male RNs based on adjusted earnings gap data.
Approximately 9.9% of RNs are black or African American (non-Hispanic); 8.3% are
Asian; 4.8% are Hispanic or Latino; and 1.3% categorizes themselves as two or more
races.
Strategies to overcome the pay gap in nursing:
o Your starting salary is important because is forms the foundation for your
lifetime earning potential – determine the average nursing salary and cost of
living in the local labor market and shoot for a salary at the top of the range.
o Be prepared to negotiate for your salary, work schedule, benefits, etc.
o Know when to walk away from a job offer.
Sources of personal power:
o What you are (personal capital)
▪ Power derived from your ability and expertise
▪ Power in your self confidence and other’s perceptions of your
abilities
o Where you sit (positional capital)
▪ Power derived from the role you play in the organization
o Who you know (relational/social capital)
▪ Power derived from your networks
It’s not what you know but who you know…
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Network is the set of relationships critical to your ability to get things done, get
ahead, and develop professionally. Networks facilitate access and cooperation.
o All encounters are opportunities for expanding and diversifying your
network.
o Think long-term and build ties before you “need” them
o Understand the natural tendency to stick to our own kind and break out of it
o More networks not always better – too many relational demands consumes
time and slow things down
o Be prepared to adjust over time as network needs change
Power is the ability to get people to do things they wouldn’t otherwise do. Politics
is the use of power either to gain more power or exert influence.
Empowering social structures are a reflection of the management team and the
value they place on nurses and nurses’ contributions. Social structures within the
work environment provide employees with access to:
o Information
o Support
o Resources
o Strong interpersonal relationships
o Opportunities to learn and grow
Money generally equals power. Nurses do not bring in revenue, they do save
costs/money, and represent the largest salary cost for the hospital. Unions are
organizations that represent workers –individuals and the group—to the managers
of organizations.
o Collective Bargaining is the process that unions use to represent workers to
negotiate terms and conditions of work. Works on the principal of mutual
aid and protection.
o Approximately 16-22% of all nurses belong to a collective bargaining unit.
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New York State Nurses Association is the largest union and professional association
for registered nurses, with 37,000 frontline nurses.
Nurses can only strike over issues related to patient safety or working conditions
(e.g. staffing, use of float nurses; use of unlicensed assistive personnel; Ebola
preparedness; discharge policies; mandatory flu vaccines).
o Managers need time to make arrangements to cover patient care needs
during a strike
o Used as a last resort after negotiations/discussions have failed
American Nurses Association represents nurses on both professional issues and
working conditions. Promoting safe and well-functioning work environments are a
component of the Nurses’ Code of Ethics.
Policy involves principles that govern actions directed toward given ends, such as
allocation of resources. Policies may result in laws, regulations, or guidelines that
govern behavior in public or private arenas, such as health policy.
Politics is a process that influences the allocation of scarce resources.
Nurses must understand the connections between public policy and their
professional practice and personal lives. Associations recognize that political action
is a professional responsibility essential to nursing practice.
o When nurses influence the politics that improve the delivery of healthcare,
they are ultimately advocating for their patients. Unfortunately, nurses have
historically had little involvement in policy that affects healthcare delivery.
Article: Politicization: The Power of Influence (McNeal, 2011)
This Editor contends that as the nation moves forward in its implementation of the
Healthcare Reform Act, it is imperative that the members of the discipline of nursing are on
point to engage in those political activities that will help to inform the future of healthcare
delivery. To provide detail with regard to how nurses might become more involved,
delineated below are the political activities used to effect change: campaigning,
communicating, voting, and protesting.
Week 12: Career Story
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Characteristics of a profession:
o The service provided is vital to humanity and welfare of society
o There is a special body of knowledge expanded through research
o The service involves intellectual activities; individual responsibility is a
strong feature
o Practitioners are educated in institutions of higher learning
o Practitioners are relatively independent and autonomous
o Practitioners are motivated by service and consider their work an important
component of their lives
o There is a code of ethics to guide decisions and conduct
o There is an organization/ association that encourages and supports high
standards of practice
Nursing has an active and enduring leadership role in public and political
determinations about the following six key areas of health care:
1. Organization, delivery, and financing of quality health care
2. Provision for the public’s health
3. Expansion of nursing and healthcare knowledge and appropriate application
of technology
4. Expansion of healthcare resources and health policy
5. Definitive planning for health policy and regulation
6. Duties under extreme conditions
Article: Crafting Your Career Story (Ibarra & Lineback, 2015)
All of us construct narratives about ourselves –where we've come from, where we're going.
To know someone well is to know her story-the experiences that have shaped her, the trials
and turning points that have tested her. The kinds of stories we tell make an enormous
difference in how well we cope with change.
Telling a compelling story to coworkers, bosses, friends, or family inspires belief in our
motives, character, and capacity to reach the goals we've set. We need a good story to
reassure us that our plans make sense-that, in moving on, we are not discarding everything
we have worked so hard to accomplish and selfishly putting family and livelihood at risk. It
will give us motivation and help us endure frustration, suffering, and hard work. A good
story, then, is essential for making a successful transition.
Notice what moves a story along. It's change, conflict, tension, discontinuity. What hooks us
in a movie or novel is the turning point, the break with the past, the fact that the world has
changed in some intriguing and fascinating way that will force the protagonist to discover
and reveal who he truly is… [they] make listeners lean forward and ask the one question
every effective story must elicit: "What happened next?"
Practice telling your story so it becomes natural and you start seeing yourself in your new
nursing career.