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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.

Mehmet Can | Veer

I have one more year left of being a student, and still have a ton of knowledge to consume. But one thing I know for sure: Being a nurse practitioner student is equal parts excitement and aggravation.

The excitement is seeded in the information-laden state I’m in. Every day I learn something new and cutting edge, and yet so basic and simple to advanced practice. I’m a nurse learning to dip my feet in the deep, deep waters of medicine.

Just when I think I’ve got a hold on a subject, I get that slap in the face from reality. It’s tough being the new kid on the block sometimes.

The aggravation stems from the resistance nurse practitioners have been fighting for years. Being mid-level providers, the world of medicine seems to have drawn a line between support and rejection. To them, we are either here to help them deliver the very best evidenced-base care, or we are here to step on their toes.

I’m not sure why. I’m guessing some of the states that are lobbying for independent practice have struck a nerve in some areas. But once again, I’m still a student, I’m still learning.

Then there’s the offensive and degrading position some physicians have taken. I’m wondering if it’s a defense mechanism?

Today I was told by a physician that NPs are simply hired to do all the “scut-work” that physicians don’t want or like to do. In the physician’s words, “You guys do all the crap/garbage stuff we don’t like or have time for. Is that what you really want to do?”

It took everything I had to not resort to physical violence and/or verbal rampage. (Sorry, folks.)

No doctor, my career and my (soon-to-be) position in the healthcare system is not as your receptionist or your transcriptionist. I actually DO have a set of skills that can not only help you, but may, in fact, elevate the delivery of care to your patients. I am here to help you, not replace you or fill your shoes. I know my limitations.

Today’s healthcare team is supposed to be filled with forward thinkers. Unfortunately, this physician wasn’t one. It may be presumptuous of me to say this, but I think it had something to do with an “old dog learning a new trick.”

Am I wrong to think this way? I know that NPs and their function are gaining popularity and are becoming more widely acknowledged, but we aren’t that new to the block. In fact, NPs have been around for just shy of half a century. I suppose I shouldn’t be too upset by my experience, since it’s the first one of its kind. I guess the edge of the blade was just sharper than I expected.

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

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This semester starts the strong wave of clinical hours for my Nurse Practitioner program. I’ll be spending many, many hours in the hospital as a student…again.

I’m just a tad bit nervous.

Okay, let me re-phrase that. I’m scared outta my mind!!

I feel like I’m back in nursing school–learning the ropes, talking the talk. Just when I started to find my own walking pace, I’m back to crawling at the next level.

I can’t help but wonder how different things are now from when I was in my diploma program. (I cannot believe it’s been seven years since I became an RN?!)

Here are a few comparisons between me as a basic nursing student and me as an advance practice nursing student:

1. If you don’t know it, know where and how to look it up!

When I was in nursing school, I carried around an average of four textbooks that totaled more than 75 lbs. I lugged my bookbag full of textbooks, notes, and drug reference guides everywhere I went. I can remember trying to figure out how I was going to stash my book bag while on clinicals, because students didn’t get lockers.

As an NP student, I’m still utilizing all the above, but now we have these things called smartphones–all 75 lbs worth of reference material in the palm of my hand. You gotta love technology.

2. The 7 P’s

Prior Proper Planning Prevents Piss-Poor Performance. (I think there are different versions, some more colorful than others. You can blame my time in the armed services for that one.)

I still remember the sleepless nights prior to a day of clinical. I would be up all hours of the night researching my meds, checking and rechecking contraindications, checking and rechecking the whys and why nots of a patient’s care. Oh, and care plans. Gooooood grief. I remember having to write them out. Objectives, interventions, outcomes…they still haunt me to this day.

Now as an NP student, I’m verifying evidence-based nursing and medical research management of care, risk reduction, test sensitivity, outcomes, and physiological response techniques. The game hasn’t changed, but the level of play is elevated beyond my imagination.

3. Stranger in a strange land

I remember the first time I set foot onto the clinical floor as a new student nurse. I was terrified. People were speaking a different language than me; they had a level of familiarity I could only dream of; and ultimately, they didn’t look scared and nothing shook them. I was in awe.

Boy, I can’t wait to feel that way again, let me tell you. (I hope you caught the sarcasm!)

In the end, I’m equal parts nervous, scared, anxious, excited, eager and motivated. Only time will tell how this first round of clinical rotations will go. Wish me luck.

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.

alexraths | Veer

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.

Yuri Arcurs | Veer

I’ve been a working nurse for three and a half months now. It’s not a lot, and I still feel like a beginner in many ways.

But even though it’s been only a short time, my career has launched and I’m on an amazing ride.

As I reach my fourth month of training, this is how I’d describe my life as a nurse so far:

• Stressful. In nursing school, you learn about stress. It’s not always a bad thing–remember, there is eustress (the good kind!) too. It’s like the stress of getting married: It’s intense and there’s anxiety, but it can be both positive and negative. In a bad way, nursing is stressful because there is so much to learn and remember, and there is so much at stake with your every action. But it’s stressful in a good way because with every day that goes by, you know you’re making a difference.
• Emotional. I always knew nursing was an emotional job, and I got a taste of it when I was a nurse’s aide, but there really are some things you can’t prepare for. We see people at their very worst; kids who are sick and parents who are worried sick. Sadness, hopelessness, frustration, anger–nurses get hit with the brunt of it. It’s all about being therapeutic and trying to remember the more positive emotions we get to experience–happiness, hope, love, caring.
• Intense. I’ve had a few patients who have been in some intense situations. I haven’t been in a code yet, and I haven’t called for an RRT, but there have been some close calls. In those moments, I’ve really been surprised at how quickly I was able to think, and how calling the doctor (which is usually pretty intimidating) is not an issue. In fact, it’s in these moments that I really feel the whole team unite.
• Not. Real world nursing is NOT like nursing school. I haven’t yet figured out if this is a good thing or a bad thing. It’s not that what we learn in school is wrong or misguided information, or that we don’t follow policy and EBP on the units. It’s just not the same.
• Fun. Nursing is fun. I think #4 has a lot to do with this. When you’re in school EVERYTHING is so intense, you can’t even enjoy your time with the patient because you’re worried your instructor is going to come by and think you’re not staying on top of your tasks. Nursing isn’t all tasks, and a lot of the time, you can do so much more for a kid just by giving him or her some TLC and having a good time than any med will do.
• Love. I use this word for many reasons–I love my job. I love my nursing team, my unit, my managers. I love leaving work feeling like I made a difference for someone. Despite the challenges, I love that it’s stressful and keeps me on my toes. I love that it’s emotional–it should be; when it’s not, it’s time to leave. I love the intensity and I love that it’s fun.

Nursing is an amazing career. Is it everything I expected? It’s way more! Here’s to another month and a half of training, and a long career ahead!

Medioimages | Photodisc | Thinkstock

Random, right? But she had this amazing-looking water with oranges, ginger, cucumbers, and berries in it. Just looking at it made me thirsty! It got me thinking: I wake up, drink coffee, take coffee with me to work, drink that, get more, and don’t drink anything else for the rest of the shift. How bad is that!?! And what’s worse is that I never even thought about it.

So I went home and dug through the cupboards looking for just the right water cup–one of those plastic, reusable ones with the straws (straws help me drink more of just about anything…not so good when it comes to cocktails, but GREAT when it comes to water!). I even filled it with lemons and ice to keep it flavored and cool.

What a difference! I don’t feel as tired anymore, and I don’t snack as much (when your water tastes good–try flavoring it with Mio drops too!–you don’t feel the need to snack on whatever’s lying around). It’s a lot easier to make it through my shift when I’m well hydrated. Sure, it means more bathroom breaks, but that’s a small price to pay. Even my skin feels better now.

So lesson learned: wanna feel great, hydrate! It’s amazing what you learn when you least expect it. Now excuse me while I go fill up my water bottle!

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A Q&A with Kathleen D. Pagana, Ph.D., RN

Q: Dear Nurse Pagana, One thing I never learned in school, and haven’t figured out as a nurse, is how to handle embarrassing situations in the clinical area. For example, if my patient “lets go of gas,” he and I both feel uncomfortable. Do you have any etiquette guidelines to help me handle uncomfortable situations? —Needs Help

A: Dear Needs Help,
You’ve raised an important concern. Unfortunately, the very fact that embarrassing situations make people uncomfortable is also the reason you probably never addressed this as a student and the reason your nursing colleagues don’t discuss this now. The best way to handle any embarrassing situation related to physiology is to clinicalize it—explain it in a clinical context. Here are three examples, with suggested responses or explanations:

• The patient “lets go of gas” (has flatus): “That’s a good sign. It means your intestines are working.”
• You’re in the operating room and your male patient has an erection: “General anesthesia causes vasodilatation. The patient has no control over this response.”
• Your post-operative patient is embarrassed because he fainted when he tried to get out of bed: “This happens often. Many patients feel lightheaded and pass out when they first get up after surgery. This dizziness will pass as your body fluids are replaced and the effects of the anesthesia are gone.”

Of course, there are many nonclinical examples of embarrassing moments. Here are three that are very common, with suggestions for handling them:

• You address a patient by the wrong name: Admit your mistake. For example: “I’m sorry, Mrs. Smith. This is the reason we depend on the name bands.”
• You address a doctor by his or her competitor’s name: Admit your mistake. For example: “I’m sorry, Dr. Bailey. I was just speaking to Dr. Carey on the phone and had his name in my head.”
• You bend down to empty a foley bag and your pants rip: Know where you can go to get some alternative clothing. A common solution may be getting scrub pants in the operating room.

Embarrassing moments are common in health care. Providing a clinical response is the best way to handle situations related to bodily functions. Being honest and maintaining a professional attitude will help in nonclinical situations. Learn from each situation. Remember, you’re only human.

Kathleen D. Pagana, Ph.D., RN, is a keynote speaker and bestselling author. She recently wrote The Nurse’s Etiquette Advantage: How Professional Etiquette Can Advance Your Nursing Career. She is also the coauthor of Mosby’s Diagnostic and Laboratory Reference and Mosby’s Manual of Diagnostic and Laboratory Tests. These books have sold more than one million copies and have five language translations. Please visit Kathleen’s Website at kathleenpagana.com.