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Cover_FINAL 3/26/12 11:52 AM Page 1
January | February 2012
National
NURSE
T H E V O I C E O F N AT I O N A L N U R S E S U N I T E D
SENIOR ADVANTAGE
Retired nurses get organized
MENTAL BREAKDOWN
Massachusetts RNs on
campaign to save state
mental health
Road Block
How hospitals are crashing
the careers of new nurses
and the nursing profession
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Letter from the Council of Presidents
as many of us can recall, the
first few years of our nursing
careers can be tough. But for
an increasing number of new
RN graduates, the biggest
challenge right now is even
finding a job.
In certain parts of the
country, only about half of new
RN graduates are finding
employment. Yet most hospital
floors are completely understaffed and working nurses
report that their hospitals are making heavy use of traveler
or registry nurses. Given the obvious need in this country for
more healthcare professionals, particularly registered nurses, it is truly scandalous that newly graduated nurses are
having such difficulties in finding job placements.
Why? The problem, as usual, is the hospital industry.
Fixated on short-term profits, hospitals deem new RN
graduates unworthy of the initial investment of hiring and
orienting, preferring to staff hospitals with travel nurses
where there is no long-term commitment to the health of
the local populace from either party.
In talking to these new RNs, NNU leaders and staff have
been struck by their passion. Nurse after nurse spoke about
investing in their education so that they can be assets to their
local communities, as nurses have always been. Instead, they
find themselves anxious, desperate, and confused, often burdened with excessive student loan debts. Many are willing to
work for free in order to gain experience.
These circumstances pose a danger of taking our profession
NATIONAL NURSE,™ (ISSN 2153-0386
print/ISSN 2153-0394 online) The
Voice of National Nurses United,
January | February 2012 Volume 108/1 is
published by National Nurses United,
2000 Franklin Street, Oakland, CA
94612-2908. It provides news of organizational activities and reports on developments of concern to all registered
nurses across the nation. It also carries
general coverage and commentary on
matters of nursing practice, community
and public health, and healthcare policy.
It is published monthly except for
backwards not only in terms of workplace standards we’ve
all worked so hard to raise, but in terms of safety for
patients. When current graduating classes of RNs are not
getting the chance to practice and gain valuable experience,
particularly from veteran nurses preparing to retire in a few
years, the hospital floors of the future will be staffed largely
by the most inexperienced nurses. Again, the predicament of these nurses reminds us we
are right to press forward with our Nurses’ Campaign to
Heal America. We must establish an equitable health system that serves everyone in our communities, instead
of financial gain for the few.
For those of us who are starting to think retirement
thoughts, please check out the article in the issue about the
work of our retiree division. With so many of us approaching retirement age, the retiree division is a way for us to stay
involved and unified as registered nurses.
Finally, in this issue, we also honor the memory of Relie
Dema-ala, a Los Angeles RN and former CNA/NNOC
board member who was instrumental in the late 90’s and
early 2000s wave of successful RN organizing in Southern
California. We will miss you, Relie.
Deborah Burger, RN | Karen Higgins, RN | Jean Ross, RN
National Nurses United Council of Presidents
combined issues in January and February, and July and August.
Periodicals postage paid at Oakland,
California. POSTMASTER: send address
changes to National Nurse,™ 2000
Franklin Street, Oakland, CA 94612-2908.
To send a media release or announcement, fax (510) 663-0629. National
Nurse™ is carried on the NNU website
at www.nationalnursesunited.org.
For permission to reprint articles,
write to Editorial Office. To subscribe,
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Stay connected
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Please contact us with
your story ideas
They can be about practice or management trends you’ve observed, or simply
something new you’ve encountered
in the profession. They can be about
one nurse, unit, or hospital, or about
the wider landscape of healthcare
policy from an RN’s perspective.
They can be humorous, or a matter
of life and death. If you’re a writer and
would like to contribute an article,
please let us know. You can reach us at
nationalnurse@nationalnursesunited.org
EXECUTIVE EDITOR
RoseAnn DeMoro
EDITOR
Lucia Hwang
GRAPHIC DESIGN
Jonathan Wieder
COMMUNICATIONS DIRECTOR
Charles Idelson
CONTRIBUTORS
Gerard Brogan, RN,
Hedy Dumpel, RN, JD,
Jan Rabbers, Donna Smith,
David Schildmeier,
Ann Kettering Sincox
PHOTOGRAPHY
Jaclyn Higgs, Tad Keyes
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Contents
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9
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News Briefs
Minnesota RNs launch major campaign for ratio
law 5 | Massachusetts RNs defend mental
healthcare 6 | Honoring the life and work of Relie
Dema-ala, RN 7 | Michigan RNs introduce ratio
bill 8 | RNs at Sutter Medical Center in Santa Rosa
settle contract; Fresno County Nurses Strike; Cook
County Chicago RNs win new contract; Veterans
Affairs nurses score big win on comp time grievance
4
Court of Public Health
The Supreme Court will debate the legality of
Obamacare in spring, but all indicators show we
need single-payer now. By RoseAnn DeMoro
16
Life After Work
18
CE HOME STUDY COURSE
Lost Generation
Entire classes of nursing graduates are unable
to find work because the hospital industry doesn’t
want to spend the money to hire and train them.
What does this mean for our profession?
By Heather Boerner
The RN Retiree Division is one way for nurses to
stay involved in their profession and union after
they retire. A Staff Report
Workplace Violence: Assessing
Occupational Hazards and
Identifying Strategies for
Prevention, Part 1
As any registered nurse can attest, all forms of workplace violence are on the rise. Learn more about how
to prevent it through this home study CE.
JANUARY | FEBRUARY 2012
W W W. N A T I O N A L N U R S E S U N I T E D . O R G
N AT I O N A L N U R S E
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NewsBriefs_JanFeb REV 3/26/12 10:05 AM Page 4
NEWS BRIEFS
MINNESOTA
A
rmed with new—and
disturbing—evidence gathered
from the front lines of hospitals
across the state, Minnesota
nurses introduced legislation
on Feb. 28 aimed at addressing patient safety through adequate staffing levels.
“We have nearly 1,000 incidents from
the final six months of 2011 where our
patients suffered and in some instances
even had their lives put at risk because of
inadequate staffing levels,” said Minnesota
Nurses Association President Linda Hamilton, RN. “What’s even more disturbing is
that in nearly 900 of these incidents, hospital management did not—in the professional opinion of our registered nurses—take
adequate steps to remedy the situation.
That means hospital administrators failed
patients and nurses more than 90 percent
of the time whenever patient safety issues
were brought to their attention.”
After a new online reporting system was
formally launched on the MNA website and
mobile application, MNA nurses filled out
988 Concern For Safe Staffing (CFSS) forms
during the final six months of 2011. Copies
of each CFSS form were submitted to both
hospital management and MNA representatives. Of those documented incidents, 54
percent put patient safety at “high” or
4
“extreme” risk, according to the professional
judgment of MNA RNs.
“Unfortunately, these numbers don’t
represent a new problem or a new pattern of
hospital administrators failing to act,”
Hamilton said. “After years of broken promises from hospitals to work directly with
nurses to address patient safety issues that
resulted from inadequate staffing, we’ve
been left with no choice but to take our
concerns to the state legislature.”
The 2012 Staffing For Patient Safety Act,
which enjoys bipartisan support from Rep.
Larry Howes in the House and Sen. Jeff
Hayden in the Senate, includes setting a
maximum patient assignment for registered
nurses based on factors including nursing
intensity and patient acuity, and would
require hospital administrators to work
directly with nurses to ensure that adequate
resources are provided to keep patients safe.
It would also increase transparency
surrounding the staffing process. “Hospital administrators have said for
years that they’re willing to work with nurses
and allow us—based on our own professional
judgment—to add staff in an appropriate
and timely manner when our patients are
not safe,” Hamilton said. “That simply hasn’t
happened. And until it does, we need legislation like this to hold hospital administrators
accountable and keep our patients safe.”
In June 2010, 12,000 Minnesota RNs
conducted the largest nursing strike in
history to call attention to patient safety
issues resulting from inadequate staffing in
the Twin Cities and beyond. As part of the
ensuing contract settlement, 14 of the state’s
biggest hospitals once again promised to
work directly with nurses to ensure patient
safety through adequate staffing levels. Nearly 18 months later, the problem is
worse than ever inside numerous hospitals
across the state, according to Hamilton.
Instead of keeping their word, Minnesota
hospital executives even went so far as to
secretly plan a three-year long public relations
campaign aimed at stonewalling any attempts
by nurses to address patient safety through
adequate staffing. The plan was uncovered in
late 2010 after MNA nurses learned of a Minnesota Hospital Association (MHA) memo
outlining the strategy. (Visit www.mnnurses
.org/Memo for complete details.)
“This is not some sort of game,” Hamilton
said. “We’re talking about real people here.
Real families. We had one recent example
where a nurse was caring for a dying baby,
but was forced to take another patient
because the unit wasn’t staffed adequately.
That meant this nurse was severely limited in
her ability to comfort the grieving family. To
begin with, a dying baby should never be
paired with another infant. On top of that,
think of what this must have been like for the
parents of the dying child. And you know
what management did in response? They
ordered pizza for the nurses.” —John Nemo
Massachusetts RNs Oppose Proposed Closure
of State Mental Hospital, Mental Health Cuts
MASSACHUSETTS
T
he massachusetts Nurses Association/National Nurses United is
now engaged in an organizationwide effort to protect mental health
services in the state. The effort was
kicked off after the Massachusetts Department of Mental Health (DMH) in January
informed members of the MNA/NNU of their
plan to close Taunton State Hospital, one of
only six state-operated mental health facilities
in the state to care for people suffering from
acute and chronic mental illness.
The shocking announcement came at a
meeting held with senior DMH staff, and
could result in the loss of more than 169
beds from a mental health system in Massachusetts that already is overloaded, and
unable to provide appropriate mental
healthcare as it is currently constituted. “This is a cold-hearted and dangerous
decision that will have devastating consequences for the mentally ill in our state,” said
Karen Coughlin, RN, a nurse at Taunton
State Hospital and vice president of the
MNA/NNU. “We have no mental healthcare
safety net in Massachusetts. There are not,
and have not been, enough beds or services
in the system for years. This decision will
only exacerbate a long-standing crisis.
People will continue to go without care,
crime will increase, homelessness will
increase, more people will end up in the
corrections system, and many more will
commit suicide. This closure, along with
other cuts to programs and services, represents the state’s continued abandonment of
the mentally ill in our society.”
“Their plan makes no sense,” Coughlin
continued. “Our system has been operating
well over full capacity for years. We can’t
provide the care people need even with our
facility open. The other issue is
geography. We are now forcing patients and
families to travel to Worcester, Tewksbury,
or out to Western Mass for their mental
healthcare. It’s a travesty.” To understand the role and value of the
state’s inpatient facilities, one needs to have
a clear picture of the clients they serve. “At
our inpatient facilities, particularly at my
facility, Taunton State Hospital, we take care
of a significant number of forensic patients,
which means they come to us from corrections facilities or the court system, with
varying levels of criminal involvement and
some with histories of violent behaviors,”
explained Coughlin. “At all of our facilities
we have many frail, elderly mentally ill
patients who can’t be cared for in nursing
homes. A large percentage of our patients
have a dual diagnosis of mental illness and
substance abuse, which complicates their
placement in community settings. We have a
number of women suffering from serious
trauma who are self abusive and suicidal
and need intensive mental health monitoring and care. These are patients that often
have nowhere else to go in the system.”
In fact, Massachusetts is currently experiencing a shortage of psychiatric beds throughout the entire state’s healthcare system,
including both the public and private
sector. Psychiatric patients are clogging emergency rooms across the state, with some waiting 72 hours or longer for a psychiatric bed
placement. According to a recent statement by
Massachusetts Attorney General Martha
Coakley in a report concerning the disposition
of psychiatric beds following sale of hospitals
to Cerberus/Steward Health Care, “The need
for inpatient psychiatric and detoxification
hospital beds is critical. Any further reduction
in these services would have a significant
negative impact on the ability of the
Commonwealth to provide for mental health
services.” A January Boston Globe article
reports that the state mental health system
has lost more than 200 beds since 2007.
The MNA/NNU, which represents nearly
100 RNs and health professionals who work
at Taunton State Hospital, and more than
1,800 staff who work throughout the state
system, is committed to working with policy
makers and elected officials to ensure that
Massachusetts, which used to be a national
leader in the provision of mental healthcare,
maintains its commitment to the most
vulnerable residents of the Commonwealth. Public opposition to the proposed closure
of Taunton State Hospital was clear immediately after the announcement.
More than 100 local and state officials,
workers, and concerned citizens crowded
into a local church meeting opposing the
proposal to close the hospital.
The meeting was organized by State Sen.
Marc Pacheco, D-Taunton, with the primary
message that the proposal is not set in stone.
“For those that think [the proposal] is a
done deal, please get that out of your mind.
It is not a done deal,” said Pacheco.
In addition to Pacheco, a number of
politicians and other officials from the region
attended the meeting to show their support
for Taunton State Hospital, including Rep.
Patricia Haddad, D-Somerset; Rep. Keiko
Orrall, R-Lakeville; Rep. Shaunna O’Connell, R-Taunton; Mayor Thomas Hoye, Jr.,
and representatives from Rep. Barney
Frank’s office and Sen. Scott Brown’s office.
“Too many people look at this issue as only
a Taunton issue, and those of you in mental
health know that this could not be further
from the truth,” said Pacheco. “The Taunton
facility is crucial and a critical component to
statewide mental health services.”
“This has gone beyond an issue of funding and finances,” Coughlin concluded. “This
is a moral and ethical issue of human rights
and common decency.” —David Schildmeier
Need a shot of funny for your heart
and a dose of smart for your brain?
Then tune in every week to Nurse Talk, where RN hosts
Casey Hobbs and Dan Grady are always ready to pass
those meds! Visit www.NurseTalksite.com for details.
5
NEWS BRIEFS
A Purposeful Life
T
he california Nurses Association, National Nurses United,
and the nation’s nursing movement lost a dedicated and
passionate leader when Relie
Dema-ala, RN, died from breast cancer on
March 1, 2012. Dema-ala was 60.
She will be particularly missed by the Southern California nursing community, where she
was a prominent figure and had been one of the
major players in the organizing renaissance of
the late 1990s that led to a wave of RN unionization at many Los Angeles hospitals, including her own workplace of more than 25 years,
Glendale Memorial Hospital. Indeed, many of
her friends and colleagues will remember her as
a powerhouse organizer.
“Relie was a very exceptional person,”
said Debbie Cuaresma, a St. Vincent
Medical Center RN and CNA/NNOC board
member who also was deeply involved in
organizing Los Angeles hospitals. “She was
very friendly and just knew everyone. Her
network was just awesome.”
Dema-ala was born May 30, 1951 in the
town of Dumangas, Iloilo in the Philippines as
the eldest of eight children. She decided to
pursue a career in nursing, as had many
members of her family. After graduating nursing school in 1972 from St. Paul University in
Manila, Dema-ala in 1974 immigrated along
6
with many of her nursing school classmates to
the United States for the opportunity to work as
registered nurses. Many Filipino nurses who
work abroad do so in order to earn more money
that they then send home to support their families, and Dema-ala was one of them. “She always
sent money home for us and for our education,”
said one of her younger sisters, Malinda Demaala, who is also an RN. “She really cared about
us and was always thinking about us.”
After working in Atlanta, Ga. for a year,
the adventure bug bit Dema-ala again. Her
classmates and she decided to coordinate a
move in 1975 to Los Angeles. They chose to
work in different hospitals to be able to get
the same days off, and organized a support
network—taking vacations together and turning to one another to discuss nursing issues.
Dema-ala started at Hollywood Presbyterian
Hospital, but soon moved as a medical-surgical RN to Glendale Memorial Medical Center,
where she would stay for the rest of her career.
In the mid 1990s, working conditions worsened for the registered nurses at Glendale
Memorial. The RNs had lost several of their
benefits, including premiums, weekend pay,
and several holidays. Years went by without any
pay increases. The ratio of nurses to patients
was too high. Nurses were being floated unsafely to units and floors where they did not have
expertise and were not comfortable practicing.
Dema-ala found that she had no time to
do what she loved best about being a nurse:
talking to and comforting patients, helping
patients understand their medical condition, and teaching patients how to take care
of themselves. After she and others contacted CNA, an organizing drive was soon
underway, which culminated in a victorious
2001 vote to join the union. “Instead of
moving, I decided to stay and fight,” said
Dema-ala in a 2007 profile CNA published
about her. “It was hard to talk to people at
first because there is the question of trust,
but in the end we won. I think that was the
best thing that happened to the hospital.”
Those who knew Dema-ala would laugh at
the idea that it would be hard to trust her. “In
the hospital, we all looked up to her. She was a
person of integrity: dedicated to nurses, dedicated to her patients, and dedicated to CNA,”
said Myrna Valmeo, an oncology RN at Glendale Memorial and one of Dema-ala’s work
friends. “She’s a tough person and can convince
anybody of anything. But she is brutally honest
and not afraid to tell you the truth. That’s what
I like about her. That’s what I need in a friend.”
After organizing her own hospital,
Dema-ala rolled up her sleeves and got to
work helping unionize other hospitals across
Southern California and even other states.
With her outgoing personality, winning
smile, and extensive personal and professional network, Dema-ala quickly became
one of the key members of a core group of
rock-star RN organizers.
“Ate Relie had the gift of connecting with
people,” said Erik Macatuno, a CNA labor
representative who always used the term
“ate,” or older sister, when referring to
Dema-ala. “If there’s one thing I would
always remember about her, it was her beautiful smile. She used her gift to organize many
unorganized facilities.” Macatuno remembered that when he was helping to organize
Citrus Valley Medical Center, he asked a
colleague who represented Dema-ala if her
could “borrow” her for a few days to work on
the campaign. “She was fearless. She was a
natural organizer. She talked about the benefits of the union using the language of RNs.”
DeAnn McEwen, an ICU RN at Long
Beach Memorial Medical Center and a
CNA/NNOC copresident who first got to
know Dema-ala because both of their hospitals were organizing at the same time, remembers how Dema-ala was well spoken,
responsible, all business, and a good listener
while at the same time being approachable,
funny, and even a little mischievous at times.
One story McEwen will never forget is the
time she, Dema-ala, and other nurses were
sitting at a fast food restaurant, preparing to
attend a candlelight vigil at a hospital across
the street that was organizing. They had heard
that the nuns at the hospital had written in the
hospital chapel prayer books that they hoped
the union would not win. So the nurses decided to “sneak” into the chapel and write their
own comments, praying for a union victory. “It
was a kind of prank,” said McEwen, “but Relie
was game for that kind of stuff.”
In 2002, Dema-ala was elected to the
CNA/NNOC board of directors, a position
she would hold for five years. While on the
board, she continued to help organize
nonunion RNs and advocate for safe staffing
ratios, for expanding Medicare to all, and for
building a national nurses movement. “She
was a rock, a solid organizer, and a from-theheart activist every step of the way,” said
RoseAnn DeMoro, CNA/NNU executive
director. “A wonderful woman, activist, and
friend has left us, but she leaves behind an
organization which she helped to build that
will help save the lives of many, many others.”
Even in the final days of her illness, she
was ever the organizer. When Macatuno visited her at the hospital one day, she explained
to him that she had written a number of
letters to Glendale Memorial’s CEO about
unsafe staffing, reminded him about the work
that needed to be done, and that nurses had
to “organize, organize, organize.”
Friends, family, and colleagues will
always remember her as a devoted fighter
who worked nonstop to advocate for her
fellow nurses and for patients everywhere,
but also as a fun-loving person who enjoyed
attending concerts and traveling anywhere.
She worshipped the singer Neil Diamond,
often trailing him on his concert tours
through different cities. She shared a fondness for the Dutch classical musician André
Rieu with McEwen, and would hunt down
hard-to-find CDs of his music.
“We are lucky to have had her,” said
Valmeo. “I like to think that she’s busy in heaven now, organizing all the people up there.”
Dema-ala is survived by her mother,
Ceferina, and her younger siblings Malinda,
Merlyn, Jacqueline, Nora Ritchell, Ireneo,
Jr., Lilybeth, and Jeanifer. —Lucia Hwang
Michigan RNs
Introduce Ratio Bill
MICHIGAN
M
ore than 500 nurses and
nursing students from
across Michigan rallied at
the Capitol March 14, advocating for policies and priorities to heal their patients and
communities. This year’s event focused on
the introduction of the Safe Patient Care
Act, long-overdue legislation backed by the
Michigan Nurses Association that would
require Michigan hospitals to provide
minimum levels of nursing staff in order to
protect patients’ care and safety.
“Nurses are tireless advocates for our
patients, and that doesn’t stop at the
bedside,” said Jeff Breslin, an RN at Sparrow Hospital and president of Michigan
Nurses Association. “We can take great
care of people while they’re in the hospital,
but elected officials are the ones with the
power to make broad changes that can
improve lives and heal our communities.
We’re here from all across Michigan to tell
Lansing politicians to make constituents—
not corporations or their own interests—
their top priority, just like nurses put their
patients first.”
The newly introduced Safe Patient Care
Act (HB 5426, sponsored by Rep. Jon
Switalski in the House and Sen. Rebekah
Warren in the Senate), requires hospitals
to develop a plan that incorporates minimum patient-to-nurse ratios and also bans
mandatory overtime for nurses.
The need for the Safe Patient Care Act is
especially urgent, as nurses today are dealing with patients who are sicker and suffering from more complicated and severe
conditions. Nurses are also often under
more pressure to discharge them sooner.
Studies show that inadequate staffing levels
for nurses lead to a higher death rate, infections, pneumonia, falls, and other dangers
for patients. Minimum nurse-to-patient
ratios can save thousands of lives while
saving hospitals millions by avoiding bad
patient outcomes and nurse turnover.
“It’s outrageous that day care centers
have staff ratios but when your loved one is
in intensive care, there is no law requiring
the hospital to maintain a safe level of
nursing staff,” said Marietta Brooks, an RN
from University of Michigan Health
System in Ann Arbor. “Nurses will work
until they fall over, but when staffing is
short, something has to give. The Safe
Patient Care Act is a solution that works
for everyone, and legislators need to
support it and help nurses deliver quality
care to each and every patient.”
—Staff report
7
WRAP-UP REPORT
Fresno County
RNs, who care
for some of the
area's neediest
and most vulnerable residents,
went on strike
in January.
California
SUTTER MEDICAL CENTER SANTA ROSA
Registered nurses at Sutter Santa Rosa
Medical Center in February ratified a new
30-month contract for the 350 RNs that will
strengthen patient protections and maintain
affordable healthcare coverage for nurses
and their families. The settlement came after
the hospital withdrew proposals that would
weaken nursing practice standards and
patient protections, key issues for the RNs at
the facility. Some of the proposed changes
included reducing the ability of charge nurses, who make clinical assignments for their
unit, to advocate for patients while increasing their own patient loads.
“A universal sigh of content was heard at
Sutter Santa Rosa as the CNA RN membership overwhelmingly voted to ratify our new
contract,” said Toril Hayden, an RN who
works on a general medical surgical floor
and is a member of the nurse negotiating
team. “Our only concern now is that the
remaining Sutter affiliates follow suit to
ensure that a high level of patient care is
maintained at all Sutter hospitals.” Sutter
has continued to take a hard line with other
Bay Area Sutter facilities, demanding
hundreds of takeaways.
FRESNO COUNTY NURSES STRIKE
in protest of a harsh new contract that
the Fresno County Board of Supervisors
imposed upon them and to pressure the
board to return to bargaining in good faith,
all of the county’s registered nurses staged a
three-day strike starting Jan. 23. About
4,000 other county workers represented by
other unions also went on strike at the same
time over similar contract bargaining issues.
8
After the board, in a split November 2011
vote, changed the terms and conditions of
their contract, nurses asked the state Public
Employees Relations Board, which oversees
labor issues involving public agencies, to
block the county’s actions. On Jan. 18, PERB
reported numerous “unfair practices” on the
part of the county, including unilaterally
injecting new terms into contract talks,
ignoring the RNs’ requests for information
and explanation, and barring a lawful
assembly.
“The PERB findings give critical insight
into how the county does business—without
real negotiations, refusing to provide information and data, on a ‘take-it-or-leave-it
basis,’” said Mary Morrisson, a public health
nurse who works with high-risk infants and
a CNA/NNU member. “The county leaves us
no alternative but to strike.”
The county is attempting to dramatically
reduce nurses’ compensation, in some cases
ordering cuts of up to one-fourth of the RNs’
wages, and to force them to shoulder more
healthcare costs. Fresno County’s nurses
have already gone without raises for five
years, and their staffing numbers in the past
few years have been reduced by almost 60
percent. Most of the nurses are public health
nurses, work in county jails, and work in
county clinics. The nurses provide essential
healthcare services for some of the county’s
most vulnerable and low-income families,
many of them children, including vaccinations, preventative programs for preschoolage kids, and programs to protect children
from abuse and neglect. The cuts are particularly egregious
because almost all of the county’s public
health services are paid for through state
and federal grants, not county money, so
little to no fiscal benefit for the county will
result from the cuts. Indeed, the board also
turned down $58 million in federal funds
that had been available to help Fresno
County’s neediest.
Illinois
registered nurses working for the Cook
County Health and Hospitals System, the
public health system serving the greater
Chicago area, recently won a new contract
that not only preserves all the benefits and
standards RNs currently have, but makes
improvements to staffing language, gives
across-the-board raises as well as an additional step for senior nurses, and protects
nurses from furlough days—among other
enhancements. This contract, which expires
Nov. 30, 2012, represents a significant
bargaining accomplishment with the county,
which has consistently attempted to balance
budget deficits on the backs of frontline
healthcare workers and patients.
Veterans Affairs
nnu-va scored a big win recently by
prevailing on a national grievance of importance to all VA RNs. Nurses who choose to
work for comp time (hours off instead of
overtime pay) have a limited period in which
to use it. But due to a change that had not
been made to the electronic timekeeping
system, VA nurses had been losing valuable
compensatory time off. To address this issue,
NNU-VA filed a grievance on lost time, and
Veterans Affairs is now going to audit the
time cards of all NNU-VA RNs from 2007
until 2011 and restore any compensatory
time RNs may have lost due to this
error. RNs will then have one year to use the
compensatory time off. After NNU-VA took
the lead on this issue, other unions are now
filing for the same thing for the RNs they
represent. Initial reports coming in indicate
that some RNs are getting 40 hours or more
of comp time restored to them.
In addition, NNU-VA has been busy
negotiating our national master contract
with Veterans Affairs, with about 70 percent
of the work completed. The RN bargaining
team reports that they have agreed on some
great provisions for protecting nurses’
rights. They anticipate a completion of
bargaining by July and are eager to share.
—Staff report
RAD_JanFeb 2012 3/26/12 10:07 AM Page 9
RoseAnn DeMoro
Executive Director, National Nurses United
Court of Public Health
W
The Supreme Court will debate the legality
of healthcare laws this spring, while all indicators
show the country needs single-payer.
ith the approaching Supreme Court
showdown on President Obama’s 2010
healthcare law (the
Affordable Care Act
(ACA), modeled, of course, on Mitt
Romney’s law in Massachusetts), the U.S.
healthcare system remains a dysfunctional
mess, as nurses bear witness to every day.
In late March, the court will devote six
hours over three days to oral arguments on
the legal challenges to the law—the most
time the court has given a case in 56 years.
The testimony will likely be accompanied by
a possible record 100 “friend of the court”
briefs, Kaiser Health News reported Feb. 15.
While the ACA had some undeniable
positive elements, such as permitting young
adults up to age 26 to remain on their
parents’ health plan, and a few limitations
on insurance industry abuses, such as
barring them from denying coverage due to
pre-existing conditions, our healthcare
nightmare is far from over.
And, as nurses have reported repeatedly
the past year, the economic crisis has greatly
aggravated the suffering with broad declines
in health status that are directly linked to
job loss, unpayable medical bills, and families having to choose between paying for
food, housing, clothing, or healthcare.
As to the law itself, despite its name, the
ACA has done little to actually make healthcare affordable. Out-of-pocket health costs
for families continue to soar largely unabated. Nurses now routinely see patients who
have postponed needed care, sometimes
even life-saving or life-prolonging care,
because of the co-pays and deductibles.
A Commonwealth Fund study in November, comparing the United States to other
high-income countries, found that we stand
out for sick adults having cost and access
problems, with 27 percent unable to pay
medical bills in the past year, compared to
within 42 days of childbirth has actually
from 1 to 14 percent in other countries, and
doubled in two decades, from 6.6 deaths
42 percent skipping doctor visits, recomper 100,000 live births in 1987 to 13 deaths
mended care, or not filling prescriptions.
per 100,000 in 2007. One reason: a 10
Nationally, premiums have jumped on
percent cut in federal spending for materaverage 50 percent over the past seven years
nal and child health programs over the past
with more than six in 10 Americans now
seven years.
living in states where their premiums
Those who think that
consume a fifth or more of
Despite its name, giving more handouts to the
median earnings.
private insurers and other
the Affordable
Universal coverage
healthcare corporations will
Care Act has
remains a far-off dream.
improve these dreadful
done little to
Fifty million Americans
statistics should think again.
actually make
still have no health coverThe wholesale domination of
healthcare
age. Another 29 million are
our health by the same Wall
underinsured, meaning
affordable. Outthey have massive holes in
of-pocket health Street types who tanked our
their health plans, an
costs for families economy is exactly what has
caused the falling health
increase of 80 percent since
continue to soar
barometers on access, cost,
2003, according to the
largely unabatand quality.
journal Health Affairs. The
ed. Nurses now
There is an alternative
percentage of adults with
routinely see
which most of the rest of the
no health insurance, at 17.3
patients who
world has discovered, a
percent in the third quarter
have postponed
national or single-payer
of 2011, was the highest on
needed care,
system, such as expanding
record, up from 14.4
sometimes even
and adequately funding
percent just three years
life-saving or
Medicare to cover everyone.
earlier, Gallup reported.
life-prolonging
Even in other countries
On quality, the United
care, because of
where conservative politiStates continues to fall far
the co-pays and
cians have proposed privatibehind other nations.
deductibles.
zation or sweeping health
What should have been a
cuts, they are being met with
shocking, underreported
study from the University of Washington last an aroused public unwillingness to trade
their health systems for the broken model
June found more than 80 percent of U.S.
we have here.
counties in free fall on life expectancy
Whether the 2010 law is fully or partially
compared to nations with the best life
thrown out by the courts, repealed in
expectancies. Some U.S. counties are more
Congress, or fully implemented, the need for
than 50 years behind their international
real reform, single-payer/Medicare for all,
counterparts, meaning they have the life
will continue to grow. At this point the fight
expectancy that those nations had in 1957.
for single-payer is being taken up state by
One reason for this disturbing news is
state, a movement that we will continue to
the regression in death rates for childbearproudly support.
ing women. The United States ranks just
41st in the world, and it has been getting
worse, according to the World Health
RoseAnn DeMoro is executive director of National
Organization. The average mortality rate
Nurses United.
9
Grads_2 3/26/12 10:19 AM Page 10
Grads_2 3/26/12 10:21 AM Page 11
Lost
Generation
Entire classes of nursing graduates
are unable to find work simply because
the hospital industry believes investing
in new grads is bad for its bottom line.
What troubles lie ahead, then, for
the future of our profession?
by Heather Boerner
I
n the three months since Jacqueline Schubert graduated
with a BSN, she’s sent hundreds of résumés, stayed in contact
with her preceptor, asked her boyfriend, an ER doctor, to see if
there were any openings for new grads at his hospital, and
walked the halls of every medical practice in the south Florida
area, asking about work and knocking on doors.
In this economy, she says, the only chance for getting noticed in a sea
of new RN grads is to “storm into people’s offices and shove my name
down their throats.”
But even then, the results are discouraging. She’s marched her way
into the nurse recruiting and nurse manager offices, where, if she’s
lucky, a recruiter will give her portfolio a cursory glance. Then he’ll
usually tell the 26-year-old New Jersey native that there’s a hiring
freeze and to check back later. If she’s not lucky, they dismiss her outright. Does she have an appointment? No? Go home. Did she apply
online? Yes? Go home.
And then there’s the hand-written note she received from one nursing manager asking her to stop applying at that hospital.
After such long periods of rejection, new nurse graduates like Schubert can’t help but get demoralized and start thinking that something
might be wrong with them. They might even start questioning whether
the country needs as many nurses as everyone thought, or whether
going into nursing was a good idea.
They’d be wrong to do so, though. In the case of nursing, few people
are discussing the real problem: Hospitals are simply unwilling to
11
Grads_2 3/26/12 12:03 PM Page 12
invest the money needed to hire new nurses right now
and instead using the bad economy as an excuse for not
hiring, squeezing more work out of existing staff, and
thereby boosting profits. In addition, many hospitals that
do need the staff turn to travelers or registry nurses who
may be quite expensive, but do not hold the same level of
commitment to the community, are less likely to challenge management, and do not reinvest their dollars into
the local economy.
While some public hospitals or hospitals serving
high uninsured populations may be struggling financially, the vast majority of hospitals are still raking in
money. HCA, the country’s largest for-profit hospital
chain, reported a profit of $2.5 billion for 2011. The
next largest, Community Health Systems, reported a
profit of $280 million for 2011. Kaiser Permanente, one
of California’s biggest systems, also posted a profit of $2
billion last year.
Meanwhile, the country’s patients still need nurses.
According to the U.S. Department of Health Services’
Bureau of Health Professions, the United States was
short about 275,000 RNs in 2010, and this deficit will
peak in 2020, when the country will be short about
800,000—almost one million—registered nurses.
Nurses in facilities across the country report constant
understaffing; it’s obvious more RNs are still needed.
The failure of hospitals to invest in hiring and precepting new nursing graduates today will also certainly
spell problems in the future. Without a constant influx of
new nurses who gain confidence, skills, and expertise on
the job, hospitals could soon be left with a huge knowledge gap as veteran RNs retire and only nurses with little
experience are left on the floors.
“Not do I believe for one second that hospitals cannot hire new grads,” said one RN who works for a California nursing school but wanted to withhold her
name for fear of damaging the prospects of graduates
from her program. “They are buying expensive equipment. They are hiring travelers at great expense that
they don’t have to make commitments to. And in five years, most
experienced nursing staff will have to retire, whether they like it
or not.”
Some graduates have gotten so desperate to get a foot in the door
that they have agreed to essentially pay hospitals to let them work
there, by accepting unpaid “internships.” Not only does this practice
devalue the market value of the nursing profession, it also jeopardizes the licenses of these nurses.
Entire graduating classes of nursing students are reporting these
dire conditions. Schubert has only to glance at her Facebook page to
12
know she’s not alone. One peer gave up and took a job as an LPN.
Another moved to Mississippi, where pay was better. One took a job
but quit before her first day when she discovered how severely
understaffed the floor was. A fourth told Schubert she was getting
job interviews — but then revealed that she was looking for work at
nightclubs.
“That’s what I feel like I’ll end up doing,” she said, her voice thinning with tension. “I’m willing to put in my time [looking for an RN
job]. But I didn’t think every hospital in south Florida would say no,
no, no, no, no, no, no, no.”
Grads_2 3/26/12 10:22 AM Page 13
“Not do I believe for one second that hospitals cannot hire new
grads. They are buying expensive equipment. They are hiring
travelers at great expense that they don’t have to make
commitments to. And in five years, most experienced nursing
staff will have to retire, whether they like it or not.”
o be sure, the market for new grads is far better than
the general unemployment rate for the healthcare industry in general and the economy at large. Since the recession started in 2008, the overall unemployment rate for
RNs has more than doubled, from a low of 1 percent in
2006 to about 2.4 percent in 2010. Meanwhile, slightly less than 4
percent of healthcare workers in general and 9.6 percent of all Americans were unemployed in 2010.
But it used to be that there were eight jobs available for every
unemployed RN. By 2010, that ratio had dropped to about two
to one.
So if the average is still that there are two jobs to every unemployed RN, why are new grads reporting such trouble getting jobs?
Probably because those available jobs are going to RNs with some
experience. New graduates, who take the most investment in time,
money, resources, and existing staff to train, are unfairly seen by
hospitals as too much trouble. Experienced RNs are also working
more, whether choosing to stay in their jobs longer because they
cannot yet afford to retire, returning to work from a retirement gone
bust, or picking up extra shifts to cover for job losses in their immediate families.
A 2011 report from the National Student Nurses Association
found that 36 percent of new graduates didn’t have a job three
months after graduation — and that number is even worse for those
in the West and the Northeast, where only 55 percent and 61 percent, respectively, were employed as RNs. The central United States
is doing the best, with a new-RN employment rate of about 72 percent. Those numbers are an improvement over the year before,
when 46 percent of new grads were unemployed three months after
graduation. Alan Benson, a doctoral candidate at the Institute for
Work and Employment research at the Massachusetts Institute of
Technology Sloan School of Management, calls this a reversal of a
two decades-long trend.
The job market new RNs are graduating into looks very little like
the market previous RNs experienced as they completed training.
Just a few years ago, new RNs like Schubert, who graduated with
honors, would have been snapped up right out of their preceptorships, often with signing bonuses and with hospitals offering to pay
relocation fees. Not so today. All across the country, new nursing
grads are finding that the bidding wars and poaching so common a
few years ago have all but disappeared.
“Not two years ago, our nurses got work before they even had
their completion ceremony, and all our nurses were employed in a
few months,” said Sigrid Sexton, MSN, nursing instructor for Long
Beach City College and a former member of the California Nurses
Association’s Joint Nursing Practice Commission. “For the class that
graduated in December 2010, graduates are telling me that as of
July, only about half of the class had found jobs.”
hen new nursing graduates start their job
searches, this is what they encounter: dismissive,
unsupportive administrators whom candidates say
seem to adopt unfair or arbitrary hiring practices.
For example, a hospital will post a job because
they’re required to, but never intend to hire an outside applicant
because there’s an internal person already picked. Or human
resources will only take the first 20 people who apply, without even
looking at qualifications. Or the hospital will look more closely at
résumés delivered by hand, even though it claims not to. Sometimes
hospitals will conduct interviews en masse, calling in dozens of candidates and giving each only five minutes to “wow” or “dazzle” the
recruiter. Nursing grads say they often feel like they are participating
in a dog-and-pony show or Hollywood-style auditions instead of a job
interview that should be based on clinical qualifications.
For April Coleman of Long Beach, Calif., the situation feels, if not
dire, at least tense. At 39, Coleman isn’t what people think of when
they imagine a new nurse. The mother of three started her associate
degree at Long Beach City College in Southern California a few years
ago because nursing seemed to be such a stable field. “I felt comfortable committing the time and money to pursue my education
because I was sure I would get a job,” said Coleman, who had been
working as a pharmacy technician before pursuing nursing.
But many months out of school now (she graduated in December
2010), Coleman has a sense that the clock is ticking. She’s heard
through the grapevine that hospitals don’t consider candidates for
new RN positions once they’ve been out of school for a year. At the
time she spoke to National Nurse, it had been months since her
graduation, and there were no jobs in sight.
Coleman’s typical day goes as follows: She drops her kids off at
school, and then spends three or four hours stationed in front of her
computer, scanning all the websites she knows that list new grad
positions, as well as a number of local hospital websites where the
company lists jobs directly. Then she spends time registering for
websites and submitting résumés for any job that fit her criteria.
Sometimes she then cruises over to new-grad message boards,
where all the talk is about where the jobs are, what the options are,
and how to cope with the continued uncertainty.
Over the months, her criteria have broadened. Because of her
kids, she’s not able to pick up and move. But she’s started searching
for any acute-care job within a two-hour driving radius. So far, her
search has taken her to Los Angeles and Orange County, of course,
13
Grads_2 3/26/12 10:23 AM Page 14
but also to Bakersfield and the high desert. She wants to stick with
acute care because she knows that hospitals won’t count work that
doesn’t include such experience. Still, she does know people who,
desperate for RN jobs, have taken jobs at skilled nursing facilities,
hospice centers, and prisons. Marty Witrak, dean of nursing at the
College of St. Scholastica in Duluth, Minnesota, said she’s also seen
new grads take jobs in areas like long-term care and the military.
“The worst is when they list a job as a new RN job, but the duties
are those of a [certified nursing assistant],” Coleman said. “I went to
school for a reason and I want to use those skills.”
New nursing graduates looking for work also say that they are angry
and disappointed that local hospitals don’t give preference to local candidates or put any emphasis on hiring locally. These graduates often picked
nursing programs in their local area because of existing ties to their community, and they would like to practice nursing in their communities.
But probably the biggest frustration for new graduates is finding
out that their area hospitals are hiring travelers, but not new nurses.
One RN, who asked that her name not be disclosed because she is still
looking for work, said that she heard a local hospital recently adopted
electronic charting and needed to bump up staff, but did not hire new
grads. Instead, it hired a whole second set of travelers. Some working
RNs report that, on some units, up to 80 to 90 percent of the staff are
travelers. “We’re seen as more expensive, because we require training,
but travelers can’t be cheap,” said one relatively new RN who is working now, but struggled for eight months to find a job after graduating
in 2009. “The hospital has to pay their room, food, expenses, car.”
Recent graduates unable to find permanent work are so desperate
for any experience to put on their résumés that they are increasingly
accepting unpaid “internships” at hospitals, and hospitals appear to
be enjoying these programs as sources of free labor. Actually, the new
grads end up paying the hospital to work there because they often
complete these internships as a college course for which they must
fork over tuition. Many who have completed these programs say that
they do not lead to jobs. Even worse, while they are practicing as
“interns," their RN licenses are at risk because they are still legally
responsible for their patient assignments without the normal training
and support that comes with permanent employment.
One unemployed new grad RN said that after she completed 200
hours of work as an unpaid internship with Sutter Delta Medical
Center in Antioch, Calif., she received no feedback and no evaluation. During this time, she had an average assignment of four
patients. “I felt exploited,” said the RN, who asked to remain anonymous because she was planning, even after her bad experience, to
complete another unpaid internship with the same facility.
Other organizations, such as the California Institute for Nursing and
Healthcare, are partnering with schools and hospitals to create unpaid
“transition” programs or “residencies” for new RN grads holding active
licenses. Nursing leaders are concerned that these types of programs
externalize training and precepting programs that have traditionally
14
been the responsibilities of hospitals and that have traditionally been
permanent, paid positions. With the duty of precepting and training
new grads shifted onto other groups and the graduates themselves, hospitals will have no incentive to bring back their new graduate and precepting programs when the economy does pick up and they decide to
start hiring new nurses again. New graduate nurses could become stuck,
like interns in industries such as journalism and advertising, in an endless string of unpaid stints that do not lead to long-term employment.
“It’s appalling and unconscionable,” said Catherine Kennedy, RN and a
Northern California codirector of the California Nurses Foundation’s
nurse mentor project. “It totally disrespects the nursing profession. They
are exploiting young nurses who already have their degrees and their
licenses. They’re having them pay for this training where they’re being
used as regular staff. We need to hold these hospitals accountable.”
Grads_2 3/26/12 10:24 AM Page 15
“I’m willing to put in my time [looking for an RN job].
But I didn’t think every hospital in south Florida would say
no, no, no, no, no, no, no, no.”
Kennedy also point out that once new nurses are hired, hospitals
absolutely must ensure there are strong precepting and mentoring
programs in place to support them. Otherwise, research has shown
that they can become overwhelmed and quickly leave bedside nursing.
Juner Valencia, a California RN who graduated in 2009, found
his first job only after turning to his personal networks. In the beginning, he said he wanted to try on his own and was too “proud” to
accept help from relatives working as RNs, but after months of fruitless searching, he realized he was being naïve. Within weeks of putting the word out among his family and friends, he landed a job.
Valencia is, of course, lucky to have a personal network so deeply
entrenched in healthcare. Most new graduates do not, and continually viewing the problem of new nurse grad unemployment as a deficiency of the applicant instead of as a systemic problem with the
hospital and healthcare industry misses the point.
Lauren Kane, 27, graduated with Coleman at the top of her class
from Long Beach City College in December 2010. She spent months
looking for work before getting an internship at Hoag Memorial Hospital in Newport Beach in August. For 12 weeks, Kane worked in the
labor and delivery unit, the unit she’s wanted to work in since before
she entered nursing school. She’s been told there’s “no promise of
employment,” but Kane is hoping to secure a position from the internship. Not only was she not paid for the internship, but she paid for it.
The internship was structured as a class through Golden West College.
“I’m hoping to really knock their socks off and be invited to stay
on the unit long term,” she said. “We shall see. Until then, I plan to
make the most of the experience. If anything, it will enrich my
knowledge and beef up my résumé.”
Though Kane might seem to be setting herself up for disappointment, her excitement makes sense when you consider that Kane,
despite graduating at the top of her class and sending out hundreds
of résumés, had only had one interview in the seven months since
her graduation. She didn’t get that job. To pass the time and make
some money, she had begun waitressing in a sports bar.
hat does all this mean for the future of the nursing profession? Indeed, the drop in the number of
new RNs who are being hired, combined with
retirement-aged RNs forced to stay on the job is
creating what could be a future crisis: When hospitals finally decide to start hiring again, there will surely be a shortage
of experienced, qualified RNs. Should we expect to see whole floors
staffed with young and relatively inexperienced RNs without the benefit of older and more experienced mentors? And with new RNs
becoming discouraged by the tough job market, and some defecting
to other jobs with the pressures of student loans coming due, will they
ever come back? Can they come back if they never even got a chance
to practice in the first place and their skills have gotten rusty?
MIT doctoral candidate Benson sees the reduction in support for
new grads for what it is: a disturbing trend that will eventually cause
a crisis in the healthcare system. His paper, which was under review
by the journal Health Affairs at the time of publication, found that
hospitals have reduced their offers of bonuses for new recruits, as
well as overtime and tuition support.
In other words, they’re letting the pipeline of new nurses run dry.
“This portends a long-term dilemma, as hospitals facing budgetary
constraints are reducing educational commitments and weakening
career ladders despite the imminent retirement of baby-boom nurses
filling specialized and managerial positions,” writes Benson in his paper,
“The (New) Economics of Staffing Registered Nurses.” “Manpower
planning and resources should therefore focus not only on training new
nurses, but also on maintaining career ladders so that incumbent nurses will be prepared to fill positions vacated by retiring baby boomers.”
Or, to put it another way, the nursing field is about to be hit by a
tsunami, and hospitals are doing little to prepare for it, focusing only
on short-term financial goals.
“We’re looking at a population bubble we’ve not experienced
before: People who are between the ages of 60 and 90 are growing
in number and growing in how long they live,” said Witrak. “Individuals can put off elective procedures for a while but they can’t hold off
forever. There’s a looming backlog and we’ve got this kind of
ambiguous future in front of us.”
he new grads interviewed for this article know a little
something about ambiguous futures. Curious how they
were doing in their job searches, National Nurse contacted
them again in late 2011. All nurses reported a change in status. Kane had gotten the internship at Hoag. Schubert, who
spoke to the magazine while prepping for her first interview since graduation, is in the process of interviewing for a job as a telemetry floor nurse,
for less pay than her friends had received. But at least the job is full time,
permanent, and offered better benefits than her friend is receiving.
“The HR person later told me that as of now they have two new
grads in the hospital who were not scholarship recipients who owe the
hospital service: myself and someone else,” she said. “They were
thinking of trying to swing two more later on in the year if they could.”
For her part, Coleman is doing marginally better. She found a job
as an on-call RN, working eight hours a week at a job 20 miles from
her home. She’s also thinking of going back to school for an advanced
nursing degree to broaden her employability. Still, she feels her goal
is far away. Thus far, she estimates she’s sent out about 300 résumés.
“I’m grateful to have some work,” she said. “But it isn’t in an
acute-care setting, which means the experience won’t transfer to a
traditional hospital job.”
Heather Boerner is a health writer in San Francisco.
15
Retirees_JanFeb 3/26/12 10:10 AM Page 16
A Staff Report
LifeAfterWork
ACTIVIST NURSES NEVER RETIRE, THEY
JUST HAVE MORE TIME TO VOLUNTEER.
T
he way rebecca abrams figures it, going into
retirement just means that she no longer has to
work for the healthcare industry, not that she’s
stopped being a registered nurse. So about a year
ago, when she was getting ready to bid farewell to
her longtime job as an RN at Kaiser Permanente
in Hayward, Calif., she made some calls and
asked around her union, the California Nurses Association, for ways
she could stay active and plugged into nursing issues and patient
advocacy.
Abrams remembered seeing Kay McVay, RN and president emeritus of CNA, at an event sporting a scrub top with a slogan about
being a retired nurse. “I wanted one of those shirts!” said Abrams.
As luck would have it, McVay not only had a shirt, but headed up
a whole program to go with it: the RN Retiree Division. The Retiree
Division’s goal is to organize retired registered nurses to further
build the nurses’ movement, keep nurse activists engaged, and marshal the combined experience and wisdom of an entire generation of
RNs who are fast approaching the time when they will formally
leave the American workforce. According to some estimates, nearly
one-third of the country’s 2.7 million working RNs are approaching
retirement age over the next five to 10 years.
16
With more free time available to them and more flexibility in
their schedules, the idea is for members of the retiree division to
spearhead all sorts of educational and advocacy programs, from supporting the next generation of nurses by giving presentations to high
school or nursing school students about what it’s really like to work
as an RN, to talking to church congregations about the benefits of
expanding Medicare to cover everyone and not just seniors, to walking picket lines in support of nurse colleagues and other workers.
On March 6, the Retiree Division met for a strategy meeting about
how to expand the group and to discuss what type of work it should
take on.
This is exactly the type of volunteer work Abrams imagined herself doing after retirement. “Well, this is what I’ve been waiting for,”
Abrams remembered thinking. “We know the history of what nurses
have gone through to get what they have. We need a lot of new
blood, though. There are a huge bunch of retirees that are coming
along. As soon as they hit 65 and get healthcare benefits [through
Medicare], they’re going to go. We’ve got to find a way to get them in
a more active place.”
With the U.S. economy so depressed, government slashing support programs, and more people than ever, especially children and
seniors, struggling to meet their basic needs of shelter, food, and
Retirees_JanFeb 3/26/12 10:10 AM Page 17
“There are a huge
bunch of retirees
that are coming
along. As soon
as they hit 65
and get healthcare benefits
[through
Medicare],
they’re going to
go. We’ve got to
find a way to get
them in a more
active place.”
living in Northern California
and also a member of the
Retiree Division. “There’s lots
we could do.”
Staying active is also of
course beneficial for seniors,
especially registered nurses
who feel a calling to care for
others, said McVay, because
it connects them to their
communities and gives them
a sense of belonging and
being needed. “Seniors don’t
want to be isolated,” she said,
adding that studies have
shown social isolation
increases the risk of dementia. “They want to do something productive for their
community, for fellow workers, for students.”
A natural focus of work for retired registered nurses is pushing for a
healthcare system that offers a single standard of high-quality care for
everyone from birth to death. NNU nurses believe the answer lies in
expanding and improving the Medicare system to cover everybody, not
just those over 65. So the Retiree Division expects a “Medicare for all”
campaign to be a major focus of their advocacy work in 2012.
“As RNs, we face the contradictions and failures of our current
healthcare system all the time, and it doesn’t stop once you’re
retired,” said Smith. “Educating and building a movement around
Medicare for everyone is moving in the right direction.”
The retired RNs also brainstormed fresh avenues for educating
other nurses and the public about topics such as unions and the
labor movement, or about nursing and corporate control of healthcare. Some suggestions included hosting continuing education
courses targeted at retired RNs, since all RNs who wish to maintain
an active license must fulfill a certain number of continuing educahealthcare, Retiree Division chair Kay McVay sees a resurgence of
tion credits, and travel excursions that combine political education
interest among nursing and healthcare leaders in tapping the talent,
with fun activities.
intelligence, and energy of a group of seasoned nurse activists. Some
Members of the Retiree Division pointed out, however, that
retired nurses may even be living through those very problems and
besides working to improve overall societal conditions for future
have first-hand knowledge of what is broken and how to fix it.
patients and nurses, retired nurses do very much have a vested
“Right now is the time. We need to get all the retirees educated
interest in staying active with their union and with nursing: their
on the issues facing nurses and everybody else,” said McVay, giving
retiree healthcare and pension plans almost
examples such as major attacks on Social
always depend on the results of current and
Security, Medicare, public education, and
future contract negotiations. If working
veteran healthcare. “We need to think about
Are you an RN who is retiring
nurses are not united and powerful in barour grandchildren. Because if they take
or thinking about retiring?
gaining with their employers, retired nurses
something from us, they have succeeded in
Then it’s time for you to join
could easily lose the benefits they fought for
destroying it for our grandchildren.”
the RN Retiree Division!
and expected to be available to them in their
And since registered nurses are so highly
Continue to help build the
later years.
esteemed by the public, as shown by poll
national nurses movement and
Ultimately, it comes down to building
after poll that indicates the public trusts
your profession, support workthat
strong nurses’ movement so that nurses
nurses above other professions, the Retiree
ing nurses, and foster the next
can
provide
the kind of healthcare that
Division has the potential to grow into a
generation of RNs.
everyone
deserves—free
from considerapowerful, influential lobbying force. “We’re
For more information,
tions
of
profit.
“I
want
good
nurses out
respected in our communities. We’re intelliplease contact Kay McVay, RN,
there,”
said
Abrams.
“These
are the people
gent, and we’re great at multitasking,” said
at kmcvay@calnurses.org.
that are going to be taking care of me.”
Mike Smith, a retired emergency room RN
17
CE_JanFeb 3/26/12 10:02 AM Page 18
CE Home Study Course
Workplace Violence
Assessing Occupational Hazards and Identifying
Strategies for Prevention, Part 1
workplace violence is now recognized as a major health priority by
the World Health Organization, the International Council of Nurses,
and Public Services International. What has been described as “an
epidemic” of workplace violence in hospitals has gained national
attention since the Journal of the American Medical Association
(December, 2010) published a research paper on the increasing vioDescription
lence in U.S. hospitals.
his home study course examines conditions in the
The authors of the JAMA report include statistics from the Cenhealthcare environment associated with workplace vioters for Disease Control and Prevention and the National Institute
lence. Included is a review of key terms, relevant definifor Occupational Safety and Health. A summary of Bureau of Justice
tions, practices, standards, and regulatory policies so
statistical data estimates 1.7 million injuries per year due to workregistered nurses (RNs) can more quickly identify
place assaults, accounting for 18 percent of all violent crime in the
threatening behaviors and situations where the potenUnited States. The healthcare industry constitutes 45 percent of the
tial for lateral, horizontal, and physical violence exists. It further examincidents of workplace violence. The rate of workplace violence in
ines the scope of the problem of workplace violence and how RNs can
healthcare settings is approximately four times the national average.
be proactive in their practice settings to promote workplace security
Violence against nurses is a complex and persistent occupational
and mitigate the potential for harm to themselves and their patients.
hazard facing the nursing profession. Paradoxically, the job sector
RNs will learn strategies for taking action and, as circumstances
with the mission to care for people appears to be at the highest risk
require, changing administrative policies that encumber their ability to
of workplace violence. Nurses are among the most assaulted workers
provide safe, therapeutic, and effective patient care. Selected highlights
in the American workforce. Increasingly nurses are exposed to vioof publicly reported assaultive and violent incidents which resulted in
lence – primarily from patients, their families, and visitors. This vioharm or death to healthcare workers will help nurses formulate a corlence can range from shouting and belligerence to stalking, beating,
rective action plan for effectively dealing with the aftermath.
stabbing, and shootings. Nurses also perceive and experience onthe-job abuse from their supervisors and other healthcare workers;
Objectives
this includes acts of intimidation, coercion, harassment, bullying,
Upon completion of this home study RNs will be able to:
undermining, retaliation, and other forms of assault.
State the NIOSH definition of workplace violence
Psychological consequences resulting from vioIdentify behaviors that undermine a culture of
lence may include fear, frustration, and lack of trust
safety
in hospital administration, decreased job satisfacDescribe the concept of horizontal hostility
Submitted by the Joint
tion, and burnout. Incidences of violence early in
List OSHA workplace factors that create or potenNursing Practice
nurses’ careers are particularly problematic as nurses
tiate stress and emotional strain
Commission, DeAnn
can become disillusioned with their profession. VioIdentify signs and symptoms of potentially hostile
McEwen, RN, and
lence not only affects nurses’ perspectives of the proor aggressive patients, clients, coworkers
Hedy Dumpel, RN, JD
fession, but it also undermines recruitment and
Describe steps or actions RNs can take to reduce
Provider Approved
retention efforts which, in a time of a pervasive nursthe risk of violence in their workplace at the facility
by the California
ing shortage, threaten patient care.
level and in the public policy arena
Board of Registered
In 2009, the Emergency Nurses Association
Nursing, Provider
released
a survey that showed more than 50 percent
Background
#00754 for 4.0
contact hours (cehs).
of emergency room nurses had experienced violence
Workplace violence is a major public health concern
Recognized by all
by patients on the job (being spit on, hit, pushed or
that has grown substantially over the past decade.
states with the excepshoved, scratched, or kicked); and more than 25 perViolence in healthcare settings is on the rise throughtion of Arkansas,
cent had experienced 20 or more violent incidents in
out the nation, and the risk of workplace violence is a
Delaware, Massachuthe past three years. In addition, 70 percent had
serious occupational hazard for registered nurses
setts, Montana,
North Carolina, and
experienced verbal abuse (being yelled or cursed at,
(RNs) and other healthcare workers. Nurses are
South Carolina.
intimidated, or harassed with sexual language or
known to be at high risk as employees who provide
innuendo) in the previous year.
direct care to people in distress. The incidence of
This home study CE is part one of a two-part series and
upon final completion, provides four contact hours (CEH).
Look for the second installment and the CE quiz to appear
in the next issue of National Nurse.
T
18
The research reveals that long wait times, a shortage of nurses,
drug and alcohol use by patients, and treatment of psychiatric
patients all contributed to violence in the ER. Of note, the rate of
assault injuries to psychiatric nurses has been estimated at 16 per
100 employees per year, which exceeds the annual rate of all injuries
found in many high-risk occupations. Patients and their relatives
were the perpetrators of the abuse in nearly all incidents of physical
violence (97.1 percent) and verbal abuse (91 percent).
According to the Bureau of Labor Statistics’ latest report of occupational fatalities in 2010, fatal assaults by a newly defined perpetrator, “the customer,” has shown an increase over previous years. In
an article entitled “When Disgruntled Customers Kill,” author Alan
Fox claims this trend is because “customer service has become customer disservice.” He reports that customers and clients are feeling
increasingly frustrated and powerless as automated and scripted
recordings have replaced direct communication. As nurses on the
front lines every hour of everyday, interacting with patients and
their families, we know this to be true.
Fox urges companies and businesses to begin humanizing customer service by employing an adequate number of easily accessible “competent and concerned human beings” rather than relying
on impersonal machines. For obvious reasons, hospitals, health
maintenance organizations (HMOs), and other healthcare work
settings would be wise to heed the message. A substantial body of
research links enriched nurse-to-patient ratios with high patient
satisfaction, improved patient outcomes, increased retention, and
job satisfaction among RNs.
Selected key terms and definitions
Assault: The definition of assault used for the recording of healthcare
assault data is “intentionally, knowingly, or recklessly causing
physical injury.” This definition requires a subjective judgment of
intent and may have led to variable reporting of assaults.
Assault and Battery: Although frequently used in a single phrase
and often thought of as a single offense, the terms “assault” and “battery” refer to two separate torts. The two offenses are often committed
almost concurrently, that is, an assault followed immediately by a
battery. However, an assault does not include a battery because it is
merely the apprehension of a contact that if made would constitute a
battery. Although a battery is often a completed assault, a battery
still may be committed without an accompanying assault, as in the
case where the plaintiff was not aware that a battery was imminent.
A person may be criminally as well as civilly liable for assault
and battery. Various state penal codes commonly define assault as
19
an unlawful attempt, coupled with a present ability, to commit a
violent injury on the person of another. A similar definition is found
in the legal treatises: Assault occurs when the defendant’s acts intentionally cause the victim’s reasonable apprehension of immediate
harmful or offensive contact. A battery is any willful and unlawful
use of force or violence on the person of another. Battery occurs when
the defendant’s acts intentionally cause harmful or offensive contact
with the victim’s person.
Bullying: Overt and/or covert acts of verbal and/or nonverbal
aggression perpetrated by one in a higher level of authority. “Repeated, health-harming mistreatment, verbal abuse, or conduct which is
threatening, humiliating, intimidating, or sabotage that interferes
with work or some combination of the three” (Namie). “A person is
bullied when he or she is exposed, repeatedly and over time, to negative actions on the part of one or more other persons, and he or she
has difficulty defending himself or herself ” (Olweus).
This definition includes three important components:
1. Bullying is aggressive behavior that involves unwanted, negative actions.
2. Bullying involves a pattern of behavior repeated over time.
3. Bullying involves an imbalance of power or strength.
In conflict theory, bullying signifies an unsolved social conflict
that has reached a particularly high level of escalation with an
increased disparity in the balance of power.
Coercion: The practice of compelling a person to involuntarily
behave in a certain way (whether through action or inaction) by use
of threats, intimidation, or some other form of pressure or force.
(Social Psychology)
General Duty Clause: Section 5(a)(1) of the OSH Act, often
referred to as the General Duty Clause, requires employers to “furnish to each of his (sic) employees employment and a place of
employment which are free from recognized hazards that are causing
or are likely to cause death or serious physical harm to his employees.” Section 5(a)(2) requires employers to “comply with occupational safety and health standards promulgated under this Act.”
Horizontal Hostility:A consistent pattern of behavior designed to
control, diminish, or devalue a peer (or group) that creates a risk to
health and/or safety (Farrell 2005).
Lateral Violence: Also known as horizontal abuse or hostility, lateral violence is the disruptive, disrespectful, or antagonistic behavior
of others on the same hierarchical level. Lateral violence occurs when
people who are both victims of a situation of dominance turn on each
other instead of confronting the system that oppresses them both. Lateral violence occurs when oppressed groups/individuals internalize
feelings such as anger and rage, and manifest their feelings through
behaviors such as gossip, jealousy, putdowns, and blaming.
Moral Distress:Moral distress arises when one knows the right
thing to do, but institutional constraints make it nearly impossible
to pursue the right course of action. (Jameton, 1984)
NIOSH:The National Institute for Occupational Safety and
Health conducts research and makes recommendations to prevent
work-related illness and injury. NIOSH works with industries, labor
organizations, and universities to understand and improve worker
safety and health. NIOSH is a Centers for Disease Control and Prevention research agency in the U.S. Department of Health and
Human Services.
OSHA:The Occupational Safety and Health Administration is a
regulatory agency in the U.S. Department of Labor. With the Occu20
pational Safety and Health Act of 1970, Congress created OSHA to
assure safe and healthful working conditions for working men and
women by setting and enforcing standards and by providing training, outreach, education, and assistance. The act can be found at
www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=OS
HACT&p_toc_level=0&p_keyvalue=
Post-Traumatic Stress Disorder (PTSD): A disorder that affects a
person who has 1) experienced, witnessed, or been confronted with an
event or events that involve actual or threatened death or serious
injury or a threat to the physical integrity of self or others; and 2) the
person’s response involved intense fear, helplessness, or horror.
(DSM-MD 4th Ed., Text Rev.)
Threat: A statement or expression of intention to hurt, destroy,
punish, etc. as in retaliation or intimidation. (U.S. Department of
Justice)
Work environment: Consists of the employer’s premises and other
locations where employees are engaged in work-related activities or
are present as a condition of their employment. The work environment includes not only physical locations, but also the equipment or
materials used by the employee during the course of his or her work.
(United States Department of Labor)
Workplace Violence: Violent acts (including physical assaults,
threats of assaults, and verbal abuse) directed toward persons at
work or on duty. (NIOSH)
Introduction
According to recent research commissioned by the National Institute of Occupational and Environmental Health (NIOSH), healthcare workers, especially those providing emergency and psychiatric
care, have long been recognized as having a high risk of work-related
assault, and nurses are at particularly high risk, with the highest rate
of victimization among occupations in the healthcare industry.
The same research demonstrated that among hospitals, surveillance of workplace violence events is “uncoordinated and inefficient,”
employee training programs rarely included review of violence trends
within their specific hospital, few hospitals had effective systems to
communicate about the presence of violent patients, hospital security
equipment systems were uncoordinated and insufficient to protect
the unit, and security programs and training were often less complete in psychiatric units than in emergency departments.
Concerns over workplace violence reached a fever pitch in California near the end of October 2010, when an experienced RN
working at a county correctional/detention facility was violently
assaulted by an inmate while attempting to provide him care.Unable
to recover from the injuries she sustained from the assault, she tragically died three days later. Just days before her death, a psychiatric
technician was killed by a patient on the grounds of a state psychiatric facility that treats adults with serious mental illnesses; 90 percent of the inpatient population is forensic, referred through local
governments or the court system (including those incompetent to
stand trial; mentally disordered parolees; not guilty by reason of
insanity; mentally disordered sex offenders; minors, Department of
Juvenile Justice commitment). Their deaths sparked a public outcry
over the safety of RNs and other healthcare workers, and called into
question the efforts of healthcare employers to enact standards and
policies that ensure the safety and security of their employees.
The deaths of these healthcare workers, and the countless acts of
assault, battery, and aggression that routinely take place in health-
care settings, demonstrate a frightening trend of increasing violence
faced by healthcare workers throughout the country.
Nurses and other coworkers, together with the correctional facility RN’s relatives and friends, had gathered to remember her caring
spirit and compassion. Although staff had proposed modifications to
their work environment that would make it safer, the changes were
not implemented by facility management until after the tragedy
occurred. Upon learning of the circumstances surrounding her
untimely death, her fellow nurses said, “Enough is enough!” and
they strongly advocated for meaningful legislation to prevent such a
senseless tragedy from occurring ever again.
An investigation of this tragic and violent incident conducted by
Cal OSHA resulted in three “Citation and Notification of Penalty”
violations being issued with fines imposed on the facility. Among the
findings (excerpt):
Citation 1 (General): “At and prior to the time of the Cal OSHA
inspection, the employer did not establish and implement effective
training and instruction for health services employees, including but
not limited to nurses and their supervisors. These employees worked
with inmates and were exposed to physical assault hazards. The
employees were not provided with effective training and instruction
on the following subjects pertaining to physical assault hazards:
Escalation signs; and,
Verbal and non-verbal de-escalation techniques; and,
Physical deflection and escape techniques; and,
Control of relatively larger work objects that could be used as
weapons, such as staplers, hole punchers, monitors, and lamps.
Citation 2 (Serious): The employer did not conduct effective
inspections and evaluations of physical assault hazards in the
intake area, including:
Prior to and around the beginning of the Cal OSHA inspection,
the hazards created by unsecured and relatively larger work objects
that were kept within reach of inmates and that could be used as
weapons, such as staplers, hole punchers, monitors, and lamps; as a
result, on 10/25/10 an inmate used an unsecured and within-reach
lamp as a weapon to fatally injure a nurse; and,
Prior to the Cal OSHA inspection, the hazards created by the
configuration of the rear nurse’s intake work station (the station
adjacent to the multi-inmate female holding area); separation was
not provided between the inmate and the nurse, where separation
could have been used to minimize the assault hazard for certain
tasks.
Citation 3 (Serious): T8 CCR 3203(A)(6) “Injury and Illness Prevention Program. Effective July 1, 1991, every employer shall establish, implement, and maintain an effective Injury and Illness
Prevention Program (Program). The Program shall be in writing
and, shall, at a minimum: Include methods and/or procedures for
correcting unsafe or unhealthy conditions, work practices, and work
procedures in a timely manner based on the severity of the hazard:
When observed or discovered; and,
When an imminent hazard exists which cannot be immediately
abated without endangering employee(s) and/or property, remove
all exposed personnel from the area except those necessary to correct
the existing condition. Employees necessary to correct the hazardous
condition shall be provided the necessary safeguards.”
Findings: “The employer did not effectively implement corrective methods and/or procedures for unsafe conditions or work
practices involving physical assault hazards.”
In addition to the citations issued by Cal/OSHA to the correctional medical detention facility mentioned above, the proposed
penalties for violations of the General Duty Clause were as follows:
Citation 1 Item 1 Type of Violation: General $ 560
Citation 2 Item 1 Type of Violation: Serious$ 6,750
Citation 3 Item 1 Type of Violation: Serious$ 6,750
Total of Proposed Penalties:$14,060
After the death of the psychiatric technician, state regulators
determined the hospital facility’s administration was aware that
individuals with a history of escalating impulsive violent behavior
toward staff could result in serious injury. Although the mission of
the state hospital is “to provide hope to adults with a serious mental
illness and support each individual to achieve personal recovery,”
failure to properly monitor and provide appropriate care for predatory patients can make violence and intimidation a part of the daily
work life according to published interviews with staff. Inadequate
staffing and non-adherence with safety program guidelines and regulations not only increase the risk of violence, but serve as a barrier
to the ability of healthcare professionals to provide therapeutic
treatment.
Generally, people with mental illness aren’t especially dangerous;
many are vulnerable and at risk of being abused or assaulted themselves. They should be provided with a safe, effective, and therapeutic environment of care. Mental health professionals, law
enforcement officials, and regulators should work together to protect workers and provide violent psychiatric patients with the treatment nurses and doctors know they need without punishing people
for being sick.
In May 2011, Cal/OSHA fined the state hospital more than
$100,000 for a series of serious and willful violations in the death of
the psychiatric technician. The employer’s Injury and Illness Prevention Program was cited for being ineffective.
Citation 1, Item I (excerpt): “Program Directors/Department
Heads have authority and total responsibility for maintaining safe
and healthful working conditions for employees within their jurisdiction.”
Citation 1, Item 2 (excerpt): “Injury and Illness Prevention Program was not effectively implemented in that employer does not
ensure that employees who escort individuals comply with safety
procedures and policies.”
Citation 1, Item 3 (excerpt): “Injury and Illness Prevention Program was ineffective in that the employer’s procedure to investigate
occupational injury and illness was not implemented and maintained. Many of employer’s ‘Supervisor’s Report of Occupational
Injury or Illness’ forms pertaining to assaults showed that investigations lacked analysis of the cause and thus were ineffective in preventing further occurrences.”
Citation 1, Item 4 (excerpt): “The employer’s Injury and Illness
Prevention Program was ineffective with respect to employee training and instruction in that:
TSI training given to employees was not applicable to the type of
assaultive situations that an employee’s experience from unsupervised individuals on the grounds in the Secure Treatment Area.
The employer’s program did not train employees in how to recognize stalking behavior by individuals on the grounds of the Secure
Treatment Area, nor how employees were to be protected from this
behavior.”
21
Citation 2, Item 1 (excerpt): “The employer’s Injury and Illness
Prevention Program was ineffective with respect to the employer’s
communication system on health & safety matters in that:
Employer required all employees to confront unsupervised individuals engaged in prohibited behavior. Employer’s procedures did
not provide for communication to the employees the history and
behavioral triggers of the hundreds of unsupervised individuals that
they were expected to confront.
Employees had no effective, available means of communicating
threatening behavior by individuals to the employer.
Employer’s communication system used during assaults introduces delay or the potential for failed communications.”
Citation 3, Item 1 (excerpt): “The employer’s procedures for
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22
identifying and evaluating hazards were ineffective in that, as the
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procedures for sounding emergency alarms outside of the units for
employees engaged in traversing the grounds to and from work, or
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procedures for correcting the hazards posed by violent individuals to
employees were not implemented:
Employer through its Safety & Security Committee meetings,
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by individuals allowed outside on the grounds of the Secure Treatment Area. However, it failed to address the hazard, as it did not
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Employer was aware of the hazard posed by one of these individuals because of his recent history of aggressive behavior, illegal drug
usage, and stalking, and made no reasonable effort to protect the
employees against the hazard by allowing this individual to maintain his grounds pass without restriction, with no supervision, in a
totally unstructured environment. As a result, an employee was
killed by this individual out on the grounds.”
While there is no amount of money that can compensate a bereaved
family for the unjust loss of a precious life, substantial fines may serve as
an effective deterrent and tool that compels employer compliance with
existing health and safety laws. However, when the proposed fine for
violations is a less expensive alternative to implementing and following
the law (e.g., safe staffing and an environmentally safe work site), it
State of California, Division of Occupational Safety and Health
(2011). Citation and Notification of Penalty. Inspection Number 300752581; Inspection Dates: 10/25/2010-; Issuance Date:
04/12/2011, pp. 1-14.
Stokowski, L. A., and (2010) Violence: Not in my job description.
Workplace violence in healthcare settings. Retrieved on
November 14, 2011 from http://www.medscape.com/viewarticle/727144
The Joint Commission. Behaviors that undermine a culture of
safety. Sentinel Event Alert, Issue 40, July 9, 2008. Retrieved
on November 14, 2011 from
http://www.jointcommision.org/SentinelEvents/Sentineleventalert/sea_40.htm
The Joint Commission. Preventing violence in the healthcare setting. Sentinel Event Alert, Issue 45, June 3, 2010. Retrieved on
November 14, 2011 from
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_45.htm
Trinkoff, A. M., Geiger-Brown, J. M., Caruso, C. C., Lipscome, J.
A., Johantgen, M., Nelson, A. L., Sattler, B. A., & Selby, V. L.
(2008). Personal safety for nurses. Chapter 39, 1-36. In
Hughes, R. G. (ed). Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Agency for Healthcare
Research and Quality. Publication 08-0043. Rockville,
Maryland. Retrieved November 14, 2011 from http://www.
ahrq.gov/qual/nurseshdbk/
United States Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Special Report, Workplace Violence, 1993-2009, March 2011. Retrieved on October
26, 2011 from http://www.bjs.gov/index.cfm?ty=pbdetail
&iid=2377
United States Department of Labor, Occupational Health and
Safety Administration (2004). Guidelines for Preventing
Workplace Violence for Healthcare and Social Service Workers. Retrieved on November 14, 2011 from
http://www.osha.gov/Publications/OSHA3148/osha3148.html
Wagner, J., & Garrison, J., Long Beach hospital shootings make
“no sense.” April 18, 2009. Retrieved on November 14, 2011
from http://articles.latimes.com/print/2009/apr/18/local/mehospital-shooting18
23
becomes a travesty of justice. Puny fines are an insult to the sensibilities
of the working people the laws are designed to protect.
A fine alone is not going to prevent a malicious and villainous act
that proceeds from an evil heart or purpose. But every event has a
preventable component. A substantial fine doesn’t always serve as a
deterrent, nor does it mitigate the egregious violation of employer
responsibility to provide a safe work place. Puny fines give the
impression that the value of a human life is dirt cheap compared to
the crime committed against innocent victims due to their employer’s lack of diligence and accountability.
The facts speak for themselves. The fact that the nursing and
healthcare staff had proposed changes to their work environment that
could’ve prevented these tragedies is heartbreaking. It’s unconscionable that the changes weren’t made until after healthcare workers died. Had management implemented the changes recommended
by staff, and exercised due diligence as employers rather than cutting
corners, loss of life could have been averted. Some cuts don’t heal.
California Nurses Association/National Nurses United (NNU)
sponsored emergency legislation to bring uniform standards, stricter
guidelines, and enforcement penalties to help ensure facility compliance with regulatory and professional workplace safety initiatives.
Promoting a Socially Just Culture
According to the Institute of Medicine, lapses and mistakes are all
serious and can potentially harm patients and jeopardize careers.
Current responses to errors in healthcare settings tend to focus on
active errors by punishing individuals. Although a punitive response
may be appropriate in some cases (e.g. deliberate malfeasance, gross
negligence), it is not an effective way to prevent reoccurrence. Preventing harm and improving safety for patients and staff requires a
systems approach in order to modify the conditions that increase the
risk of harmful consequences.
Latent errors pose the greatest threat to safety in a complex system because they are often unrecognized; they can include such
things as poorly structured organizations and bad management decisions. Latent “errors” can be difficult for people working in the system to notice since they may be hidden in the design of routine
policies, processes in computer programs, or in the structure or management of the organization. People can become accustomed to such
defects and often work around them, so they are often unrecognized.
The “normalization of deviance” occurs when small changes in
behavior become acceptable; the potential for harm reoccurs because
important processes and standards are overlooked. Direct-care RNs
are important advocates who are uniquely qualified and well positioned to identify, evaluate, and intercept a majority of potentially
harmful errors and “near-misses” in their employment settings.
Nature versus Nurture: Is the System to Blame?
As the great Canadian physician Sir William Osler once said, “Variability is the law of life; and as no two faces are the same, so no two
bodies are alike, and no two individuals react alike and behave alike
under the abnormal conditions which we know as disease.” Nurses
understand this and are educated to observe and care for patients
holistically. Patients may have extremely emotional, stressful, and
personal circumstances related to age, dependency, disability, gender, sexual orientation, ethnicity, bereavement, or socio-economic
status that affects their ability to cope and adjust to their illness,
injury, medications, treatment interventions, and/or a life-changing
24
condition. Hospitals are known as caring places, but they are not
immune to workplace violence for many reasons.
The U.S. Department of Labor’s Occupational Safety and Health
Administration website describes potential psychological hazards
found in hospitals as “factors and situations encountered or associated with one’s job or work environment that create or potentiate
stress, emotional strain, and/or other interpersonal problems.”
According to NIOSH, stressors common in healthcare workplace
settings include: inadequate staffing levels, job and task
demands/work overload, poor organizational climate, unfair management practices, financial and economic factors, shift work, and
long work hours.
We’ve come a long way? Lateral Violence, Gender, and
Oppressed Group Theory
lateral violence, horizontal violence, and bullying are all terms
that have been used to describe non-physical violence between
members of groups. Lateral violence is common among nurses and
other healthcare workers, and it occurs when individuals internalize feelings of anger, frustration, fear, and rage, subsequently manifesting those feelings through behaviors such as gossip, putdowns,
jealously, “backstabbing,” withholding information, blaming, and
undermining.
Compared with physical assaults, non-physical violence is even
less well documented, although it has been reported that in many
situations, verbal abuse can produce the same degree of psychological distress as physical abuse. Researchers Magnavita and Heponiemi (2011) report that a systematic review of studies on aggression
showed that despite differing countries, cultures, research designs,
and settings, nurses’ responses to aggression are similar and include
anger, fear or anxiety, post-traumatic stress disorder symptoms, feelings of guilt, self-blame, and shame. These psychological effects can
persist for months or years after the original event.
The gender theory of lateral violence states that since professions
associated with a predominantly female workforce have been traditionally undervalued and unappreciated, women engaged in such
professions often lash out at one another, rather than collectively
confront the hierarchy that oppresses them. Many women have not
been socialized to appreciate themselves or the importance of their
role in society, a role that acknowledges their interdependence, the
dignity of their work, and their worth as human beings. “The woman
question” is a phrase often used in connection with social change in
the latter half of the nineteenth century, which questioned the fundamental roles of women and their right to be in control of their
own person, children, property, legal, medical, financial and other
civil rights that we now tend to take for granted.
A major characteristic of oppressed group behavior stems from
the ability of the dominant group to set the frame for social norms.
The dominant group’s use of patriarchal and coercive power, (control exercised through fear, threat, or force to discipline, punish, terminate, or even inflict harm), often includes forms of socio-cultural
ostracism to enforce their values. This elicits negative behaviors in
the oppressed group which leads to poor self-esteem and a paradigm
of learned helplessness. Individual members of the oppressed group
begin to believe they are powerless and, sadly, their behavior is often
congruent with that belief. In a real sense, the members of the
oppressed group become accomplices in their own subordination,
thereby preserving and even defending the status quo.
However, since the inception of modern nursing and state licensing of professionals, direct-care nurses fought for the right to control
their practice and their profession to advance the interests of the
public. Early nurse leaders such as Lavinia Dock and Lillian Wald
advocated union membership for nurses as a profession. Nurses’
moral authority and authentic power is derived from a higher level
of integrity based on human needs and ethical values of caring and
compassion. Their professional values included treating everyone
equally with dignity, respect, fairness, honesty, and a single standard
of excellence in the provision of care. Over the years they helped lead
the paradigm shift in the conceptualization of the role of the nurse
from loyal subordinate to autonomous advocate.
They recognized that belonging to a nurses’ union was essential
to helping nurses fulfill their obligation to effectively influence and
implement safe, therapeutic, and effective standards of care within
the employment setting. Union membership and collective patient
advocacy effectively shifts the balance of power away from an
oppressive hierarchy to ensure humane working conditions and the
right to fair compensation that promotes delivery of the highest
quality of nursing care.
Dock and Wald understood that the profession needed to
exert collective advocacy power in unity, to change the status
quo. They recognized the barriers to autonomy and fought to
prevent encumbrance of their professional practice by the
male/physician-dominated hierarchy and their matron enablers
existing in hospitals.
As a result, from the first decade of the century onward, physicians and hospital administrators have remained in positions of
dominance and control over nursing and healthcare. It wasn’t so
long ago that Lavinia Dock wrote of her “abounding discouragement” with regards to the American Nurses Association, because
they “actually voted in opposition to the equality amendment on
which women of all nations are pinning their hopes.”
Lavinia Dock and Lillian Wald have provided us with a respected
legacy and a challenge to carry this mission forward on behalf of our
patients and our practice. We cannot ignore our duty, or refuse to
accept it. As Lillian Wald said, “We commit ourselves to any wrong,
or degradation, or injury when we do not protest against it.”
Furthermore, Lavinia Dock warned the nursing leaders that male
dominance in the healthcare field was a major problem in the nursing profession. Her warnings went unheeded and nurses became
accomplices of their own subordination. Nurse leaders ignored all
her warnings and in the second decade of the century actually
became nonvoting members of the American Hospital Association.
They worked with physicians and administrators on joint committees, expecting their oppressors to help them solve nursing problems. They sought approval from men, not liberation.
Workplace Violence + Healthcare
Settings = Headlines in the News
workplace violence not only causes physical and emotional
damage, but it also creates a social and economic burden on communities.Measuring these costs can be difficult and most estimates
only consider the direct economic effects of violence, such as loss of
productivity or the increased use of healthcare services. Beyond
these obvious costs, the pain and suffering caused by violence can
affect human and social development and increase the risk of chronic outcomes later in life.
Nurses have a compelling obligation, inherent in the profession’s
broad social responsibility, to apply their skills to identify the preventable components and work to change the course of potentially
harmful situations by being sensitive to risk factors and early indicators of all forms of violence. Nurses know that an ounce of prevention is worth a pound of cure, whether it’s at the bedside or in the
community at large.
“CHILDREN’S HOSPITAL...FINED”
State investigators fined a California hospital for failing to provide
adequate controls and policies in the wake of violent and potentially
unsafe situations at the hospital. The state’s Division of Occupational Safety and Health, known as Cal/OSHA, issued the safety violations in connection with two incidents, one of which happened when
a homeless man armed with a gun burst into the emergency room
and briefly took an employee hostage before surrendering. In the second incident, a gunshot victim was dropped off in the front of the
hospital instead of at the emergency room entrance. Nurses reported
feeling unsafe while tending to the patient outside the hospital before
additional help arrived.
“COPS: MAN SHOOTS DOCTOR, THEN KILLS MOM,
SELF AT HOSPITAL”
Baltimore - A man who became distraught as he was being briefed on
his mother’s condition pulled a semi-automatic gun from his waistband and shot the doctor, then killed his mother and himself in her
room.
“COURT AWARDS $1.4M TO VICTIM’S FAMILY
IN PHARMACIST’S SLAYING”
A court found a Jacksonville hospital and its security company negligent for the death of a hospital employee, as a result of inadequate
security and for overlooking the killer’s history of violence.
“HOSPITAL VIOLENCE IS ON THE RISE, HEALTH AGENCY WARNS”
Once considered safe havens, healthcare institutions today are confronting steadily increasing violent crime, said an alert issued by the
Joint Commission, a national accrediting agency. Assault, rape, and
murder pose a growing threat to medical caregivers.
“LONG BEACH HOSPITAL SHOOTINGS MAKE NO SENSE”
Hours before he walked into his workplace with two handguns to
fatally shoot his supervisors and then himself, he gave his children
breakfast, took them to school, and returned home to get ready for his
job as a technician at the hospital’s pharmacy. Many of his colleagues speculated that he had turned to violence because he feared
being laid off. Officials with the police department noted that the
incident may be part of a national trend of workplace related shootings by people distraught over the economic downturn.
“SUSPECT IN FATAL SHOOTING AT CHICAGO
HOSPITAL ARRESTED”
A housekeeping employee suspected in the fatal shooting of a coworker inside a hospital parking garage, which prompted an hours-long
lockdown, was arrested during a traffic stop, police said. University
police said the suspect also was a hospital housekeeper and characterized the killing as an “apparent domestic-related shooting” in a
campus alert.
25
“SURVEY FINDS NO LETUP IN VIOLENCE AGAINST ED NURSES”
According to the report, more than a third (36.7 percent) of emergency nurses have considered leaving their current jobs because of
workplace violence. We need hospitals and hospital administrators
to take steps now to increase the safety of their emergency departments so that patients can receive the care they need.
“TWO DEAD IN TENNESSEE HOSPITAL SHOOTING”
A gunman fatally shot a woman and injured two others before
killing himself outside a hospital in Knoxville. The attack happened
at about 4:30 p.m. near the patient discharge area.According to published reports, all three victims were current or former employees of
the hospital.
“VIOLENT ASSAULTS ON ER NURSES RISE AS PROGRAMS CUT”
Columbus - An emergency room nurse suffered bruises, scratches,
and a chipped tooth from trying to pull the clamped jaws of a psychotic patient off the hand of a doctor. Nurses and experts in mental
health and addiction say the problem has only been getting worse
because of the downturn in the economy, as cash-strapped states
close state hospitals, cut mental health jobs, and eliminate addiction
programs. After her second attack in one year, she began pushing her
hospital to put uniformed police on duty.
Barriers to Workplace Violence Prevention
recently the u.s. department of Justice, Federal Bureau of
Investigation has expressed concern that there is a likely underreporting of violence and a persistent perception within the
healthcare industry that tolerating assaults are just part of the
job. According to the researchers, under-reporting may reflect a
lack of institutional reporting policies, employee beliefs that
reporting will not benefit them, or employee fears that employers
may deem assaults the result of employee negligence and/or poor
job performance.
Fear of retaliation and the stigma of blowing the whistle on colleagues are pervasive. Within certain institutions, staff often perceives that powerful “revenue generating” physicians will be let off
the hook for inappropriate behavior because of the implied consequences of confronting them. Financial considerations are controlling hospital administration responses to physicians who harass and
bully coworkers and subordinates.
Many employers deny violence is a problem in their facilities and
this denial often leads to violence prevention being a low priority.
Subsequent lack of budgeted resources is now viewed as “penny wise
and pound foolish” because the costs of workplace violence can be
very high financially. The Institute for the Prevention of Workplace
Violence estimates that one incident of violence can cost an employer $250,000 to $1,000,000 in workers’ compensation, disability,
and medical costs, as well as legal fees.
NIOSH estimates the economic cost of workplace violence
nation-wide at around $121 billion. In addition, the hidden costs of
workplace violence include decreased productivity and morale, lost
work time, legal fees, and personnel turnover. Non-fatal workplace
assaults alone result in more than 876,000 lost work days (average
of 3.5 per incident by those directly impacted), and $16 million in
lost wages. The average award in a workplace violence lawsuit
exceeds $1 million per case.
26
Nurses often fear that reporting abuse and violence will prompt
hospital administrators to retaliate against them, and some who
hesitate may have a point. Despite the initiatives to create a “blame
free” environment, nurses are often asked, “What did you do to provoke this attack?” or, “What will you do to prevent this from occurring again?” The implication is not only that the abuse is the fault of
the victimized nurse but that he or she could’ve easily prevented it.
Nurses have been reprimanded or fired if they try to defend themselves against violence. Management may fear that reporting violence will affect their patient satisfaction scores and this may be an
indication that hospitals are taking customer care and customer
service schemes too far!
Most nurses who are injured don’t seek treatment for their
injuries, which is indicative of a certain degree of resignation on the
part of victimized nurses. Of the nurses who reported experiencing
physical violence, 15 percent said they sustained a permanent injury
as a result; and, in nearly half the cases, no action was taken against
the perpetrator. Blaming the victim is a way some hospitals may
avoid taking responsibility for and solving the problem. More security, better training, and improved staffing are solutions that cost
money, yet they’re solutions that nurses should collectively demand
for the benefit of their profession and their practice. In addition,
they are effective “neighborhood watch” measures that increase
awareness and safety.
NIOSH Responds
on september 8, 2011, the Occupational Safety and Health Administration (OSHA) issued its first directive on workplace violence
detailing procedures for its inspectors. The directive puts employers
on notice with regard to enforcement on this potential hazard.
OSHA has no specific standard on the issue of workplace violence,
but instead it cites employers for workplace violence hazards under
its General Duty Clause.
To establish a violation of the General Duty Clause, OSHA must
show: (1) a workplace hazard exists; (2) either the employer or the
employer’s industry recognized the hazard; (3) the hazard is likely to
cause serious injury or death; and (4) there is a feasible and useful
way for the employer to abate the hazard. The directive explicitly
states a citation will be issued if discovery of an existing hazard of
workplace violence, likely to cause physical harm or death, is made
during inspection, if the employer has failed to take reasonable steps
to mitigate or eliminate the hazard.
The two scenarios that most likely will trigger an inspection: (1)
there has been a complaint, referral, fatality, or catastrophic event
relating to workplace violence; or (2) there is a planned programmed inspection at a worksite that is in an industry with a high
incidence of workplace violence. OSHA has identified healthcare
and social service settings, such as psychiatric facilities, hospital
emergency departments, pharmacies, and drug abuse treatment
clinics, as well as late-night retail businesses, as high-risk settings.
Bullying: Work Shouldn’t Hurt!
workplace violence may grab the daily headlines, according to
Drs. Gary and Ruth Namie, co-authors of The Bully at Work, but
outside the spotlight, the pain and degradation of corporate bullying
shatters lives nationwide. Incivility and bullying flourish in unsupportive work groups that normalize competitive and abusive behav-
iors. Nurses must learn to recognize bullying as abuse and work
toward organizing and fostering collective support for staff nurses
who are being bullied so they’ll stand up as advocates and assert
their right to work in a safe practice environment.
When a bully shows no signs of stopping, the Drs. Namie suggest a tactic and offer an example whereby other nurses on the
unit, who have seen the hostility, may call a “Code Bully.” Usually
done by word of mouth, the nurses stand behind the nurse who is
the victim. The example situation is a disruptive surgeon. Before
the surgery begins, the surgical team encircles the surgeon and
tells him they will not assist him until an apology is given. Now the
bully recognizes that he or she is not facing one person but a
group. Most of the time, the bully then realizes a power shift has
occurred and often this is enough to stop an episode of disruptive
and abusive behavior.
Verbal abuse and bullying is the most common form of violence
reported by nurses. Verbal abuse can come from patients and visitors, but it can also come from doctors, supervisors, or anyone else
in a position of power. An example of this type of “power over” situation occurs when hospital administrators impose workflow
redesign/restructuring schemes and continually expect staff nurses
to provide safe care with inadequate and unsafe levels of
staffing.Other disruptive and oppressive management behaviors
include increased surveillance, intimidation tactics, threatened discipline for RN/staff exercise of whistle-blower and professional
advocacy activities; blaming or criticizing team members for low
satisfaction and employee engagement scores, or threatening staff
with retribution and job loss.
Bullying and violent assaults often come from patients’ family
members who are frustrated by the lack of attention they’re getting
from providers. Because incidents and hazards associated with actual or potential violence and abuse differ from one facility to another,
each employer must develop a defined plan for responding to any
incident of violence. Collectively, nurses and other healthcare workers should become familiar with their employer’s guidelines, policies, reporting procedures, and methods to help prevent and reduce
workplace violence and abuse.
Where Do We Go From Here?
as with most other risks, prevention of workplace violence
begins with planning. Any organization will be far better able to
spot potential dangers and defuse them before violence develops
and will be able to manage a crisis better if one does occur, if executives and decision-makers have considered the issues beforehand
and have prepared appropriate policies, practices, and structures.
Unfortunately it is easier to persuade management to focus on the
problem after a violent act has taken place than it is to get them to
act before anything happens. Patients and the public have the right
to expect that their healthcare needs will be competently provided
for in a safe setting.
A plan should be proactive, not reactive. Employees have the
right to expect a work environment that promotes safety from violence, threats, and harassment. If there are elements in the workplace culture that appear to foster a toxic climate, such as tolerance
of bullying or intimidation; lack of trust between workers and management; high levels of stress, frustration, and anger; poor communication; inconsistent discipline; and erratic enforcement of
company policies, these should be called to the attention of management for remedial action. NNU nurses should be familiar with
OSHA recommendations for reducing workplace violence and hold
their employers accountable by working proactively to implement
effective practices.
Nurses belonging to collective bargaining units are strongly
encouraged to address workplace violence and abuse prevention in
their contract language and through their professional practice
committee (PPC) by proposing and demanding safe staffing; secure
and ergonomically designed work stations; and trained security personnel present and available should the need arise. Nurses have the
duty and the right to advocate for their profession and on behalf of
their patients. Nurses must act to change, as circumstances require,
working conditions that are against the health, safety, and wellbeing of themselves and others.
OSHA recommendations for reducing violence include:
• Adopting a written violence-prevention program, communicating
it to all employees, and designating a “Patient Assault Team,” task
force, or coordinator to implement it.
• Advising all patients and visitors that violence, verbal, and nonverbal threats, and related behavior will not be tolerated.
• Setting up a trained response team to respond to emergencies.
• Encouraging employees to promptly report incidents and to
suggest ways to reduce or eliminate risks.
• Reviewing workplace layout to find existing or potential hazards; installing and maintaining alarm systems and other security
devices such as panic buttons, handheld alarms, or noise
devices, cellular phones, and private channel radios where risk is
apparent or may be anticipated; and arranging for a reliable
response system when an alarm is triggered.
• Using metal detectors to screen patients and visitors for guns,
knives, or other weapons.
• Establishing liaison with local police and state prosecutors,
reporting all incidents of violence and providing police with floor
plans of facilities to expedite emergency response or investigations.
• Ensuring adequate staffing at all times.
• Setting up a system to use chart tags, logbooks, or other means
to identify patients and clients with assaultive behavior problems.
• Instituting a sign-in procedure with passes for visitors and compiling a list of “restricted visitors” for patients with a history of violence.
• Controlling access to facilities other than waiting rooms, particularly drug-storage or pharmacy areas.
• Providing medical and psychological counseling and debriefing
for employees experiencing or witnessing assaults and other violent
incidents.
When necessary, nurses should request assistance verbally and in
writing from outside resources, including threat-assessment psychologists, psychiatrists and other professionals, social service agencies, accrediting, licensing, and regulatory agencies, and law
enforcement. NNU regards workplace safety, including safety from
violence, as an employee’s right, just as worthy of union defense as
wages or any other contractual right such as defending workers’
rights to due process. Training in violence prevention, threat detection, threat assessment, and threat management should become
part of the workplace culture. End of Part 1
27
Cover 4_DEC 3/26/12 10:03 AM Page 28
Join our band of merry
nurses calling for a
TAX ON
WALL
STREET!
NNU registered nurses will be swooping
into Chicago to call on world leaders for
a tax on financial speculation that would
raise billions of dollars for jobs, healthcare,
and education.
MARCH AND RALLY—CHICAGO
Friday, May 18, 2012
Starts 11 a.m. at the Sheraton
Chicago Hotel & Towers,
301 East North Water St.
Help us demand justice. Be there.

Lost

Transcription

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