AACN News—August 2000—Opinions

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Vol. 17, No. 8, AUGUST 2000

President's Note: Make Waves: Be a Courageous Messenger

One of the everyday acts of courage is to be not only a truth-teller, but also a courageous messenger. To be truly effective critical care nurses and to create workplaces that support our optimal contribution to care that is driven by the needs of patients and their families, we must be able to speak the truth in such a way that it is heard and acted upon.

During my travels on behalf of AACN, many of you have told me that, though you want to be courageous messengers, you fear the result will be a CTE (career terminating event). Having been a little too close to a CTE a couple of times in my career, I have learned that being an effective messenger of hard realities means more than “telling it like it is.” The fear of losing credibility, being seen as a troublemaker, damaging relationships and even losing our jobs may be real, if we tell the truth in a reactive or finger-pointing way.

We have multiple opportunities every day to speak up about troublesome issues and positively influence the thinking, feelings and behaviors of others. However, because we are concerned about repercussions, we often hesitate. In fact, in The Courageous Messenger: How to Successfully Speak Up At Work, Ryan, Oestreich and Orr1 report on a survey showing that 70% of us fear repercussions, and many more believe that speaking up would not make a difference anyway.

Of course, we all are frustrated when our feedback fails to produce change. However, if we do not communicate our concerns, the chance of change is even less. The fact is that multiple messages from more than one person may be necessary to effect change.

To successfully influence our practice environments, we must become skilled messengers, who can communicate in a manner in which the receiver not only hears, but also understands what they are hearing. Successful messengers achieve the desired outcomes, or at least a satisfying solution, because they communicate clearly. To successfully speak up about tough issues, difficult subjects, sensitive topics or just the ugly realities of our workplace, we must be clear, direct, sincere and constructive.

As skilled messengers, we can practice integrity and live in sync with our personal values and principles, while easing stress and increasing satisfaction in our work.
Think about some of the everyday issues you could speak up about:
• Coworkers who don’t do their fair share

• Inadequate staffing that impedes the level of care needed by the patient
• Cutbacks in support services, which impact efficiency
• Physicians who communicate disrespectfully
• Coworkers who complain about others behind their backs
• A nurse who over-medicates a patient to avoid having to talk to him or her all night
• A manager who punishes staff when a mistake is made
• Patients who are not given sufficient pain medication
• A nurse who bullies coworkers

You undoubtedly can add to this list. Troublesome issues such as these eat at our souls in nursing and must be addressed when encountered. Will doing so make a difference? Will it be worth the risk? Given their impact on the quality of care and retention of staff, we have an obligation not only to speak up, but also to speak up in such a way that our concerns are heard and acted on in a proactive manner. Even if these issues persist, we will have the sense of having done the “right thing” and the courage to continue to address difficult issues.

Following is some advice on effective messaging of difficult truths:

• First, reflect on your decision to speak up, which will help you more effectively express your thoughts and avoid reactive messaging, which can lead to a CTE.
• Know what your true message is. You must be able to clearly articulate situations or issues; their impact; and your request or suggestion. This will also help you explore
your true motivation and avoid messaging out of anger and retribution.
• Think and plan how to communicate your message. Then, consider what to say and how to express yourself in an honest way that the receiver can understand. Skilled
messengers often rehearse their messages.
• Use clear, assertive communication that is not belligerent, abrasive or whiney. Be conscious of effective interpersonal communication skills. Use these to communicate not
only your perspective, but also your respect for the individual with whom you are communicating.
• Recognize that personal values shape your message, which will not only make speaking up easier, but will also motivate you to act. This helps the receiver in
understanding the intent behind the message. The ability to send a message with the intent to be helpful to an individual, unit or organization is key to having that message
received in the manner in which it was intended.

• Several conversations may be necessary to fully express your thoughts and ideas and to have adequate dialogue with the receiver, so that he or she understands what
you are saying.
• To be effective, you must invest in learning and development. Find a coach, someone you consider to be an effective messenger. Start small by giving straightforward
feedback to a coworker, before you tackle the most abrasive person in your institution.

While these suggestions address effective communication skills, what about the fear of repercussions? Are you afraid that you will get the most difficult assignments, that no one will help you, that people will talk about you behind your back, that physicians will demand that you not be assigned their patients, or that you will be scheduled to work every holiday for the next 10 years?

Fear is a powerful barrier to overcome. In every instance, you will need to assess the risks in speaking up. However, I challenge you to consider the consequences of not speaking up–the negative effect silence can have on us, our coworkers, our patients and even the success of our organizations. The risks of remaining silent far outweigh the risks of speaking up.

In last month’s column, I asked: What will your act of courage be? Being a courageous messenger is one that is needed to achieve AACN’s vision. Finding this courage is an “inside job,” achieved only by directly facing your fears and the other factors that keep you silent. Once you face these fears and develop your skills to effectively communicate difficult issues, you can “make waves” and be a courageous messenger and a highly influential critical care nurse.

Ryan KD, Oestreich DK, Orr GA. The Courageous Messenger: How to Successfully Speak Up at Work. San Francisco, Calif: Jossey-Bass Incorporated; 1996.

My Turn: Bedside Nurses Are an Endangered Species

By Laura Padron, RN, BSN

Bedside nurses are becoming an endangered species. Recognizing that “endangered,” unlike “extinct,” means there is still time to reverse the trend. How can we effectively capitalize on this time?

As a bedside nurse for 21 years, I believe we must fundamentally support and honor nurses who practice within a three-foot radius of the patient. They are the lifeblood and the backbone of the hospital.

Yet, 60% of nurses today choose not to work at the bedside in hospitals, where we care for our sickest and most vulnerable patients. As a result, staffing vacancies are astoundingly high. Is it because of the demanding workload, work hours, patient acuities, staffing ratios, compensation or the fact that more appealing positions are offered in many different arenas?

Because people are living longer and medical technologies are increasingly advanced, patient acuities are higher. Thus, we are not in a position to keep losing seasoned bedside nurses.

It has been said that those who do not learn from history are bound to repeat it, which seems to have proven true for nursing. Twenty years ago we faced a similar staffing shortage. During that time, nurses were considered a commodity and their value increased. Hospitals attracted bedside nurses by offering weekend and night incentive programs, continuing education and shared governance management. Scheduling flexibility, allowing input regarding their practice and expressions of appreciation were important to the bedside nurse. As positions were filled, units no longer battled daily staffing issues. Instead, their efforts were exerted into obtaining new benchmarks in delivering competent and compassionate care.

Healthcare is expensive, and managed care has hit us hard. As current and future patients, healthcare providers, educators, administrators and government legislators must be willing to discuss and commit to supporting safe bedside care by jointly identifying problems and solutions. If we build it, the bedside nurse will not only come, but will also stay.

Laura Padron is a bedside nurse in the cardiovascular-surgical ICU at Rockford Memorial Hospital, Rockford, Ill. She is a member and past president of the Northern Illinois Chapter of AACN. She is also a member of the AACN Chapter Leadership Development Work Group.

My Turn: Family Presence Keeps Human Qualities in Focus

By Teresa T. Solberg, RN, MSN, CCRN

It was the Fourth of July, when a man carrying a limp child entered our Emergency Department and yelled, “Help me, someone help me!” Taking the lifeless child from his arms, I laid her on a gurney. The tire tracks across her chest revealed more than I wanted to know.

A code blue was called and the father was taken to the waiting room. Several minutes into the code, the physician in charge asked me to update the family. As I entered the waiting room, a young woman grabbed my arm and begged, “Take me to my daughter! I must see her! I must be with her! She needs me!” I explained that, although we were doing all that we could do, her daughter had not yet responded to treatment. I’m sure the mother did not hear or comprehend what I was saying. Another family member led the mother to a chair, as I explained that I needed to return to the child’s room. I promised to keep them updated.

When I returned to the room, the child was intubated and CPR was being performed. No spontaneous pulse or respirations were present. I told the physician about the mother’s request. However, before he could respond, another staff member interjected: “That can’t be done. We never have allowed family in the room while we are in the middle of a code.” I repeated the mother’s request, and the physician said, “Let her come in.”

As I led the mother to her daughter’s room, I explained about the tubes, chest compressions and team of people in the room trying to save her daughter. She entered the room and calmly went to her daughter’s side, taking a seat next to the gurney. She stroked her daughter’s hand and face and talked to her. She was not in the way. She did not prevent us from carrying out our duties. Instead, she was a constant reminder that the person we were trying so hard to save was a precious human being, who was loved and who could not be separated from her family.

Allowing a family member to be present while her loved one was being coded was a new experience for everyone. Very little has been written in the nursing literature about family being present during a code. Our first instinct is to decline, because we think the family member would become hysterical and impede our work. However, perhaps the hysteria comes from being excluded and left in a waiting room wondering and not knowing. I know if my child, husband or parent were involved, no one could keep me away.

Teresa T. Solberg is an assistant professor of nursing at the University of South Dakota, Yankton, S.D., and a PRN staff nurse in the ICU at Alvera Sacred Heart Hospital, also in Yankton.


Be Part of the Solution, Not Part of the Problem
After reading the article and AACN Online Poll results on mandatory overtime (AACN News, June 2000), I believe that AACN and ANA are attempting to misrepresent the opinion of the nurses polled for some agenda. Although some employers depend on overtime to staff their units, mandatory overtime is rare and unexpected in most cases.

Professional nurses have a responsibility to meet the needs of patients, not satisfy their personal sense of fairness or comfort. At the same time, the nursing shortage provides us many options to work for responsible employers who recognize that professional staff will not tolerate being exploited—nor take a coercive, adversarial stand when patient care is at stake.

Nurses can negotiate the workplace better than our ANA colleagues believe we can. Nurses are not stupid or helpless in these matters. Misrepresentation will not persuade us to take up arms against organizations that are struggling to provide outstanding care in the face of irrational political, economic and regulatory pressures.

Please be part of the solution, not part of the problem.

J. B. Czerwinski, RN, MS
Milwaukee, Wis.

Continue to Address Bedside Nursing Issues
I was pleased to see the lead story on mandatory overtime in the June 2000 issue of AACN News.

Several months ago, after becoming disillusioned with nursing administrators, educators and nursing organizations, I decided that I would not renew my CCRN certification. Because many nursing leaders in state and local organizations are also our nursing administrators within the hospital setting, I had developed the attitude that, instead of a professional association, I needed a labor union to represent bedside nursing concerns.

At my place of employment, we have an on-call system that was instituted a year ago as a “temporary” measure until additional staff could be hired. The number of on-call hours being worked would justify the hiring of an additional six or seven nurses. The nurses are fatigued and stressed. Personal and family lives are suffering. Patient and staffing ratios are also an exploding issue.

Because of the relentless pace and demands of the job, we are losing experienced staff at a rapid pace. This is a crisis for patients and for nursing.

I am glad to see bedside nursing labor issues under discussion by AACN, and urge you to continue to promote legislative and regulatory initiatives that address nursing work force issues, patient-nurse ratios and a safe practice environment.

Name withheld by request
RN in Florida

Most Overtime Is Voluntary
As a nursing manager of three ICUs, the nursing shortage is making staffing increasingly difficult on a daily basis. I agree with AACN’s position that mandatory overtime is not the solution. However, at the majority of institutions, including ours, overtime is voluntary, not mandatory.

I would be interested in AACN’s position on voluntary overtime beyond 12 hours. In some cases, nurses preschedule 16-hour shifts in order to work fewer days. Is this considered an acceptable alternative?

Unfortunately, the staffing dilemma will be with us for some time. Creative alternatives that do not compromise patient safety will be a challenge for us all.

Steven Seeley, RN
Fort Lauderdale, Fla.

Advocate Openly for Nursing
I recently read an online interview with Anne Wojner, immediate past president of AACN. In the interview, she addressed the need to make nursing more visible and the vital role nurses have in diagnosing patients, because nurses are the ones whose expertise is communicated to physicians.

I agree with this position 100% and commend Anne Wojner for her honesty and courage in publicly stating what most critical care nurses already know. There is support for speaking the truth, regardless of whether the statements are controversial, and I encourage you to continue to do so.

AACN is well-respected and has a voice in the health professions that will be acknowledged and recognized. I urge AACN to use this power to support nurses in their pursuit of true patient-focused healthcare systems and institutions.

For the past several years, nursing associations have taken the more comfortable, “politically correct” position on issues affecting patient care and nursing. Strong leaders willing to take risks are imperative for effective advocacy of nurses in the political healthcare environment today. The front lines of nursing are ready for significant change.

AACN’s involvement in outspoken nurse advocacy and activism will demonstrate its commitment to making the healthcare system safer for all. Thank you for your commitment and service to our profession.

Steven S. Lee, RN
Austin, Texas

Nurses Just Want to be Respected
To Anne Wojner, regarding “President’s Note,” AACN News, June 2000: I applaud the insights you share about critical care nurses who have been practicing for many years.

Advanced technology, mandatory overtime, unrealistic patient-to-nurse ratios and unresponsive management all contribute to dissatisfaction among many nurses. Management continues to spend money to recruit instead of retain nurses. Input from nurses is rarely listened to, and, as you said, hospitals could save millions if they would just listen to their nurses.

Unfortunately, my experience is that the majority of bedside nurses in my age group are so dissatisfied that they are actively seeking alternative forms of employment. I am one of these nurses. Last year, I returned to graduate school to obtain my degree in library and information science and plan to be a medical librarian. What an eye opener! Set hours, no heavy patients to lift, no beds to push by myself, no back pain and a congenial environment.

Like you, I love nursing. However, “the look in patients’ and families’ eyes” is not enough to combat the abominable way nurses are treated today. Your description of what a patient most wants from the healthcare system could easily apply to what nurses’ want. They especially want to be respected.

Cathy Pedraza, RN, BSN, CCRN
Austin, Texas

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