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Think back to your middle school and high school days. There were the stereotypical bullies that everyone tried to steer clear of. They picked on the weakest, they picked on the youngest, they picked on the ones they were most threatened by. The media even hits on this rampant problem that is still around in schools today with the production of movies such as Mean Girls.

Although as professionals we all have grown up in age since then, do you ever wonder if people that surround you at work have grown up in maturity?

We have a journal club at work that meets each month to discuss articles of interest related to nursing or healthcare. This month’s article was about bullying in the workplace, most specifically in the nursing field.

Some interesting findings? Although there has been minimal research into the issue surrounding workplace bullying, all studies that have been done nationally and internationally report that over 50% of interviewed nurses have experienced some form of bullying at work. Now, one can argue that women tend to be sensitive creatures and even constructive criticism can be perceived as bullying, but by definition bullying involves multiple efforts to cause another person physical or emotional harm or injury. Obviously in the hospital setting, there is (hopefully) no physical abuse between co-workers. But a specific type of bullying that deals strictly with the emotional aspect involved, called relational aggression, is the equivalent in the adult world to the bully that walks down the hallways in school with her elbows out taking down all the weaklings.

Some examples of bullying in the workplace? Nurses that voiced their personal experiences with bullying included instances of gossiping about a certain co-worker, the formation of cliques among groups of nurses and ostracizing others, purposeful withholding of information from another nurse, bossy nurses, pushy nurses, or nurses that always criticize another nurse in front of others, and failing to help out a fellow nurse.

Who are these bullies? I thoroughly enjoyed the portion of the article where nurse bullies were given identities based on certain characteristics they displayed. The Supernurse is always right, has always been a better nurse than you, and will always be a better nurse than you. Just accept it. The Resentful Nurse is still holding a grudge against you from when you had to give her a 4th patient when you were in charge three months back. You obviously aren’t a team player. The PGR Nurse Puts downs her co-workers, Gossips about others constantly, and spreads vicious Rumors. She is always great for lunch conversations, as long as you aren’t the one being conversed about. The Backstabbing Nurse cultivates friendships then betrays them for her own good. She is the epitome of Jekyll and Hyde in nursing. The Green-with-Envy Nurse does everything in her power to obtain a certain status that she is envious of, no matter what or who stands in her way. Although some of her patients might be green from nausea, she is green from greed. The Cliquish Nurse reveals her bullying by playing favorites or by excluding others. If you’re not “in”, you can see your way “out.”

What makes you a target? As unfair as it seems, bulling trends tend to correlate with the old nursing adage that scares many away from the profession that “nurses eat their young.” New graduates or new hires are often targeted because they haven’t quite found their niche either socially or professionally.

Those that are recognized or honored for a job well done are often the target of jealous nurses displaying covert means of bullying as they try to even the playing field and increase their own recognition. And unfortunately, much like the movie Mean Girls, those nurses with close relationships with physicians may be the target of gossiping and wide open flood gates of the rumor mill. Times of stress, understaffing, and low floor morale can also increase the likelihood of bullying. As ridiculous as these examples seem, similar circumstances exist in the workplace that should be acknowledged and addressed.

What to do? To combat this problem that has recently peaked as an interest in the field, the Joint Commission, as of January 1st, is requiring that institutions have a process in place to address and handle “intimidating and disruptive” behavior in the workplace. What that means? I’m not so sure…

Some institutions are adopting a more democratic model to their management and eradicating the hierarchy found in many floors. Awareness in our own practices does wonders for a problem as preventable as this.

• If you see bullying first hand on your unit, without causing extra conflict, do you best to intervene.
• Actively UNparticipate in gossiping by redirecting conversation to something more neutral or walking away from the offender.
• If a new grad is having a difficult time, take her under your wing…we’ve all been there.

We have a council on our unit, the Recruitment and Retention Council, that I think by nature unintentionally does a nice job of eliminating some bullying tendencies by creating a sense of community among the unit. They plan team building exercises and tackle problems that are the root of low morale phases on the unit. This is an issue that can and should be resolved in the hospital setting. Nurses are nurturing and deemed the ultimate caregivers by nature of the job, so we need to start acting like it.

Has anyone experienced bullying themselves at work? How is your unit tackling the issue?

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I’ve always envied those who can flip flop back and forth between day shift and night shift. How do they do it?

I think I’ve nailed down some of their secrets, and in so doing have been able to work both day shifts and night shifts in succession. Happily! Nights are often a more peaceful time in the hospital and it’s definitely a nice change in my routine.

So, need some tips on how to survive the “dark side”?

Surviving the night shift.

Here are steps to jumpstart your circadian rhythm and allow for easier transitions from the normalcy of day shift to the non-so-routine night shift.

(1) If you are strictly a night shift nurse and you are having problems adjusting to the schedule, try a couple weeks of grouping all of the shifts together, three in a row. That way you can completely convert to night owl status for half of the week and then have four days to recover back to normalcy (that being if you indeed do work three 12-hr shifts).

For those who rotate and really cannot stand working three nights a week, ask your scheduling manager if you can split up your weeks into day and nights (be sure to work your days towards the beginning of the week and allow ample time for recovery after night shifts). For example, you would work Monday day shift and Wednesday and Thursday night shifts.

Wake up early on the day of your first night shift and take a nap in the afternoon. This strategy allows you to have a bulk of the morning to get stuff done and having some decent sleep prior to going into the long shift. I have heard people that just sleep in late (until like noon or 1 in the afternoon) crash around 3 or 4am because they have been up for so long.

My technique for the last day is to return home post last night shift, sleep for about four hours, then force yourself to wake up! You’ll be so tired by that night that you will be able to sleep during the night and be back on a somewhat normal day routine by the next morning.

(2) Right before a night shift, eat a substantial dinner prior to going into work (even if it is “breakfast-like”). That will hold you over for hours and give you a boost of energy to get the shift started. Try your best to avoid the comfort foods of night shift and bring a light meal full of protein and complex carbs that will fulfill your midnight munchies.

(3) Exercise! This not only applies to those working normal business hours. It becomes extremely important for those on night shifts because working out allows you to have more energy and creates for more sound sleep. I have friends that exercise after they get off their shift in the morning (I’ve always been too tired for that). If that is your preference, be sure to take time to wind down and drink a warm, non-caffeinated drink prior to going to sleep. I tend to exercise after I wake up – the beauty of that being that as opposed to working out early in the morning like a “normal” shift worker may do, you will be inundated with daylight hours for a nice run, pleasant early evening temperatures, and you will most likely beat the post 6pm rush at the gym. Hitting a wall at 4am? Run the stairs, it will most certainly wake you up

(4) Isolate yourself! Be sure to tell your loved ones, your neighbors, and your kids that just like they don’t like being woken up at 2am, you don’t like to be disturbed during your “night”. Turn your phone off, buy dark curtains that will keep the daylight out of your room, wear an eye mask, lock the dog out of your room, tie up the children (kidding), and for goodness sake don’t drink coffee within four hours of going to sleep. If you “need” coffee to get through the shift, drink it early in the shift and combine water with a stair run later in the shift as an energy boost.

You mind is a powerful tool. Keep in mind all of the positives of night shift. It can be extremely conducive to family life if you are a working parent. The shift differential is an added bonus in the bank account. You typically have more autonomy as a nurse on the night shift and have ample time to develop skills and master your assessments. With the pace of the shift usually being slower, you have more time to develop close relationships with your coworkers because you are relying on each other for second opinions, assistance with tasks, and camaraderie in staying awake when everyone else is snug in their beds.

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There’s been a recent surge and great interest in the “incivility in nursing.” I dare ya to do a quick search–go ahead and Google it. I’ll be here when you get back…

Incivility = violence = lateral violence = disrespect = offensive= etc, etc. In fact, I read an article that spoke of incivility as simply being mean. Mean? Really?

Better yet, I read another article that talked about actions that can be interpreted as ‘”uncivil” (incivil?), such as tardiness or sending an email without a greeting (be still my heart!).

I’m poking a little bit of fun at a real and serious problem. For some strange reason, the world of nursing thinks the problem is unique to its profession. Or that the lateral violence we experience is new or, dare I say, different.

I spent a good amount of time reading some of the leaders’ opinions, blogs, articles and presentations online. I have to admit, I’m still trying to understand the uproar here.

Incivility in the workplace is as old at time. The only difference is how it gets handled and whether or not it’s tolerated. The truth of the matter is that lateral violence or incivility will never go away. It’s everywhere–not just in the workplace, but also in our social circles, in our classrooms and in our homes. It can be less prominent or more severe no matter where you go.

I think therein lies the problem. Lately it’s become more severe in the nursing world. There are a lot of theories as to why, and they are all equally entertaining (at least to me).

1. Men vs. women (nursing is a female-dominated career)
Women are more sensitive and thus are “hurt” easily.

• How is it that women all around the world have survived in the medical community, then? Are you saying physicians are insensitive?

2. Women by their very nature can be catty
I have a hard time refuting this theory, since you don’t hear construction workers complaining about incivility. Men may resort to physical violence, but they aren’t diabolically vengeful (mostly!).

3. It’s the generation (Generation Y vs. Generation X vs. Baby Boomers)
Newer nurses feel “entitled”–they are “above” the basic bedside skills.

• I would have picked the word “spoiled.” And it’s not just the younger nurses who are guilty.

4. BSN graduates are entitled and have an ego
So you think because they advanced their degree, they forgot what it was like at the bedside? Or that they would treat a bedside nurse poorly because they have more letters after their name?

5. Newer nurses preoccupied with leapfrogging
Apparently, it’s viewed as an offense if a young nurse wants to advance his or her education? While neglect is rampant (no argument there), how is pursuing a higher education a bad thing?

6. Newer nurses have no respect
Have you heard the saying “nurses eat their young”? Since when is a bad thing if the young fight back? Respect is a two way street.

•  I think it has everything to do with you as a person (and professional) and how you deal with challenges. Period. It’s that simple. If you don’t want lateral violence to snowball, figure out a way to challenge it and deal with the root of the problem.

REALITY CHECK

We all need to grow some thicker skin
If someone offended you, don’t go tattling on them to your supervisor. Have the self-indignation to confront the assailant as a professional with your views, interpretations and explanations as well as suggestions to alleviate the occurrence from repeating. Do not turn into a high school teenager.

There should be zero tolerance from anyone holding a supervisory or leadership role
This includes every nurse who has more experience than the nurse next to them. I’ll say that again: You assume a leadership role the minute you are no longer the rookie. Period.

Newer nurses: Quit being so spoiled rotten
Just because you were coddled doesn’t give you the right to whine every time something didn’t go according to plan. Learn to roll with the punches. There is definitely a difference between self-assertiveness and immaturity.

Seasoned nurses: Quit being so vindictive and insecure
Leaving the bedside is neither good or bad, it’s just a decision to further one career. If you find it so offensive or appalling, keep it to yourself. Better yet, I dare you to try to take the same leap.

And lastly, this is for all the nurse leaders out there. If you really want to effect change, then quit with the academia-babble
Get out there in the trenches. Get your hands dirty (figuratively and literally). Quit creating new employer-based committees and developing action plans with continuum manifestos and evidenced-based theories. Walk the walk, folks.

Am I being blasé? A little too laissez-faire? Insensitive? Is it because I’m a man??!! (Ohh let the hate mail begin!) Or maybe, it’s because I don’t tolerate or accept the incivility when it shows its face.

I take a professional, head-on approach instead of whining, crying wolf and pleading with a “woe is me” attitude. There is a profound difference between being a victim and acting like one.

Let’s all put on our big-girl and big-boy pants and learn to play nice in the sand box.

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I was inspired to pay tribute to the men of nursing after reading this recent comment from one of our brothers in the profession:

I am a nursing student, and about the “man card” thing. I am a former Corporal in the Marine Corps infantry. I first got interested in healthcare in Iraq doing combat medicine, like taking care of bullet wounds, burns, and fragment wounds from IEDs. I know who I am and if someone gives me a hard time about being a nursing student, it just show me that they are overcompensating for something. As long as I am providing for my wife and son, I don’t care what other people think. I want to be a flight nurse because I like working in high-pressure jobs.

First, THANK YOU for serving, Corporal!

Second, does everyone realize just how new women are to nursing? Particularly trained, educated women from all walks of life?

2000 years ago, nursing school was for men only!

Most of the first nurses in recorded history were members of male religious orders. Many hospitals still bear their names. Some are even canonized as Saints.

When Florence went to Scutari in the Crimean War, she had to integrate her nurses into a system in which only MEN had cared for other soldiers. So men were the first military nurses–in part because only men were permitted to serve in the Army. Also, Victorian beliefs did not permit close physical contact between persons of the opposite sex unless they were married.

During the Civil War, more women worked on the front lines caring for the wounded. Many of these nurses were private citizens whose homes stood on the battlefields and had been pressed into service at field hospitals. Able-bodied men were needed for the fighting. The names that we recall from history–Clara Barton, Mary Ann Bickerdyke, and Dorothea Dix–were mostly volunteers who simply managed to outlast the doctors who opposed them.

During the two World Wars of the 20th century, men were still the only battlefield nurses, while women served in hospitals and on ships. The same continues today. The difference is that a field medic is more of a surgeon who administers lifesaving treatment according to protocols and does not have to wait for a specific order from an MD. He does not have time to wait for orders, as he is working within that Golden first hour of trauma care which makes the difference between life and limb.

Somewhere in the Baby Boomer generation, nursing became known as a “womens’ profession.” It seemed that nobody remembered that it was a male domain for most of its existence! (Perhaps it was the sexy white uniforms and caps that did it?)

The few men who bothered to attend nursing school in the latter part of the 20th century had to put up with all sorts of restrictions: they weren’t allowed in the delivery rooms when a woman was “exposed” (although male doctors were!); they had to have a female “escort” for performing catheterizations; and they were barred from certain clinical areas, like labor and delivery.

And, of course, there is the sexual assumption that became pervasive in the late 1970′s–”He’s a nurse? Well, he must be gay!” I have no doubt that most of our guys have been subjected to this. Isn’t it odd that we never seem to make the same assumption about women? (“A female doctor? She must be a lesbian!”)

Hang in there, Marine! This profession needs a Few MORE Good Men such as yourself. I wish you “fair winds and following seas” as you move forward in your career.

And, as always, Semper Fi!

        “But we in it shall be remember’d;
We few, we happy few, we band of brothers;
For he to-day that sheds his blood with me
Shall be my brother”…   -William Shakespeare, Henry V

Image: Warner Bros.

I kind of thought that Nurse Ratched of “One Flew Over the Cuckoo’s Nest” got a bum rap. Until, of course, the last part of the movie when she starts berating Billy by playing the “what will your mother think?” card.

Back in 60s psych wards, there were no counselors who held the group therapy sessions over which Nurse Ratched presided. Shock therapy and/or lobotomy was the usual treatment for extreme depression, suicide attempts, psychoses, and neuroses. The antipsychotics and antidepressants which we now take for granted did not exist.

The depiction was from an era before most modern nurses were even BORN.
A lesser nurse could not have dealt with a unit instigator like Jack Nicholson’s character. Ratched was strong enough to calmly but firmly keep her all-male unit on a schedule (something that certain psych diagnoses need), collaborate with the MD and expect her staff to do their jobs!

Fast forward to 1977: (Future) Nurse Rene is sitting in her psych nursing class with an absolutely phenomenal instructor (who not only has a master’s degree in nursing, but also a huge amount of clinical experience with patients in state institutions and war vets).

So, off the class goes, all fresh and full of textbook knowledge about neuroses and psychoses, on our way to the locked ward in an acute care urban hospital. We are all in street clothes, with only lab coats to distinguish us from the patients.

Our assignment is ONLY to talk with patients and write down what they say. We are not to attempt to treat anyone, give meds, or do any nursing care. We are, however, to report anything like suicidal expressions to the RN in charge.

We sit down at a table with a couple of patients who are sewing leather purses. Cigarettes are handed out only in the day room by staff members for those patients who have smoking privileges. (Obviously this event goes back quite a few years!)

Suddenly, there is a loud crash just behind me. One of the patients hits the floor, face-up, and another stands over him, pumping his chest, shouting, “Breathe! Breathe!”

We looked at each other wondering what to do (and not to do!) in this situation. Finally, one of the staff members comes out from behind the glass-enclosed nurses’ station and pulls the patient up from the floor. He then explains to us: “John does this often just to get attention.”

This all made for a very interesting post-clinical discussion.

Nursing is nothing if not interesting and unpredictable…

“Let us consider that we are all insane. It will explain us to each other; it will unriddle many riddles…” Mark Twain

As a new nurse, I was terrified of stories about Joint Commission visits and always hoped that the visit would fall during a week of night shifts so I could avoid the torture. Elder nurses claim that the surveyors pick out weak (new) nurses to interrogate and basically lead you to believe that the hospital’s accreditation status falls on your shoulders, and only yours.

Similar to a college hazing period, if you can get through a Joint Commission visit, you can officially be an RN. It’s human nature to have a fear of the unknown, and for nurses new to the profession, simply the words Joint Commission sound daunting in themselves.

I’m here to dispel some of these myths about Joint Commission, formerly known as JCAHO, in hopes of decreasing anxiety and pointing out some benefits of the unavoidable survey at your hospital.

Myth #1 – the Joint Commission is the Big Bad Wolf

According to the website, “Joint Commission is an independent, not-for-profit organization whose mission is to continuously improve the safety and quality of care provided to the public by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”

Sounds great, right? Not yet all bright and cheery? How about this, the Joint Commission’s slogan, Helping Healthcare Organizations Help Patients. That has a nice ring to it. Looking past the negative stigma attached to the name, the concept behind assisting healthcare organizations in better caring for their patients is actually quite a novel one, and one that should be widely embraced by healthcare providers.

Myth #2 – the Joint Commission is unnecessary

Hospitals are surveyed at least every three years and receive an official gold seal of approval via Joint Commission standards if they pass the “inspection.” In many states, Joint Commission accreditation is necessary for receipt of Medicaid reimbursement.

Myths #3 – the Joint Commission hates nurses

Although the process can be  somewhat intimidating, the level of quality required to meet Joint Commission standards ensures that our patients, our friends, and our loved ones, if they should find themselves hospitalized, will receive proper, safe, and quality care. Prior to drafting this post, I perused the Joint Commission website and found some helpful and informative links including the master list of “do not use” abbreviations. I was also pleasantly surprised to read a document that highly promoted the nursing profession in suggesting ideas for advocating for advanced practice nurses, lowering nurse/patient ratio, how to create a more positive view of the profession in society, incentives for nursing school programs for recruiting students and faculty, and ideas to combat the nursing shortage, specifically the nursing faculty shortage. What came to mind after reading said article? Sometimes our biggest fans  are our biggest critics.

Four simple habits to prep for the Joint Commission

1. Label all medications to prevent error
2. Be diligent with charting and documentation
3. Store food in the kitchen and away from the nurse’s station
4. Learn what you don’t know

I used to compare the pre-Joint Commission preparedness time period at work to natural disaster preparation. But I started noticing the positive effects of working up to Joint Commission standards including labeling of all medications to prevent errors, increased effectiveness of transfer of care, diligent charting and documentation, and even small details such as less food at the nurse’s station to improve sanitation.

I even find myself seeking out information that I use to simply overlook if I didn’t know the answer. Sure, it’s out of fear of being audited but I’m a more well-versed nurse because of it.

Although a seemingly intimidating process, if looked at with an open mind and an educated perspective, my hope is that nurses can learn to embrace a Joint Commission visit as a challenge that will enhance their workplace, promote quality care, and push them to take pride in their profession.

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There are occasions when breaking the visitation rules is the right thing to do–when a soldier or sailor has just arrived from overseas to visit a very sick relative, for example, or when the patient’s condition would benefit from such a “special” visit.

In one of the ICUs where I worked, we had a patient who was so ill with cancer that we couldn’t stabilize him enough to get him home, even under hospice care. Yet his heart’s desire was to go home and sit with his dog down by the pond.

At the time, there were two agency RNs on staff. One happened to have a SMALL dog–the kind you can fit into a tote bag. In an informal nurse’s station conference, those of us who would be on duty the next weekend decided to help arrange a “special” visit.

That Saturday, our dog owner slipped in with the little dog, freshly bathed and fully vaccinated, in her tote bag. The dog was sworn to silence and never made a sound.

The rest of us closed the door, turned off the camera and shut the window blinds so that the man could enjoy his special “visitor” for an uninterrupted two hours.

He was ecstatic.

As a result, his condition improved remarkably. He WAS able to go home and spent about two weeks with his own dog under hospice care.

Sometimes it is easier to beg forgiveness than to get permission (Rear Admiral Grace N. Hopper, US Navy, Retired).

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A recent article at Nurse.com sparked my interest. Limited (or scheduled) visitation versus unlimited visitation hours?

As a nurse, the reflex answer should be: Whatever is better for the patient.

I honestly feel anything that can improve the delivery of care is a good thing, but you’ll be hard pressed to find many nurses who are advocates of unlimited visiting hours.

It’s a touchy subject, isn’t it? I don’t think anyone is completely for or against either choice.

The article (AACN calls for expanding visitation rights in ICU) says:

Hospitals may limit visiting hours under the assumption that family visitation causes stress for the patient, interferes with the provision of care, is mentally exhausting to patients and families or contributes to increased infections.

Other than the increased infections, I’d agree with that statement. I’ve seen many times where my patient’s recovery in the ICU is hampered due to exhaustion from too many visitors. I think many patients try to “entertain” or talk with their visitors when they sometimes all they need is rest.

I think we as nurses have to put our personal feelings aside and consider what is ideal and best for our patients. If that means structured visitation, great. If that means unlimited visitation, so be it. I’m willing to admit, my reflex reaction to the unlimited visitation is, “You’ve got to be kidding me?”

I think there are just certain aspects of the care we give that do not need to be witnessed by family and loved ones. But then as I say it out loud, I wonder if it could be portrayed as “hiding” something? Or not wanting the family to see a mistake I could make?

Hmm.

Maybe we all need to have unlimited visitation? This way we don’t get caught up in the task and always remember there is a human being on the other side of the bed, not just an assignment.

We have an amazing responsibility as nurses. We are entrusted with our patients’ most prized possession. It’s our job to continually speak for them when they cannot speak for themselves. That includes proper visitation rights and schedules. What is best for the patient. Period.

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You hear it all the time in the professional realm: People complaining about their jobs.

Truth is, nursing is not immune to job gripes.

But in light of the new year, I vowed to be a more positive person with an optimistic outlook. During this little introspective session, I realized that in our profession, if you don’t like it, change it. That’s the beauty of the job.

You get out of school and you enter the workforce with a vast amount of options based purely on schedule. Do you want to work three days a week? Do you want to work night shift? Do you want to work normal business hours in an office setting? These options increase the marketing value of the profession–if you get sick of your schedule, go work somewhere else!

Many mothers that I have spoken with agree that working night shift is great for family life. You can sleep when the kids are in school and spend a couple of hours in the evening with the family, then the dad watches the children at night when the mom goes to work. And when the kids grow up and mom is exhausted from working night shift all these years, she switches to day shift. It doesn’t get much more conducive to family life than that.

Nurses also can choose the genre of people they want to encounter and care for. You don’t like adult patients? Work at a pediatric hospital. You don’t want your patients to be awake when you are caring for them? Work in an OR or an ICU. The beauty of nursing is that you can find an area that appeals to you most and where you will find the greatest happiness and job satisfaction.

I have heard many nurses complain about their pay. Some wonderful options for job growth include moving to a management position or going back to school to obtain a master’s degree (which has incredible growth potential itself). To complain about pay is a pity when there are vast opportunities to grow as a nurse.

I think the most compelling reason why nurses should never complain, gripe, or moan about their jobs is because while we are working there, we are not the patients. That doesn’t mean that we are all in perfect health or we don’t have family members that may be patients, but at that very time and place, we are not dealing with their illness on a personal level. Every day that I walk into work I try to maintain a positive attitude by telling myself how blessed I am not to have a child with a congenital heart defect. It puts things in perspective on a daily basis.

So, although it is easy to think the grass is always greener, this 2012 I’m going to do my best to do away with excuses and take nursing for all of the good that it has. Because it has a lot to offer.

What are you missing? What could you do in the next year? The next three years? The next five? I think a lot of nurses fail to acknowledge that they might not want to do the type of nursing they are currently in forever.

Take advantage of any educational classes that your institution might offer. For example, if your institution offers free ACLS for everyone, don’t ignore that just because you work in a Pediatric unit. Take the class–you never know when you might want to hop on over to the adult ortho unit!

I tell nurses to ensure that they have their own five-year plan. That way, no one else tries to make it up for you!