Final

Whistleblower

- Anyone who reports a worker to an outside agency - RaDonda Vaught was convicted of murder b/c giving wrong medicine. - In state of Maryland, nurses are considered managing nurses b/c we must delegate (when delegating it is considered management) and it is not protected under whistleblower act. Could lose job if you become a whistleblower.

Report sexual harassment

- Confront: Tell them to stop - Report: Chain of command and HR - Document: What was said or done, when and where, and what witnesses saw it - Support the victim

Preventing Shift Work Disorders

- Consistent schedule: Ask if we are required to change shifts. - Be proactive and promote healthy sleep patterns: Get at least 7 hours of sleep in dark room, no caffeine half way through the shift, get a meal break at the same time, and wear sunglasses on during daylight to save energy. - Good nutrition and exercise: Ask when is food available? Most facilities closed food after dinner.

Formal Mentoring Programs

- Mentors can provide the support needed to increase new nurses' clinical success, job satisfaction, and retention - New graduates need help with organizing their work; time management; communicating with other members of the health-care team, especially with physicians; and recognition of critical changes in their patients. - Even experienced nurses, when newly hired or transferred to different positions, need to learn the culture of the new organization, their role on the new team, and new skills - A mentor-mentee relationship may be formal, as in the previous example, or it may develop informally through time. - Formal relationships usually include some training for the mentor and mentee, have specific objectives, and often have mentors assigned to mentees, whereas those in informal mentoring relationships usually choose each other - Either approach can be a valuable and rewarding experience for both mentor and mentee.

Types of practice concerns

- Negative impacts on patients and nurses - Dangerous staffing practice: Mandatory overtime, insufficient staffing ratios - Reporting questionable practice: Responsibility to act

Job Satisfaction and the Joy of Work: The Health-Care Team

- Nurses work with and interact with many different people in a day: patients, families, nursing assistants, many kinds of therapists, housekeeping and transport staff, social workers, and physicians, to name a few. - How well they all work together, whether cooperatively and collegially or in constant conflict, affects job satisfaction. - In a study of 3,675 nursing staff from five hospitals, Kalisch and colleagues (2010) found that higher levels of teamwork (trust, cohesiveness, mutual help and understanding, and leadership) and adequate staffing lead to greater job satisfaction.

Solutions to transition challenges

- One of the goals of leadership courses, immersion experiences, and clinical intensives in school is to prepare you to meet the expectations of your first employer. - You can also use independent study opportunities to further immerse yourself in the clinical world of patient care. If possible, these clinical placements should match your preferences for future employment. - Part-time or full-time employment in a healthcare setting is another way to prepare yourself for the realities of clinical practice. However, you need to be sure that this work does not interfere with your schoolwork and that you distinguish the work you might do as an LPN or certified nursing assistant (CNA) from the work you will do as an RN. If your instructors discourage you from doing this, it is probably because of these concerns.

Substance recognition

- Physical and Behaviors: Posture, Pupils, Odor, Diaphoresis, Dress, Gestures, Speech. Abusive - Report: Patients, Staff, Colleagues, Change in productivity - Unprofessional Conduct: Absenteeism, Excessive sick time, Tardiness, Elaborate excuses, Mysterious absences, Lack of Attention

Natural Disasters and Terrorism Threats

- The ANA provides nurses with valuable information on how they can better care for their patients, protect themselves, and prepare their hospitals and communities to respond to acts of bioterrorism and natural disasters - Nurses are often called upon when a disaster occurs. For example, many worked with the ANA to provide support for the victims of Hurricane Katrina. A nurse holding a newborn rescued from the severely damaged NYU Langone Medical Center became a symbol of the rescue efforts following the destruction caused by Super Storm Sandy (2012) in New York. - Disasters can be natural or man-made, either accidental or an act of terrorism. They may be natural or environmental (e.g., tornados, floods, hurricanes), biological (e.g., a flu pandemic), chemical (e.g., a chemical spill), radiological (e.g., a nuclear event) or explosive (e.g., a terrorist bombing) - Special health-related considerations during these disasters include attention to mental health needs of both the victims and the responders, addressing special needs populations, and the surges in patients coming to hospitals and clinics that can overwhelm their capacity.

Job Satisfaction and the Joy of Work: The Work Itself

- The ability to provide high-quality patient care is very important to most nurses. - In a study of 1,091 medical-surgical nurses, Amendolair (2012) found a positive relationship between perceived ability to express caring behaviors and job satisfaction. - Their ability to do so was related to the amount of time available to spend with patients.

Burnout

- The ultimate result of unmediated, unresolved job stress is burnout. - A useful definition of burnout is the "progressive deterioration in work and other performance resulting from increasing difficulties in coping with high and continuing levels of job-related stress and professional frustration" - Much of the burnout experienced by nurses has been attributed to the frustration that arises because care cannot be delivered in the ideal manner. - For those whose greatest satisfaction comes from caring for patients, anything that interferes with providing the highest-quality care causes work stress and feelings of failure. - People who expect to derive a sense of significance and meaning from their work enter their professions with high hopes and motivation and relate to their work as a calling. When they feel that they have failed, that their work is meaningless, that they make no difference in the world, they may start feeling helpless and hopeless and eventually burn out

Workplace Stress

- Workplace stress is related to a mismatch between an individual's perception of the demands being made and his or her ability to meet those demands. - An individual's stress threshold also depends on the individual's characteristics, experiences, and coping mechanisms and the circumstances of the event

Paths to advancement

-Continuing education and certification -Mentoring -Professional activities

Job of a preceptor

-Helps you with time management, communication, and recognizing changes in condition.

Stages of a nursing career

-Promise phase: Years 1-3, identify strength and building your knowledge. -Momentum phase: Years 3-6, become master and expert, and preceptor -Harvest phase: After year 6, Prime leadership phase.

1. Which of the following organizations supports nursing education? 1. NINR 2. NLN 3. AMA 4. ANA

1. Answer: 2 Rationales: 1. The National Institute of Nursing Research (NINR) primarily supports nursing research. 2. The National League for Nursing (NLN) supports nursing education. 3. The American Medical Association (AMA) supports the medical profession. 4. The American Nurses Association (ANA) supports advancement of the nursing profession.

Most employers have policies that encourage the reporting of behavior that may adversely affect the workplace environment, including but not limited to (ANA, 1994):

1. Endangering a patient's health or safety 2. Abusing one's authority 3. Violating laws, rules, regulations, or standards of professional ethics 4. Grossly wasting funds

Once ready, the action steps are to:

1. Have conversations with staff about what makes a bad day for them and what is needed to increase the number of good days. 2. Identify the main barriers (impediments) to experiencing joy in work in your organization. 3. Identify leaders at each level (unit to top administration) who are responsible for making the changes that will improve joy in work. 4. Select and use an improvement method to try out the changes identified: set an aim, select measures that would indicate if progress was being made, decide on the change to be made, and test it.

10. Stephanie Beals was a little nervous during her first week of work as a licensed nurse. Distracted by a lead nurse behind her, her hand slipped, and she was stuck by the needle she had just used. What is most important for Stephanie to do? 1. Disinfect the site of the needlestick. 2. Apologize to the patient, clean the site, and properly dispose of the needle. 3. Update her hepatitis B immunization. 4. Report the incident and obtain post exposure prophylaxis (PEP) within 2 hours.

10. Answer: 4 Rationales: 1. Disinfection of the site is insufficient. 2. These actions are also inadequate given the risks associated with a sharps injury. 3. Hepatitis B immunization is appropriate but not sufficient. 4. PEP (post-exposure prophylaxis) includes the necessary actions to be taken.

8. As a new graduate, what features should you look for in a TPP program? 1. Match with an experienced nurse mentor 2. Shortest transition time possible 3. Rapid movement to full assignment 4. Opportunities to network with peers

8. Answer: 1, 4 Rationales: 1. Being matched with an experienced nurse mentor is very valuable for the new graduate. 2. Transitions take time; there is no advantage to rushing through them. 3. Again, rushing through the transition has little advantage and may leave the new graduate unprepared for the full responsibility of a practicing nurse. 4. Opportunities to network with peers provide support and a chance to hear others' ideas for making a successful transition.

Not all violence occurs in hospitals. Social services employees are also vulnerable:

A social services coordinator regularly visited potentially violent clients at home and drove them to facilities for mental and physical evaluations. A mentally ill client with a history of violence stabbed her to death in front of his home. Again, OSHA cited her employer for failing to have a comprehensive violence prevention program or assisting employees who express concern about their safety

Threat: Terrorism

Biological Bombings Mass shootings

U.S. Health-Care System Challenges: Regulation and Legislation

The diverse interests of consumers, providers, insurance companies, government, and regulators also present challenges to those trying to redesign the current system to make it more cost-effective as well as more responsive to health-care consumers' needs.

Addiction:

There is non-disciplinary program under the Maryland nurse practice act. First offense: Report to MBON, and the person goes into voluntary rehab Second offense: Depending on the severity, consequences varies from limited access to nursing, suspension, or required testing for 6 months to 2 years.

Much of the responsibility for enhancing the workplace rests with the people who have the

authority and resources to encourage organization-wide improvements. - Nurses, however, have begun to take more responsibility for identifying workplace issues and advocating improvement.

Multi-generational workforce:

recognize the difference between each generation, value each generation, and support each other

Growth and innovation

s Encouraging staff growth and creativity -Continuous learning -Opportunities for improvement s Encouraging new ideas and critical thinking s Rewarding professional growth: Staff recognition s Staff recognition programs

Following are some steps that can be implemented in the workplace to better prepare for these threats:

■ Know the evacuation procedures and routes for your facility. ■ Monitor your patient caseload for any unusual disease patterns and notify appropriate authorities as needed. ■ Know the backup systems available for communication and staffing in the event of emergencies. Become familiar with the disaster policies in your facility.

Job Satisfaction and the Joy of Work: The Employing Organization

- An organization that supports its most valuable asset, its staff members, is one that keeps its experienced nurses. - Effective nurse leaders are key to accomplishing the goal of a healthy work environment - Higher pay, better benefits, and the means to turn sources of dissatisfaction into actual improvements in the work environment (one could call this empowerment) are elements contributing to the retention of experienced nurses . - A study of the effects of six proposed "antidotes" to burnout, related to workload, autonomy, reward, communication, respect and civility, and constructive values, in 289 hospital nurses experiencing restructuring or budget cuts found that high workload and low reward, control, and value congruence were related to greater distress - Burnout not only affects productivity but also the quality of the care provided.

National League for Nursing (NLN)

- Another large nursing organization in the United States is the NLN, the "Voice of Nursing Education." - Unlike ANA membership, NLN membership is open to other health professionals and interested consumers, who number 40,000 altogether. More than 1,200 nursing schools and health-care agencies are members of the NLN - The NLN was formed to promote excellence in nursing education in order to build a strong and diverse nursing workforce, thereby improving health care. - The NLN participates in test services, research, and publication. It also lobbies actively for nursing issues and works cooperatively with the ANA and other nursing organizations on health-care issues. To do such things more effectively, the ANA, NLN, American Association of Colleges of Nursing, and American Organization of Nurse Executives have formed a coalition called the Tri-Council for the purpose of dealing with issues that are important to all nurses. - The NLN formed a separate accrediting agency, the National League for Nursing Accrediting Agency (NLNAC), which is now called the Accreditation Commission for Education in Nursing (ACEN). The ACEN provides for the specialized accreditation of nursing education schools and programs, both postsecondary and higher degree (master's degree, baccalaureate degree, associate degree, diploma, and practical nursing programs). The ACEN has entered into a partnership with the Organization for Associate Degree Nursing (OADN) to increase support for associate degree programs and their students

Why Join Your National Organization?

- As the ANA works on the goal of preparing nurses for the demands of the 21st century, nurses need to work together in their efforts to identify and promote their unique, autonomous role within the health-care system. - Membership in the ANA offers benefits such as informative publications, group life and health insurance, access to malpractice insurance, and continuing education courses. - As the primary voice of nursing in the United States, the ANA lobbies legislators to influence the passage of laws that affect the practice of nursing and the safety of consumers. - The power of the ANA was apparent when nurses lobbied against the American Medical Association's (AMA) proposal to create a new category of health-care worker, the registered care technician, as an answer to the nursing shortage of the 1980s. The registered care technician category was never established despite the AMA's vigorous support. - The ANA frequently publishes position statements outlining the organization's position on particular topics important to the health and welfare of the public or the nurse, which can be accessed on the ANA Web site (www.nursingworld.org/positionstatements). Likewise, the CNA publishes position statements on such issues as education, ethics, public health policy, leadership, practice, primary health care, protection of the public, and research. - The ANA also offers certification in various specialty areas through its subsidiary, the American Nurses Credentialing Center (ANCC) (www.nursecredentialing.org). Certification is a formal but voluntary process by which the professional nurse demonstrates knowledge of and expertise in a specific area of practice. It is a way to establish the nurse's expertise beyond the basic requirements for licensure and is an important part of peer recognition for nurses. In many facilities, certification entitles the nurse to salary increases and position advancement. Some specialty nursing organizations also have certification programs.

Organization for Associate Degree Nursing (OADN)

- Associate degree nursing programs prepare the largest number of new graduates for RN licensure. Many of these individuals would never have had the opportunity to become RNs without the access afforded by the community college system. - The move to begin a national organization to address associate degree nursing issues began in 1986. - The organization identified two major goals: to maintain eligibility for licensure for associate degree graduates and to interact with other nursing organizations. - Today, the mission of the OADN is to "provide visionary leadership in nursing education to improve the health and wellbeing of our communities". The OADN is an organizational affiliate of the ANA. - The OADN notes U.S. Department of Health and Human Services data that 57% of U.S. nurses begin their career with an associate degree. Many continue their education to earn the BSN degree. The OADN supports the development of RN to BS degree programs at community colleges, which are currently available only in some parts of the United States.

Bullying:

- Consistent pattern of inappropriate abusive/aggressive behavior toward another colleague that is designed to intimidate, diminish, devalue, and disrespect. - Examples: Unreasonable criticism, rumors or gossip spreading, withholding information intentionally. - Characteristic of a bullying culture: Lack of teamwork, lack of collegial respect, cliques - How to respectfully address incivility? Cognitive rehearsal (a prepared response). Be assertive.

Discrimination:

- Fifth and Fourteenth Amendments to the Constitution - Equal Employment Opportunity Commission (EEOC) - Civil Rights Act - Discrimination protection only affects employers with 15 or more employees

Transition Challenges:

- Gap between nursing education and nursing practice - Employer expectations: Provide safe and effective care, prioritize, time management, organize, teach disease process to patients. - Expected behaviors—school versus workplace - Pace—Not prepared for long hours or so many patients at one time

Transgender Issues

- Highest levels of sexual harassment - Inclusive patient education materials - Preferred name and pronouns - Using terms such as partner - Displaying signs of LGBTQ acceptance - Providing LGBTQ training for all staff

U.S. Health-Care System Challenges: Societal Demographics and Diversity

- Increased numbers of older adults, longer life expectancy, a more ethnically and racially diverse population, and recognition of serious inequities in the U.S. health system present challenges that must be met to improve access to care for all members of society. - Older adults and ethnic minorities include many at-risk or vulnerable individuals who suffer disadvantages in access to care, payment for care, and quality of care.

Current trends in HC

- Infections - Opioid crisis - Adverse drug events - Gun violence - Care LGBTQ - Substance use disorders - Rise in autism and diabetes - Increasing use of electronic health-care records and data, outpatient surgery, alternative and complementary modalities - Decreasing number of hospital admissions, health disparities - Use of integrated health-care systems as well as acute and long-term care

Job Satisfaction and the Joy of Work

- Job satisfaction encompasses the feelings or attitudes, positive or negative, that an individual has about his or her work. - The nature of the work, people with whom one works, and the organization in which this all takes place are usually the focus of job satisfaction studies. - Factors found to be important in nurses' satisfaction with their work are the work itself, the health-care team, and the employing organization.

U.S. Health-Care System Challenges: Addressing the Problem

- Nearly 52 million Americans, including 9 million children, had no health-care insurance. Even worse, two-thirds of the working-age population had a health-care-related financial problem such as unpaid medical bills, being underinsured, or being uninsured. - The quality of the care provided was a second major concern. - Hospital-acquired, drug-resistant infections have become a major problem, having increased a hundredfold during the last 10 years or so. - Additional concerns included fragmented, impersonal care; failure to consider the whole person when treating a problem; and continuation of an illness focus rather than prevention focus. Furthermore, the United States is facing what Buchan called a "demographic double whammy" of an aging population that will need more health care and, at the same time, an aging workforce. - In Canada, a debate regarding privatization versus public funding of health care continues. Health care is still illness- and disease-focused as in the United States. Although there is interest in complementary and alternative treatments, they have not been integrated into general care. Disparities in the care of members of minority groups threaten to increase if not addressed more effectively. - Global interconnectedness has brought new concerns about how quickly and easily infectious diseases can cross national borders. Human immunodeficiency virus (HIV), severe acute respiratory syndrome, Ebola, Chikungunya, and the annual waves of influenza that cross the globe are just a few reminders of how vulnerable populations remain. These risks create an increased need for health-care provider surveillance across continents.

Back Injuries

- Occupation-related back injuries affect more than 75% of nurses during the course of their careers. - Every year, 12% of nurses leave the profession because of back injury, and 52% complain of chronic back pain. - The problem with lifting a patient is not just one of overcoming heavy weight but also of overcoming improper lifting technique. - Size, shape, and deformities of the patient as well as the patient's balance, combativeness, uncooperativeness, and contractures must be considered. - Any unexpected movement or resistance from the patient can throw the nurse off balance and result in a back injury. - Limited space, equipment, beds, chairs, and commodes also contribute to back injury risk - The Back Facts: A training workbook to prevent back injuries in nursing homes and the OSHA guidelines for nursing homes are comprehensive resources. - Your responsibility is to learn safe patient handling in school and later at work. - Your employer's responsibility is to provide safe patient handling education and to provide assistive patient handling equipment that can improve the quality care of patients, improving patients' comfort, dignity, and safety during transfers.

Nursing in the Future

- One issue to address is image-related challenges. Too often, members of the public and colleagues in other professions think of nurses in only an assistive role, as "perpetual servants of heroic physicians" based on impressions from the media. This limited view ignores our unique perspective that encompasses the whole person within his or her family and community. - Michael Bleich (2012, p. 184) says we need to "publicly give voice to the value of this perspective," particularly during this time of debate regarding the shape of our health-care system in the future. If we do not participate in the debate, we "will be left to react to models that may stymie our capacity to influence health" and the future of the nursing profession. - Another concern is external appearance. - The following are some additional suggestions to improve nursing's image: ■ Always introduce yourself as an RN. ■ Define professional appearance appropriate to your workplace and enforce it. ■ Define professional behavior and enforce it. ■ Take every opportunity to speak to the public about nursing. ■ Document what nurses do and how important they are. - It is important that more members of minority groups be brought into nursing so that nursing better reflects the increasing diversity of the population. - Collaboration with colleagues in other health professions is also vital to improving health care. - Patients and their families, too, are concerned and personally affected by the quality of care provided. All these groups together would have a strong voice in health-care reform. - Given their number and unique position within health care, nurses should be full partners in health-care reform - Issues on which nurses should have a say include patient safety, quality of care, reducing medical errors, health promotion, and prevention. The urgency of making our voices heard is undisputable. - Hassmiller (2011) wrote that "right now is the right time to tackle the difficult and essential work of bringing nursing perspectives, knowledge, and voices into health policy decision making" (p. 308). This is still true today.

Nursing Care Delivery

- Only an RN will assess, plan, and evaluate a patient's or client's nursing care needs. - Consistent with the preceding sentence, the individual RN has the autonomy to delegate (or not delegate) those aspects of nursing care the nurse determines appropriate based on the patient assessment. - When a nurse is floated to a unit or area where he or she receives an assignment that is considered unsafe to perform independently, the RN has the right and obligation to request and receive a modified assignment, which reflects the RN's level of competence. - The ANA, the American Organization of Nurse Executives (AONE), and the state Labor Employee Relations Commission (LERC) recognize that changes in the health-care delivery system have occurred and will continue to occur while emphasizing the common goal to provide safe, quality patient care. The parties also recognize that RNs have a right and responsibility to participate in decisions affecting the delivery of nursing care and related terms and conditions of employment. - All parties have a mutual interest in developing systems that will provide quality care on a cost-efficient basis without jeopardizing patient outcomes. Thus, commitment to measuring the impact of staffing and assignments to patient outcomes is a shared commitment of all professional nurses irrespective of organizational structure.

Orientation Programs

- Orientation programs for new graduates typically offer classroom, online, and on-unit training. - Programs that are tailored to the individual's learning needs and provide consistent preceptors or mentors are usually the most effective. Traditional orientation programs are shorter in length than are internship or residency programs. - Ohio Health, a not-for-profit health-care system, developed a simulation-enhanced orientation program divided into three distinct stages: JumpStart week, Assessments, and Unit-based orientation. - JumpStart week included a series of skill stations (such as blood administration) and simulation scenarios. The new graduates worked in groups of five to seven nurses. Two participated in each scenario while the others watched via live video followed by debriefing. During the Assessments phase, orientees were identified as "green" if they were ready to function as staff, "yellow" if they needed more time to learn, and "red" if they were assessed as unsafe or below standard. Assessments included the assessment of procedural skills, critical thinking, medication administration, documentation, prioritization of care, telemetry, time management, and safety. - A systematic review of these TPP programs by Edwards and colleagues (2015) indicated that they had beneficial effects for both the new nurse and the employer, including higher confidence and competence, lower stress and anxiety, and job satisfaction. They suggest that it is the focus on the new graduate rather than the specific approach that is the source of the program's success. If they are correct, then it is more important to seek a first position that offers a well-developed TPP than it is to find a particular type of program. - In some cases, the orientation program may be cut short and the new nurse required to function on his or her own very quickly. One way to minimize initial work stress is to ask questions about the orientation program before accepting a position: How long will it be? With whom will I be working? When will I be on my own? What happens if at the end of the orientation I still need more assistance?

Assignment issues

- Practicing Out of Scope - Abandoning or neglecting a client that needs nursing care and without making reasonable arrangements - Failure to Supervisor - Decision Making Guidelines

Facilitate transitions

- Professional Identity: Accepting challenges, letting knowledge grow - Organization: Learn roles - Energy: Conserve energy, or best ways to utilize energy - Communicate: Ask questions - Feedback: Without feedback, there is no growth - Support - Time

What to do if you are given an assignment that you believe is unsafe for you and the patient?

- Report through the chain of command. - Notify them with reason why its not safe (safety of the patient), should have a response within 4 hours, protest if needed. - Document everything you say and do, including the reasons you made the decision . - Chain of command includes: Charge Nurse, nurse manager, and house supervisor/designee

Assignment Despite Objection (ADO)/Documentation of Practice Situation (DOPS)

- Staff nurses today often face untenable assignments that need to be documented as such. Critical, clinical judgment should be utilized when evaluating the appropriateness of an assignment. - Refusal to accept an assignment without appropriate discussion within the chain of command can be defined as insubordinate behavior. Each RN should become familiar with organizational policies, procedures, and documentation regarding refusal to accept an unsafe assignment. - The ANA has recently adopted a position statement and model ADO form available for use by state nurses' associations (SNA) members. - In the event an RN determines in his or her professional opinion that he or she has been given an assignment that does not allow for appropriate patient care, he or she shall notify the supervisor or designee, who shall review the RN's concerns. - If these concerns cannot be resolved by telephone, the supervisor or designee, except in instances of compelling business reasons that preclude him or her from doing so, will then come to the unit within 4 hours of being contacted by the nurse to assess the staffing. Such assessment shall be documented, with a copy given to the nurse. Nothing herein shall prohibit an RN from completing and submitting a protest of assignment form.

American Nurses Association (ANA)

- The ANA Web site (www.nursingworld.org) provides up-to-date information related to workplace advocacy and safety for all nurses. - In 1999, the ANA established its Commission on Workplace Advocacy, which addresses issues such as collective bargaining, workplace violence, mandatory overtime, staffing ratios, conflict management, delegation, ethical issues, compensation, needlestick safety, latex allergies, pollution prevention, and ergonomics.

American Nurses Association (ANA):

- The ANA's mission is "Nurses advancing our profession to improve health for all" - The ANA advances the profession by "fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health-care issues that affect nurses and the public" The ANA's Strategic Goals for 2017 to 2020 are: ■ RN profession-wide engagement: through increasing direct relationships with all RNs, increasing the number and level of engagement of nurses ■ Nurse-focused innovation: encourage RN-focused innovations and best practices to improve health care ■ Nurse-to-consumer relationships: increase consumers' awareness of the importance of nurses.

Disabled Employees

- The Americans With Disabilities Act, enacted in 1990, makes it unlawful to discriminate against a qualified individual with a disability. - Employers are required to provide reasonable accommodations for the disabled person. - A reasonable accommodation is a modification or adjustment to the job, work environment, work schedule, or work procedures that enables a qualified person with a disability to perform the job. - Both you and your employer may seek information from the Equal Employment Opportunity Commission (EEOC) for information

Centers for Disease Control and Prevention (CDC)

- The CDC partners with other agencies to investigate health problems, conduct research, implement prevention strategies, and promote safe and healthy environments. - The CDC publishes continuous updates of recommendations for the prevention of HIV transmission in the workplace and universal precautions related to blood-borne pathogens and other infectious diseases. -The CDC also targets public health emergency preparedness and response related to biological and chemical agents and threats

10. Health-care reform encompasses many issues and concerns. Which of the following is probably the most controversial goal? 1. Requiring everyone to have some form of health insurance 2. Developing school-based health-care centers 3. Eliminating preexisting condition rules in insurance coverage 4. Eliminating lifetime limits to insurance coverage

10. Answer: 1 Rationales: 1. Many believe that people have a right to forego insurance if they wish. 2. School-based centers themselves are not highly controversial, but some of the services they might offer could be. 3. There is considerable support for eliminating the preexisting condition clause. 4. There is also support for eliminating lifetime limits on insurance.

10. Professional careers typically go through several phases. Which of the following would be the final phase of a successful career? 1. Promise phase 2. Harvest phase 3. Transition phase 4. Momentum phase

10. Answer: 2 Rationales: 1. The Promise phase is an early phase that follows transitions to practicing nurse. 2. The Harvest phase is the time when you reach your prime, usually the final phase of your career. 3. Transition (from student to practicing nurse) is the first phase. 4. The Momentum phase is usually the middle phase of your career.

10. A colleague tells you, "I'm so burned out, I think it's time for me to resign." What can you tell your colleague? 1. "You probably need a break from work. Why don't you ask for a 6-month leave of absence?" 2. "Why don't you apply for a position at our rival hospital?" 3. "Tell me how you take care of yourself and what you like about your work." 4. "We're all burned out. Welcome to the club."

10. Answer: 3 Rationales: 1. Although time away from work may help address fatigue, it is more likely to be an escape from the causes of burnout instead of a solution to it. 2. It is likely that your colleague will encounter the same concerns at the next hospital and will not have learned anything about managing stress or preventing burnout. 3. These are good opening questions to lead into learning how to manage stress and burnout. 4. Although it may help to know others have the same problem, it does not solve the problem.

2. What is an important contribution of the nursing specialty organizations? 1. Setting standards for specialty practice 2. Improving nursing's image on television 3. Supporting the associate's degree in nursing education 4. Providing collective bargaining agreements

2. Answer: 1 Rationales: 1. Nursing specialty organizations support the interests of a defined practice area or special interest group. 2. They may be concerned about nursing's image but are more focused on the specialty or special interest group that defines their purpose. 3. Specialty organizations do not focus on basic preparation. 4. Collective bargaining agreements are generally provided by a union or state nurses association.

2. Factors found to increase nurses' joy at work include: Select all that apply. 1. Ability to provide quality care 2. Consistently high workload 3. A pattern of continuous conflict and disagreement 4. Civility and respect

2. Answer: 1, 4 Rationales: 1. One of nurses' greatest sources of satisfaction derived from their work is providing high quality care. 2. High workloads, especially insufficient numbers of RNs, have been shown to reduce the quality of care and even increase patient mortality. 3. Working in an environment where conflict is virtually continuous is a source of stress for most staff. 4. On the other hand, showing civility and respect to one another creates an environment in which most nurses can thrive.

2. In the U.S. health-care system, who is the real "customer"? That is, who actually pays most of the health-care bill? 1. The U.S. government 2. The head of the household 3. Government entities and employers 4. Employees and their families

2. Answer: 3 Rationales: 1. The U.S. government pays a large portion of the health-care bill but not all of it. 2. The head of household may contribute to the cost of health care, but most do not pay the majority of the bill. 3. Government entities (state and federal) and employers together pay for most of the cost of health care in the United States. 4. Employees and their families contribute but do not pay for most of the cost of health care.

Major Provisions of the Affordable Care Act 2010-2015

2010 Young adults can be covered by parents' health insurance to age 26 instead of 19. Insurers will eventually be prohibited from denying coverage for preexisting conditions. In the meantime, the government will provide coverage. 2011 Insurers are required to spend 80% of their premiums on patient care or reimburse policyholders for the excess. Reimbursement for Medicare Advantage plans (HMOs) is frozen at 2010 rates. 2012 Hospitals with high readmission rates will be penalized by Medicare. States are expected to submit plans for insurance exchanges. 2013 Tax increases on medical devices and for Medicare on high-income wage earners. State to begin enrolling people through their insurance exchanges. 2014 State health exchanges up and running. Preexisting condition rule effective. Medicaid expanded to those earning 133% of poverty-level wage. Businesses with more than 50 employees must provide health insurance. Uninsured individuals will pay increased taxes. 2015 Added tax on so-called "Cadillac" insurance plans offered by employers.

3. Enhancing the quality of work life can be achieved by: 1. Encouraging critical thinking and new ideas 2. Discouraging a working relationship with one's peers 3. Being negative 4. Endangering a client's health or safety

3. Answer: 1 Rationales: 1. Opportunities to express ideas and make suggestions are empowering. 2. Discouraging the development of working relationships creates isolation and a sense of powerlessness. 3. Negativity, especially if it is frequent, can create an atmosphere of powerlessness, inadequacy, and hopelessness. 4. Endangering a client's health or safety is not an acceptable strategy.

3. Benefits of membership in the ANA include all but which one of the following? 1. Advocacy for nurses' rights 2. Provision of lower-cost health insurance 3. Work toward a safer workplace 4. Improvement of patient safety

3. Answer: 2 Rationales: 1. The American Nurses Association (ANA) does advocate for nurses. 2. The ANA does not provide health insurance. 3. The ANA has put considerable effort into making the workplace safer. 4. Improvement of patient safety is an additional concern of the ANA

3. In the United States, health-care insurance can best be described as 1. Universal 2. Available to all 3. Free 4. Expensive

3. Answer: 4 Rationales: 1. Health-care insurance is not universally available in the United States. 2. Likewise, it is not available to everyone. 3. Neither health care nor health-care insurance is free in the United States. 4. Health-care insurance in the United States is relatively expensive.

4. Which of the following best describes the nurse of today? 1. Assistant to the physician 2. Member of the largest health-care profession 3. Member of the most powerful lobby group in health care 4. Woman in white

4. Answer: 2 Rationales: 1. Nurses today have many independent functions. 2. Nurses constitute the largest health-care profession by numbers. 3. Nurses are not the most powerful lobbying group in health care but have considerable potential to influence legislation. 4. Not all nurses are women; not all wear white.

4. The occurrence of sexual harassment may be reported to: 1. IHI 2. ANA 3. EEOC 4. CDC

4. Answer: 3 Rationales: 1. The IHI is concerned with quality of care provided, staff issues are not an issue they are prepared to address. 2. ANA can provide nurses with useful information about the issue of sexual harassment (some state associations can provide some support and guidance as well). 3. The EEOC is the government agency charged with investigating employment issues such as sexual harassment. 4. The CDC is concerned with the health of the population but would not be in a position to investigate a specific incident.

4. What does the NSNA provide to its members? 1. Help in improving course grades 2. Guidance in choosing a good nursing school 3. Career development information 4. Opportunities for graduate school

4. Answer: 3 Rationales: 1. The National Student Nurses' Association (NSNA) does not provide tutoring or similar assistance. 2. The NSNA does not provide advice in selecting a nursing school. 3. The NSNA does provide career development information. 4. The NSNA itself does not provide graduate education

5. Burnout at work can be identified best by: 1. Expressions of frustration and powerlessness 2. Fatigue and refusal to work double shifts 3. Allergic reactions 4. A preference for efficiency

5. Answer: 1 Rationales: 1. Expressions of frustration or powerlessness are clear warnings of burnout. 2. These may be related to burnout but to other factors as well. 3. This is clearly not a symptom of burnout. 4. Efficiency is not a symptom of burnout, although inefficiency might be.

5. Who may become a member of the NSNA? Select all that apply. 1. Associate degree program students 2. Graduates of associate degree programs 3. Diploma school students 4. Baccalaureate degree students

5. Answer: 1, 3, 4 Rationales: 1. Associate degree students are eligible for National Student Nurses' Association (NSNA) membership. 2. Graduates of nursing degree programs are not eligible. 3. Diploma school students are eligible for NSNA membership. 4. Baccalaureate degree students are also eligible for NSNA membership.

5. What does "be visible and vocal" mean? Select all that apply. 1. Take a course on health-care policy. 2. Speak out on issues important to nursing. 3. Write letters to the editor, and e-mail your state and federal representatives. 4. Look for opportunities to appear on radio or television.

5. Answer: 2, 3, 4 Rationales: 1. Taking a course will help you be a better-informed advocate but not be "visible and vocal." 2. Speaking out is being "vocal." 3. Writing letters and e-mails are also ways to be visible and vocal. 4. Likewise, appearing on radio or television is both visible and vocal.

6. Which of the following health and safety concerns is NOT one of our greatest concerns currently? 1. "Escape" of health-care-acquired infections into the community 2. Spread of poliomyelitis and smallpox 3. Increase in opioid-related deaths 4. Health disparities (poorer health and treatment outcomes in minority, limited-income, and other groups)

6. Answer: 2 Rationales: 1. Antibiotic-resistant infections continue to be a great concern. 2. Both polio and smallpox are relatively well controlled. 3. Opioid-related deaths are increasing. 4. Health disparities are a continuing concern.

6. New graduates usually experience a "honeymoon" period at their first job, which is characterized by: 1. Extreme criticism from colleagues 2. Long hours and low pay 3. Feeling undervalued 4. Excitement about the new position

6. Answer: 4 Rationales: 1. Colleagues rarely criticize a brand new nurse in the first few weeks or "honeymoon" period. 2. New graduates are not usually assigned long hours. Their pay may reflect the amount of training time they require, however. 3. Most new graduates find themselves welcomed by their colleagues. 4. Excitement about the new (usually first) registered nurse (RN) position is common in the honeymoon phase.

6. Jean Paul has practiced nursing for 5 years and wants to continue his education. He has an associate degree and is trying to decide whether to pursue a nursing degree or a nonnursing degree. Which of the following is an advantage of choosing a nursing degree? 1. Higher time demand of the nonnursing degree 2. Opportunity to learn about other professions outside nursing 3. Broader focus of the nonnursing degree 4. Opportunity to advance knowledge and skills in his profession

6. Answer: 4 Rationales: 1. Nursing degrees typically have a higher time demand than do nonnursing degrees. 2. Learning about other professions is useful but not as important as advancing knowledge and skills in one's own profession. 3. Likewise, the broader focus of nonnursing degrees fails to provide advanced preparation in nursing. 4. Advancing one's knowledge and skills in one's own profession is the primary goal of obtaining a higher degree.

7. An effective way to help a diverse staff work together is to: 1. Provide equal opportunities for advancement 2. Pretend there are no cultural differences 3. Promote uniformity in communication styles 4. Establish an English-only policy institution-wide

7. Answer: 1 Rationales: 1. Providing equal opportunities for raises and promotions is an excellent approach to managing a diverse team. 2. Ignoring cultural differences does not help staff work with them. 3. Promoting uniformity may appear to be an attempt to diminish diversity. 4. An English-only policy may be troublesome for non-English-speaking patients.

7. Which of the following characterize the transition from nursing student to practicing nurse? Select all that apply. 1. Increased number of assigned patients 2. Higher productivity expectations for the student compared with the practicing nurse 3. Greater emphasis on efficiency in practice 4. Shorter hours, fewer workdays back to back in practice

7. Answer: 1, 3 Rationales: 1. Students generally are assigned fewer patients. 2. Productivity expectations for the practicing nurse are higher. 3. Efficiency is emphasized more in practice than in school. 4. Shorter hours and fewer back-to-back workdays characterize student assignments.

7. Which of the following are the primary current problems with the U.S. health-care system? Select all that apply. 1. Increased use of EHRs 2. Less-than-optimum outcomes (quality issues) 3. Number of people who are uninsured 4. High cost of care

7. Answer: 2, 3, 4 Rationales: 1. Increased use of electronic health records (EHRs) is occurring but is not a major problem. 2. Outcomes that are less than optimal continue to be a concern. 3. The number of uninsured also continues to be a concern. 4. Likewise, high costs continue to be a concern.

8. Which of the following events should be reported? Select all that apply. 1. A patient is placed in a broken wheelchair that tips over. 2. A staff member tells a neighbor about the famous athlete who is a patient. 3. An employee reports to work under the influence of alcohol. 4. A patient spills her supplemental protein drink on the floor; the certified nursing assistant (CNA; aide) mops it up.

8. Answer: 1, 2, 3 Rationales: 1. Unprepared equipment should not be used, as it may cause injury or death. 2. This represents a Health Insurance Portability and Accountability Act (HIPAA) violation of patient privacy. 3. This is an example of an impaired employee. 4. Although an accident occurred, no one was hurt, and the risk to others (wet floor) was addressed immediately.

8. Janice Mendoza is settled in her nursing position and wants to devote some time to one of the issues facing the nursing profession. Which of the following activities would probably have the LEAST impact on advocating for the nursing profession? 1. Contribute to the ANA's PAC 2. Visit the representatives when the state legislature is in session 3. Talk with her friends, explaining her concerns 4. Speak on radio and television programs

8. Answer: 3 Rationales: 1. The American Nurses Association's (ANA's) political action committee (PAC) actively advocates for nursing and for patients. 2. Visiting one's representatives continues to be an effective strategy. 3. Talking only with one's friends is less likely to be effective. 4. Speaking on public media is another effective strategy.

9. Which of the following is a current concern related to the nursing profession? 1. Aging of the nursing workforce 2. Oversupply of nurses versus decreasing demand for nursing care 3. Emphasis on evidence-based practices 4. Expansion of EHR use into the community

9. Answer: 1 Rationales: 1. Aging of the current nurse population continues to be a concern. 2. Demand for nursing care is not decreasing; oversupply occurs only sporadically. 3. Evidence-based practice is a positive trend. 4. The use of electronic health records (EHRs) is also a positive trend.

9. What can the new graduate do to make a successful transition from student to practicing nurse? 1. Try to maintain one's student identity. 2. Move into nursing management as soon as possible. 3. Learn about the organization as a whole as well as about your assigned unit. 4. Focus on the stress of making this difficult transition.

9. Answer: 3 Rationales: 1. Transition includes changing one's identity from student to nurse. 2. New graduates are not ready for management and may fail to mature as a practicing nurse if they move into management too quickly. 3. The organization is the context in which a nurse practices and has an important influence on the practice environment. 4. Focusing on one's stress may increase negativity and may impede programs through the transition. Stress needs to be managed and eventually reduced, but it is not the primary focus of your transition.

9. A new nurse manager has observed several instances of horizontal violence between staff members on her unit, primarily verbal abuse and malicious gossip. What should she do? 1. Ignore it because it is not physical violence and will not hurt anyone. 2. Model this bullying behavior so that staff can see how it affects people. 3. Keep a log of observed bullying behavior to discuss during the employees' annual evaluation. 4. Confront the bullying behavior and discuss strategies for responding to it.

9. Answer: 4 Rationales: 1. Verbal abuse may also become very harmful and should not be ignored. 2. A nurse manager's bullying behavior may confuse staff. It may appear that the manager is encouraging it. 3. Presenting these concerns at the annual evaluation delays dealing with it for too long. 4. Direct but carefully worded confrontations will make it clear that bullying is not tolerated.

Which of the following characterize the transition from nursing student to practicing nurse? (Select all that apply.) A. Increased number of assigned patients. B. Higher productivity expectations for the student compared to the practicing nurse. C. Greater emphasis on efficiency in practice. D. Shorter hours, fewer work days back-to-back in practice.

A, C

Professional Nursing Associations

American Nurses Association (ANA) National League for Nursing (NLN) Organization for Associate Degree Nursing (OADN) National Student Nurses Association (NSNA) American Academy of Nursing (AAN) National Institute for Nursing Research (NINR) Specialty organizations - These organizations advocate, do research, offer collegiality.

Vocational Rehabilitation Act of 1973

An employer receiving financial assistance from the federal government may not discriminate against individuals with disabilities and must develop affirmative action plans to hire and promote individuals with disabilities.

How do you know if you're culturally competent?

Aware of your own biases, willing to explore biases, willing to accept the opportunity to learn, remain respectful, and use culturally competent strategies. - Ethnicity, race, culture, gender, sexual orientation, lifestyle, primary language, age, physical capabilities, and career stage

A new nurse manager observes instances of horizontal violence between staff members on the unit, mainly verbal abuse and malicious gossip. What should the manager do? A. Ignore it. It's not physical violence and will not hurt anyone. B. Model this bullying behavior so staff can see how it affects people. C. Keep a log of observed bullying behavior to discuss during the employees' annual evaluation. D. Confront the bullying behavior and discuss strategies for responding to it.

D

OSHA is responsible for what? A. Providing training to handle difficult clients and their families B. Providing research and education training C. Upholding the standards of nursing practice D. Developing and enforcing workplace safety and health regulations

D.

T or F: Maryland is a mandatory overtime state

False

Specialty Organizations

In addition to the national nursing organizations, nurses may join specialty practice organizations focused on practice areas (e.g., critical care, nephrology, obstetrics) or special interest groups (e.g., male nurses, Hispanic nurses, Philippine nurses, Aboriginal nurses). These organizations provide nurses with information regarding evidence-based practice, trends in the field, and standards of specialty practice.

Transition to Practice Programs (TPPs)

It's not just your instructors in school who are concerned that your transition to practicing nurse goes well. Your potential employer also wants it to go well. Unless you are aware of this, you might be surprised at the great effort invested in designing postgraduation transition programs. We will consider a few examples to give you an idea what is available in some health-care organizations.

Paths to Advancement

Most health-care organizations offer advancement opportunities, a career ladder you can climb from staff level to management and administration along an administrative track or to preceptor, clinical specialist, and educator along a clinical track. There are usually specific criteria for moving up these levels within the organization and several optional activities and responsibilities you can offer to take on to add to your accomplishments and to your value to the organization. This includes serving as a mentor to new graduates, chairing committees, obtaining extra training, working on quality improvement or research projects, and so forth. Jakubik (2008) suggests thinking of all these activities as tools to promote career advancement. These "tools" should be collected in a tool box for building your career. There are four core compartments in your career "tool box": 1. Continuing education Your state may require that you complete a minimum number of hours of continuing education to renew your license. This requirement is just a minimum accomplishment. In addition, you can attend local and national conferences in your specialty area, attend training sessions offered by your employer, and take online courses offered by your nursing association. You can also pursue formal education, progressing through the levels of education described earlier from earning your BSN degree to master's level programs and a doctorate in nursing. 2. Certification Certification is a formal acknowledgement by a recognized nursing association that you have achieved either a basic or advanced level in your specialty area. There is also required certification for advanced practice (nurse practitioner). 3. Mentoring Experienced nurses often find it very satisfying to be able to share their experience with new nurses. Most health-care organizations not only offer training for the mentoring role but also reward employees for taking on this additional responsibility. From the perspective of the mentor, this activity provides satisfaction, recognition, and reward. 4. Professional activities This last compartment in your career building tool box can be filled with a great variety of activities. The following are just a few examples: ■ Join one of the committees of your local or state nursing association or specialty association. Even better, become a chair of one of these committees. ■ Offer to serve on the innumerable committees that form in almost every work environment. For career advancement purposes, seek opportunities to serve on committees concerned with practice issues such as patient safety, design of a new unit, or quality improvement. ■ Lead or participate in a research study or quality improvement project. ■ Volunteer to speak at local schools of nursing, at organizational meetings, and at research conferences. ■ Join interprofessional initiatives where you can showcase nursing's contributions to health care. Finally, be sure to keep detailed records of all these activities so that you can include them in your annual evaluations and list them on your employment applications.

What agency prevents injuries and make sure that employers are compliant to rules/regulations in the facility?

NIOSH

Agencies addressing workplace safety

National Safety Council (NSC ) National Institute for Occupational Safety and Health (NIOSH) Occupational Safety and Health Administration (OSHA) Centers for Disease Control (CDC) American Nurses Association (ANA) The Joint Commission (TJC) Institute of Medicine (IOM)

Quid Pro Quo (Sexual harassment)

Occurs when a manager or supervisor withholds or awards job benefits on the basis of sexual favors. - This includes work assignments, hiring, termination, promotions or demotions, positive or negative performance reviews or any other job-related benefits.

Hostile Environment (Sexual harassment)

Occurs when a pattern of sexual conduct unreasonably interferes with an individual's work performance or creates an intimidating, hostile, or offensive working environment. - Most common and difficult to prove - Based on gender

Americans with Disabilities Act

Passed by Congress in 1991, this act banned discrimination against the disabled in employment and mandated easy access to all public and commercial buildings. - Reasonable accommodations

If violence occurs

Report the incident Call security Get medical attention Contact the appropriate organization Be proactive Mental Health - Try to de-escalate, if that doesn't work then get help, then get out. - If it is a manager, go get help right away.

Major contributors to sexual harassment

Sex-role stereotypes, persistent societal tolerance, unequal balance of power between men and women

US Healthcare reforms

Societal demographics and diversity Regulation and legislation Technology Addressing problems (retrograde, they work on small fixes; not addressing major flaws)

American Academy of Nursing (AAN)

The AAN consists of more than 2,400 nursing leaders in practice, education, management, and research. Its mission is to advance health policy and practice through the generation, synthesis, and dissemination of nursing knowledge. The mission of the AAN is to "serve the public and the nursing profession by advancing health policy, practice and science." Nursing Outlook is the AAN's official journal. Membership is through nomination and election by current Fellows of the Academy.

National Institute for Nursing Research (NINR)

The NINR, unlike the other associations described here, is an arm of the federal government, one of the 27 institutes and centers of the National Institutes of Health (NIH). The NINR supports and conducts basic and clinical research focusing on symptom science, wellness, self-management of chronic conditions, end-of-life care, and palliative care, as well as promoting innovation and developing nurse scientists for the 21st century

National Student Nurses Association (NSNA)

The NSNA has 60,000 members across the United States. Students enrolled in associate degree, baccalaureate, and diploma programs are eligible for membership. The NSNA offers opportunities to meet students from other programs, prepare for initial licensing, develop leadership skills and career planning, and advocate for high-quality, affordable, accessible health care.

The Joint Commission (TJC)

To maintain TJC accreditation, organizations must have an extensive on-site review, including workplace safety, by a team of TJC health-care professionals at least once every 3 years.

Preventing Violence

Workplace assessments Note behaviors that precede violence Know clients Maintain calm behavior

Burnout:

s Stages of burnout -High expectations or idealism; Have to be practical things are going to go wrong -Pessimism, early job dissatisfaction; physical and psychosocial symptoms -Withdrawal or isolation; anger comes in. -Detachment, loss of interest s Buffers against stress and burnout -Personal control; control expectations. -Commitment to both work and life's activities -Perception of demands and changes

US Healthcare Challenges

sAffordable Care Act (ACA) sInsurance reforms sState health insurance exchanges sSupport for education and students sFederal funding for clinics sSchool-based health centers sTransitional care, chronic disease management

Ineffective Coping Strategies: Some less successful ways of coping with the transition from student to practicing nurse are provided in the list that follows.

■ Abandon professional ideals When faced with reality shock, some new graduates abandon their professional ideals. This may eliminate the conflict but puts the needs of the organization before their own needs or the needs of the patient, which is not a satisfactory resolution. ■ Leave the profession A significant proportion of those who do not want to give up their professional ideals escape these conflicts by leaving their jobs and abandoning their profession. There would probably be fewer recurring shortages of nurses if more health-care organizations met these professional ideals. - When you have made it through the first 6 months of employment and are finally starting to feel as if you are a "real" nurse, you are probably beginning to realize that a completely stress-free work environment is unrealistic. Shift work, overtime, staff shortages, and pressure to do more with less continue to place demands on nurses.

The ANA uses Professional Issues Panels to engage members in active dialogue on important issues related to nursing practice and health-care policy. You need to be an RN and a member of the ANA to serve on one of these panels. The topics addressed by these Professional Issues Panels in 2018 give you an idea of the scope of issues facing our profession and our health-care system:

■ Barriers to RN Scope of Practice Panel ■ Care Coordination Quality Measures Panel ■ Connected Health/Telehealth ■ Moral Resilience Panel ■ Nurse Fatigue Professional Issues Panel ■ Palliative and Hospice Nursing Panel ■ Workplace Violence and Incivility Panel ■ Revision of the Code of Ethics for Nurses With Interpretive Statements Panel

The following are some specific actions you can take to exert leadership in supporting your profession and improving health care:

■ Be sure you are registered to vote if you are eligible. Every county has a supervisor of elections office that you can visit, call, or connect with online to register. ■ Learn more about the health-care system and your role in it. ■ Take advantage of legislative days when your state nurses organization or your college organizes groups of nurses and nursing students to visit their legislators either locally or at the state capitol building to discuss nursing issues and ask for their support. ■ Another excellent learning experience supported by many community colleges involves service learning programs. In these programs, students commit up to 20 hours a week to engage in community projects of endless variety: urban gardens, autism programs, Special Olympics, health screenings, care kits for hospital patients or nursing home residents, and so forth. You can gain an appreciation of the needs of people in your community, learn how health and social welfare programs do and do not work well, and gain leadership skills. Evangeline Manjares, dean of academic and student service at Nassau Community College in New York, added another benefit of these programs, "Everyone is too involved with looking at our cell phones. It's time to maybe share some of their cell phone time with the community". ■ Join both your professional association and specialty association and support their efforts to improve care. ■ Talk about these issues with everyone and anyone who will listen. ■ Write letters to the editor, speak on local radio and television programs, and participate in online discussions. ■ Send e-mail messages to your legislators, sign petitions if you support them, and communicate your position through social media. ■ Speak to your local, state, and national representatives about these concerns. ■ Consider supporting the ANA or your specialty organization's PAC (political action committee) even if you can only afford a small amount. These funds make it possible for the organization's staff to be visible and speak with key legislators on issues important to nursing. In summary, be "visible and vocal" in your support of nursing and improved health care

Instead of focusing on the stress, new nurses can manage their transition from student to practicing nurse by taking responsibility for their own successful transition.

■ Develop a professional identity Opportunities to challenge one's competence and develop an identity as a professional can begin in school. Success in meeting these challenges can immunize the new graduate against the loss of confidence that accompanies the shocks of the transition to practice. ■ Learn about the organization The new graduate who understands how organizations operate will not be as shocked as the naïve individual. When you begin a new job, it is important to learn as much as you can about your new organization and how it really operates. ■ Use your energy wisely Much energy goes into learning a new job. You may see many things that you think need to be changed, but you need to recognize that to implement change requires your time and energy, so choose your targets wisely. ■ Communicate effectively Confront problems that might arise with coworkers. Use the problem-solving and negotiating skills you've learned in this course to do this constructively. ■ Seek feedback often and persistently Seeking feedback pushes the people you work with to be more specific about their expectations of you and any concerns they might have. It also engages your coworkers in helping you make the transition successfully. ■ Develop a support network A support network is a source of strength when resisting pressure to give up professional ideals and a source of power when attempting to bring about change. Identify colleagues who have held onto their professional ideals with whom you can share your problems and the work of improving the organization. Their recognition of your work can keep you going when rewards from the organization are meager. ■ Give yourself some time Above all, give yourself time to make this transition. Engage actively in this process of professional development, but don't expect it to happen overnight.

It Is Nursing Management's Responsibility to:

■ Ensure competent nursing care is provided to the patient. ■ Evaluate the nurse's ability to provide specialized patient care. ■ Organize resources to ensure that patients receive appropriate nursing care. ■ Collaborate with the staff nurse to clarify assignments, assess personal capabilities, and jointly identify options for patient care assignments when the nurse does not feel personally competent or adequately prepared to carry out a specific function. ■ Take appropriate disciplinary action according to facility policies. ■ Communicate in written policies to the staff the process to make assignment and reassignment decisions. ■ Provide education to staff and supervisory personnel in the decision-making process regarding patient care assignments and reassignments, including patient placement and allocation of resources. ■ Plan and budget for staffing patterns based on patient requirements and priorities for care. ■ Provide a clearly defined written mechanism for immediate internal review of proposed assignments, which includes the participation of the staff involved, to help avoid conflict.

Current Concerns: Despite its length, it only highlights current concerns and is not by any means exhaustive. It will, however, give you an idea of the number and scope of these issues.

■ Health-care-associated (i.e., nosocomial) infections, which have "escaped" from hospitals and now can be found occurring in nursing homes and in the community ■ The opioid crisis, which has caused many potentially preventable deaths across the country. Life expectancy in the United States declined for the second year in a row in 2016 because of the increase in fatal opioid overdoses, whereas the decline in deaths because of heart disease seems to have leveled off ■ Adverse drug events, including prescribing errors, medication administration errors, and serious side effects, which have harmed many patients ■ Gun violence resulting in injury and death from misuse of firearms, a public health problem of rising concern ■ Ensuring appropriate care for LGBTQ (lesbian, gay, bisexual, transgender, and queer) individuals. ■ Nurses with substance use disorders ■ The rise in cases of autism found in children

One of the fundamental reasons why the United States has not achieved successful health-care reform is that there hasn't been agreement on whether access to health care is a privilege or a right. Citizens of the United States are guaranteed access to basic education, fire and police protection, mail, parks, and many other benefits but not health care. Ideally, a new model of health care is needed that offers the following:

■ Holistic, person-centered care ■ Seamless connections across community, acute-care, and long-term care settings ■ Elimination of health disparities ■ Guaranteed accessible, affordable care for everyone ■ Safe care that heals and does not harm the patient ■ Equivalent support for prevention, health promotion, and mental health care as for acute and primary care ■ Creation of a healthy environment, from green buildings to the elimination of air, water, soil, and other forms of pollution ■ Attention to global health concerns: climate change, hunger, poverty, and disease at home and in developing countries

Current trends in the provision of health care that present some challenges but may improve care include the following:

■ Increased use of electronic health-care records, which eliminates paper and allows remote access but requires increased attention to cybersecurity ■ Reduction of unnecessary hospital admissions ■ Increase in surgical procedures done on an outpatient basis ■ Attention to providing patient-centered care, reducing the ineffectiveness of fragmented, uncoordinated, unresponsive, inaccessible care ■ Using "big data" from many sources, including patient data from large health-care systems, to identify trends that otherwise would not have been noted ■ Integrated health-care systems that provide community-based primary care and home health care as well as acute care and long-term care within a single coordinated system ■ Keeping the caring in nursing in a highly technological setting ■ Continuing the efforts to reduce health disparities in people who are poor or members of minority groups ■ Continuing increase in the use of alternative and complementary modalities such as meditation, massage, and nutraceuticals

After lengthy arguments and despite some strenuous opposition, the Patient Protection and Affordable Care Act, known familiarly as Obamacare after the president who promoted it, was enacted in 2010. This complex legislation contained provisions for sweeping changes in health care. The following are some of the changes of most interest to nurses:

■ Insurance reforms that prohibit cancellation if the person is ill, eliminate preexisting condition clauses, and prohibit lifetime limits ■ Creation of state health insurance exchanges to offer affordable insurance coverage ■ Support for nursing education and nursing students ■ Nurse-managed clinics eligible for federal funding ■ Expansion of school-based health centers ■ Support for transitional care and chronic disease management ■ Creation of accountable care organizations and medical homes that bridge the gap between hospital, nursing home, and home and medical office care ■ Free preventive services for women, including HIV screening, contraception, breastfeeding, and domestic violence services ■ A standardized report of health insurance coverage so that consumers can compare different plans.

A comprehensive plan with a Get Ready phase and a four-step action plan is included in the report. To Get Ready, leaders of a health-care organization should do the following:

■ Listen and learn from the facility's employees what matters most to them. ■ Provide leaders with enough time to engage in the "what matters?" conversations and the follow-through to be sure they can work on resolving problems. Failure to follow through will lead to increased employee frustration. ■ Appoint a senior level leader who can lead the effort and make needed changes at the organizational level.

The National Center for Health Workforce Analysis (2017) reported that 2.8 million registered nurses (RNs) were actively practicing nursing in the United States in 2014. Based on these statistics and despite the prediction that more than 1 million RNs will leave the nursing workforce within this time frame, it is estimated that there will be 3,895,600 RNs in the United States by 2030. The anticipated demand for RNs by 2030 is only 3,601,800, creating a small national surplus of RNs. Although there may be a national surplus, California, Texas, New Jersey, and South Carolina are projected to have shortages of greater than 10,000 RNs. This distribution problem is due, in part, to factors affecting the supply and demand, which include:

■ Population growth and shifts ■ Changing demographics such as the aging of the baby boomers and the nursing workforce itself ■ Health-care legislation and its impact on insurance coverage and reimbursement ■ Workforce availability

Behaviors and activities relevant to giving, accepting, or rejecting a work assignment that could lead to disciplinary action include:

■ Practicing or offering to practice beyond the scope permitted by law or accepting and performing professional responsibilities that the licensee knows or has reason to believe that he or she is not competent to perform ■ Performing, without adequate supervision, professional services that the licensee is authorized to perform only under the supervision of a licensed professional, except in an emergency situation in which a person's life or health is in danger ■ Abandoning or neglecting a patient or client who is in need of nursing care without making reasonable arrangements for the continuation of such care ■ Failure to exercise supervision over persons who are authorized to practice only under the supervision of the licensed professional - Of the previous list, the issue of abandonment or neglect has thus far proven the most legally devastating. - Abandonment or neglect has been legally defined to include such actions as insufficient observation (frequency of contact), failure to ensure competent intervention when the patient's condition changes (qualified physician not in attendance), and withdrawal of services without provision for qualified coverage. Because nurses at all levels most frequently act as agents of the employing facility, the facility shares the risk of liability with the nurse.

It Is the RN's Responsibility to:

■ Provide competent nursing care to the patient. ■ Exercise informed judgment and use individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others. ■ Clarify assignments, assess personal capabilities, and jointly identify options for patient care assignments when he or she does not feel personally competent or adequately prepared to carry out a specific function. ■ Refuse an assignment that he or she does not feel prepared to assume after appropriate consultation with a supervisor.

Change and innovation are constants in health care. The following are trends that are expected to affect the nursing profession and the care nurses provide to their patients in the near future:

■ The continued aging of the nursing workforce will increase the need for new nurses across the globe. ■ The aging of the large baby boomer generation reaching retirement age now will cause a demand for more health-care services, especially care related to chronic illnesses. Some have asked if we can afford the increased costs of these demands. ■ Evidence-based practice will become integrated into nursing education programs and eventually become standard nursing practice. ■ Efforts to ensure patient safety, especially in acute care, will continue to be emphasized, including reduction of nosocomial infections, medication errors, failure to rescue, and other serious adverse events. ■ Quality improvement efforts will also continue to increase along with the drive for patient safety. ■ The use of EHRs will become standard practice in hospitals, nursing homes, and community settings, along with other technological innovations (computerized order entry, telehealth, mobile devices, sensors, webcams, etc.). ■ The beneficial effects of alternative and complementary approaches (such as meditation, herbs, use of nutraceuticals, yoga, visual and musical arts, etc.), already widely accepted by many members of the public, will be integrated into standard medical and nursing practice. ■ Increased focus on care transitions (from hospital to home, from the nursing home back to the hospital, etc.) will involve nurses in better preparing patients for these transitions. ■ Whenever and wherever possible, care will move out of the hospital and into the community. ■ Hospitals and nursing homes are anticipating further cuts in reimbursement from Medicare and Medicaid. In response, they are looking for additional ways to reduce costs and diversify into community-based services, such as hospice and rehabilitation. ■ Continued cost cutting will increase use of "physician extenders" (nurse practitioners and physician assistants, etc.) but may also put additional strain on current nursing staff. ■ Improved communication and increased travel bring increased exposure to disease from other parts of the world. - What does all this mean for the new nurse? Many opportunities for nurses will open up in community-based care, transitional care, quality improvement efforts, telehealth, and nontraditional roles. But there will also be challenges ahead as cost cutting increases the demand on individual staff members and the tolerance of errors that threaten patient safety and well-being becomes very limited.

Issues Central to Potential Dilemmas Are:

■ The right of the patient to receive safe, professional nursing care at an acceptable level of quality ■ The responsibility for an appropriate utilization and distribution of nursing care services when nursing becomes a scarce resource ■ The responsibility for providing a practice environment that ensures adequate nursing resources for the facility while meeting the current socioeconomic and political realities of shrinking health-care dollars

The CNA is the national organization of RNs in Canada. The purpose of the CNA is "Registered nurses contributing to the health of Canadians and the advancement of nursing." The CNA's mission includes:

■ Unifying the voices of RNs ■ Strengthening nursing leadership ■ Promoting nursing excellence and a vibrant profession ■ Advocating for healthy public policy and a quality health system ■ Serving the public interest

Institute of Medicine (IOM)

- The IOM is a private, nongovernmental organization whose mission is to improve the health of people everywhere; thus, the topics it studies are very broad. - In 1996, the IOM began a quality initiative to assess the nation's health-care system. - One result was the 2004 report, "Keeping Patients Safe: Transforming the Work Environment of Nurses." The report identified concerns related to organizational management, workforce deployment practices, work design, and organizational culture

Professional Growth and Innovation

- The difference between a climate that encourages staff growth and creativity and one that does not can be quite subtle. - The increasingly rapid accumulation of knowledge in health care mandates continuous learning for safe practice. Much of the responsibility for staff development and promotion of innovation lies with upper-level management. - Some of the ways in which first-line managers can develop and support a climate of professional growth are to encourage critical thinking, provide opportunities to take advantage of educational programs, encourage new ideas and projects, and reward professional growth.

Registered nurses (RNs), as licensed professionals, share the responsibility and accountability, along with their employer, to ensure that safe, quality nursing care is provided.

- The scope of professional nurses' accountability involves legal, ethical, and professional guidelines for ensuring safe, quality patient care. - Legal responsibility for the provision, delegation, and supervision of patient care is specified in the Nurse Practice Acts and the Administrative Rules. The American Nurses Association (ANA) Code for Nurses With Interpretive Statements (2015) guides the ethical conduct and decision making of professional nurses. The ANA Standards and Scope of Practice (2015) provides a systematic application of the nursing process for patient care management across patient care settings. Lastly, the employer requirements for safe, competent staffing are outlined in facility policies and guidelines. - Within ethical and legal parameters, the nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others. The nurse's decision regarding accepting or making work assignments is based on the legal, ethical, and professional obligation to assume responsibility for nursing judgment and action.

U.S. Health-Care System Challenges: Technology

- The use of technology and the implementation of electronic health records (EHRs) are projected to decrease costs and improve clinical outcomes, quality, and safety. - Technology also produces advancements in disease treatments (e.g., in the area of genetics and genomics, cancer treatment, and so forth). - The three primary problems with the U.S. health-care system are the number of uninsured, high costs, and less-than-ideal outcomes. - For most people, health insurance comes through their place of employment. A serious problem with this is that if one loses one's job, health insurance is also lost. - The term universal health care means that every individual has access to affordable, high-quality health care. - Redwanski describes the effect that a universal health-care system would have on prescription drugs: All pharmacies would be reimbursed the same amount and expected to have the same drugs in their formulary. To adjust to the lower prices, however, pharmaceutical manufacturers may reduce their budgets for developing new drugs. - Managed care was originally designed to reduce the amount spent on health care by emphasizing prevention. As managed care plans grew and spread across the country, these companies became powerful enough to negotiate reduced rates (discounts) from local hospitals. - With the upsurge in for-profit health plans and the purchase of not-for-profit hospitals by for-profit companies, U.S. health care became increasingly "corporatized." It was thought that this would yield a highly efficient, responsive system ("the customer is always right"). That has not happened, because the "customer" who pays for insurance coverage is usually the employer or the government, not the individual.

Levels of Educational Preparation Within Professional Nursing

- There are several paths a person can take to become a professional registered nurse (RN). These are the bachelor of science degree in nursing (BSN), associate degree in nursing (AD), and the diploma degree from an approved program - The diploma is usually offered by a hospital-based school of nursing. There are about 35 diploma schools in the United States today. - The associate degree in nursing is typically a 2-year degree offered in community colleges and at some hospital-based schools of nursing. It is meant to prepare graduates for RN licensure and for employment within the technical scope of practice. - The BS or BSN is a 4-year degree obtained through colleges and universities that prepares graduates for licensure and professional nursing practice. Bachelor's degree programs typically are a combination of liberal arts, science, and nursing-specific courses. - There are also RN to BSN programs for those who are already RNs but want to earn their 4-year degree. If done full-time, they can usually be completed in 2 years. - Advanced degrees in nursing are also available at both the master's and doctoral level. Most master's degrees prepare the student for specialized roles in nursing. These may include certified midwife, clinical nurse specialist, certified nurse anaesthetist, clinical nurse educator, and several nurse practitioner roles. - Many nurses work for several years or more before pursuing these advanced degrees. The reasons for this delay are many, including the cost of advanced education, the time demand, developing practice skills, and allowing time to choose a specialty. Most of these programs are an additional 2 years in length. - The highest degree in nursing is the doctoral degree. In nursing, there are two primary choices at this level: the doctor of nursing practice (DNP) or the doctor of philosophy (PhD) in nursing. DNP programs focus on highly specialized advanced practice; PhD programs focus on the preparation of nurse researchers, especially for clinical nursing research. There are even opportunities in nursing to pursue postdoctoral studies, honing research skills and seeking grant funds to support one's nursing research. - Nonnursing degrees may be an attractive alternative to the high standards and time demands (especially for clinical courses) of nursing degrees. Given the highly complex nature of health care and expectations of practicing nurses today, the advanced preparation in nursing provided by nursing degree programs is an essential part of higher education for nurses.

Internships and Residency Programs

- These programs for new graduates average 6 months to 1 year in length. Some require licensure before acceptance. - Others may offer lower salaries to offset the cost to the employer of offering both learning sessions and work experience to the new nurse - The content of the programs varies but may include (1) patient-centered care skills, the technical skills to provide safe, high-quality care, emergency care, and end-of-life care; (2) organizational skills, including organizing work, delegating, prioritizing, and time management; (3) clinical leadership skills; and (4) communicating with members of the interprofessional team, patients, and families - Development of a support network for the new graduate is considered an essential part of these programs. This network may include peers (other new graduates), a preceptor or mentor, and nurse manager. New graduates typically begin these programs feeling very positive and confident but hit a low point halfway through them when they realize how much they still have to learn and how demanding nursing can be. However, they gradually regain their confidence and show a satisfactory level of competence, caring for even very ill patients by the end of their 12-month residences, having achieved technical skills, decisional competence, and self-confidence.

Transition From Student to Nurse: Transition Challenges

- Transitions are challenging. They can shock and stress you if you are not prepared for them. But they also provide opportunity. - Your first RN position provides you with an opportunity to test yourself, to put what you learned into practice, and to earn a salary for the work you are doing. - It has been known for some time that the transition from student to nurse is difficult. It is generally agreed that the difficulties encountered during this important transition are because of a gap between nursing education and nursing practice as the new graduate is expected to have sufficient "know-how" to provide nursing care and the fact that it is overly hard to develop a "professional self" at the same time. - Employers expect new graduates to come to the work setting able to provide safe care, organize their work, set priorities, and provide leadership to ancillary personnel. Even though nursing programs are designed to help students prepare for the multiple demands of the work setting, new nurses still need to continue to learn and practice their skills on the job. - Experienced nurses say that what they learned in school is the foundation for practice and that school provided them with the fundamental knowledge and skills they need to continue to grow and develop as they practice nursing in various capacities and work settings. - Another source of some shock to new nurses is that many of the behaviors that brought rewards in school, such as crafting detailed care plans, taking extra time to prepare a patient for discharge, or delaying another task to look up the side effects of a new medication, are not necessarily valued by the organization. Some of these behaviors may even be criticized. - When efficiency is the goal, the speed and amount of work done may be rewarded rather than the quality of the work. This creates a conflict for the new graduate who, while in school, was allowed to take as much time as needed to provide good care.

Incivility and uncivil behavior

- Uncivil behavior: Eye rolling, demeaning/sarcastic comments, exclude/marginalize others, refusing to help. - Incivility meaning: Rude behavior that results in emotional distress.

Stages of a Nursing Career

- Upon graduation, perhaps even sooner, you will begin your search for your first nursing position. Your transition to practice begins when you begin that first position and will require most of your attention during your first year as a practicing nurse. - Shirey (2009) notes that common elements for a successful career are the ability to recognize one's strengths, align them with one's passions, and build upon them. This takes some thought and insight. She has applied a framework from Citron and Smith (2003) to nursing careers that divides a career into three phases: promise, momentum, and harvest: 1. Promise phase This is the time when you identify your strengths and build your knowledge and skill base. 2. Momentum phase This is the time when you achieve mastery in your specialty and become recognized for your expertise. 3. Harvest phase This is when you reach your prime in your profession but need to continue to grow and develop to retain your position and status. There is a possibility of establishing a legacy for nurses following you.

Nursing Issues

- Work-related issues of high workloads, mandatory overtime, incivility, workplace violence, and lack of professional autonomy contribute to these concerns, along with an aging nurse workforce. - On the bright side, there are indications of increasing interest in a nursing career as salaries improve and job opportunities expand. - Safe staffing, defined as the appropriate number and mix of nursing staff, is a critical issue for nurses and the people who need their care. - There is powerful evidence that nurses save lives: for each additional patient assigned to a nurse, there is a 7% increase in the likelihood of a patient dying within 30 days of admission - Nurses cannot gain in-depth understanding of their patients, protect their patients, or catch early warning signs if they are overloaded by the number of patients for whom they are responsible. - Adequate numbers of nurses affect patient mortality, length of stay, prevalence of urinary tract infections, fall rates, incidence of hospital-acquired pneumonia, and more. - Recent reports also showed that increased surveillance and improved infection control techniques decreased the number of methicillin-resistant Staphylococcus aureus (MRSA) infections from 2005 through 2011. This decrease is partly attributed to an increase in nursing interventions and patient teaching both within acute care settings and in the community.

Nurse-to-Nurse Lateral Violence (NNLV)

-Verbal abuse, punishment, humiliating comments, and malicious gossip -Incivility and bullying -Common occurrence -It dramatically decreases morale -Report to management

1. An incident of sexual harassment as identified by the EEOC is: Select all that apply. 1. Telling jokes about sexual identity issues 2. Separate restrooms 3. Providing coffee and doughnuts to the nursing staff 4. Demanding a daily kiss for writing a favorable evaluation

1. Answer: 1, 4 Rationales: 1. Many people would find this behavior offensive in a workplace environment. 2. Separate restrooms are the norm in our society. 3. Providing coffee and doughnuts to everyone on the staff would not constitute harassment. 4. Demanding a daily kiss for writing a favorable evaluation could be interpreted as a quid pro quo.

1. A good description of the present U.S. health-care system would be: 1. The best in the world 2. Efficient and effective 3. Needs improvement 4. Meets everyone's needs

1. Answer: 3 Rationales: 1. There are health-care systems in other countries that are less expensive but have better outcomes in terms of population health indicators. 2. U.S. health care is expensive, not efficient. 3. There are many ways in which the U.S. health-care system could be improved. 4. Given the number of health disparities, the current conclusion is that the U.S. health-care system does not meet everyone's needs.

Application of Guidelines for Decision Making

1. CLARIFY what it is you are being asked to do. 2. ASSESS yourself. Do you have the knowledge and skill to meet the expectations that have been outlined for you? Have you had experience with similar patient populations? Have you been oriented to this unit or a similar unit? Would the perceived discrepancies between your abilities and the expectations lead to an unsafe patient care situation? 3. IDENTIFY OPTIONS and implications of your decision. 4. POINT OF DECISION AND IMPLICATIONS: If none of the options is acceptable, you are at your final decision point. a) Accept the assignment, documenting your professional concern for patient safety and the process you used to inform the facility (manager) of your concerns. Keep a personal copy of this documentation, and send a copy to the nurse executive. Courtesy suggests that you also send a copy to the manager(s) involved. Once you have reached this decision, it is unwise to discuss the situation or your feelings with other staff or patients. b) Accept the assignment, documenting your professional concerns for the chronic nature of the request and possible long-term consequences in reducing the quality of care. Documentation should follow the procedures outlined in the first item of this list. c) Accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee personal commitments. This documentation should go to your manager. You may wish to request a meeting with your manager to discuss the incident and your concerns regarding future requests. d) Refuse the assignment, being prepared for disciplinary action. If your reasons for refusal were patient safety or an imperative personal commitment, document this carefully, including the process you used to inform the facility (nurse manager) of your concerns. Keep a personal copy of this documentation, and send a copy to the chief nurse executive. Courtesy suggests that you also send a copy to the manager(s) involved. e) Document the rationale for your decision. It may be necessary to use the facility's grievance procedure.

You can be a culturally competent practitioner and a role model for others by becoming:

■ Aware of and sensitive to your own culture-based and personal preferences ■ Willing to explore your own biases and values ■ Knowledgeable about other cultures and people who are different from you ■ Respectful of and sensitive to diversity among individuals ■ Skilled using culturally sensitive intervention strategies

If you develop a latex allergy, be aware of the following precautions (CDC, 1998):

■ Avoid all types of latex exposure. ■ Wear a medical alert bracelet. ■ Carry an EpiPen with auto-injectable epinephrine. ■ Alert your employer and colleagues to your latex sensitivity. ■ Carry nonlatex gloves.

Age Discrimination in Employment Act of 1967

Private and public employers may not discriminate against persons 40 years of age or older except when a certain age group is a bona fide occupational qualification.

Needlestick Safety and Prevention Act of 2001

This act directed OSHA to revise the blood-borne pathogens standard to establish in greater detail requirements that employers identify and make use of effective and safer medical devices.

Lilly Ledbetter Fair Pay Act of 2009

This act supports fair pay and provides protection against discrimination in compensation based upon race, color, religion, sex, or national origin.

Pregnancy Discrimination Act of 1968

Pregnant women cannot be discriminated against in employment benefits if they are able to perform job responsibilities.

Professional Growth and Innovation: Rewarding Professional Growth

- A primary source of discontent in the workplace is lack of recognition. - Everyone enjoys praise and recognition, and there is no monetary cost to providing it. A smile, a card or note, or a verbal "thank you" goes a long way with coworkers in recognizing a job well done. - Staff recognition programs have also been identified as a means of increasing self-esteem, social gratification, morale, and job satisfaction

Your Employer's Responsibility in preventing sharp injuries

- All health-care facilities should have a written plan to prevent sharps injuries that is updated annually. Staff should receive annual training during work hours and have a right to be involved in the selection of safety devices. - The employee must be evaluated and treated within 2 hours of a sharps injury, including a free hepatitis B vaccine. - The safety and efficacy of sharps purchased must be evaluated. - Recapping of needles and related practices should be prohibited. - Contaminated work surfaces must be cleaned according to established guidelines. - Employers must provide personal protective equipment (PPE) of good quality, including gloves, gowns, and masks in all needed sizes.

Horizontal Violence

- Also called incivility or bullying, it includes verbal abuse, punishment, humiliating comments, and malicious gossip. - Regardless of their place on the organizational chart, they can cause a great deal of distress to others in the workplace. - The Joint Commission (TJC) characterizes horizontal violence as a sentinel event because it may pose a threat to patient safety. - Trépanier and colleagues (2016) estimate that almost 40% of nurses are exposed to bullying. Reviewing research on this subject, they found that workgroup cohesion, social support from the supervisor and mentor, communication and trust within the teams, and value congruence were protective. - The presence of cliques, lack of trust, poor communication, and a lack of support are related to the occurrence of bullying. - Although lower in intensity than physical violence, the long-term effects of incivility are far from benign and need to be addressed. - Similar to some of the other workplace problems (discrimination, for example), bullying creates a toxic environment that hurts the individual targeted, interferes with the smooth functioning of a health-care facility, and reduces the quality of the care provided.

Shift Work Disorders

- Although nurses who work nights permanently often can readjust their sleep-wake cycle from night to day, even permanent night-workers may be subject to continuous sleep deprivation. - Those who continuously rotate shifts may seriously disturb their circadian rhythms - Symptoms that continue for more than a month indicate the presence of shift work disorder. Those who suffer this disorder have a higher risk of ulcer, heart disease, depression, chronic fatigue, poor work performance, and accidents both on and off work. - Making healthy food available around the clock and providing nap facilities can help employees stay healthy and alert during their shifts - The ANA position on reducing the risks of nurse fatigue is that both nurses and their employers have a responsibility to consider the nurse's need for adequate sleep in allowing on-call status, as well as voluntary or mandatory overtime.

4. Actions to address violence in the health-care workplace include: Select all that apply. 1. Identifying the factors that contribute to violence and controlling as many as possible 2. Allowing the violence to escalate 3. Assessing staff attitudes and knowledge regarding responses to violence 4. Providing weapons training to those identified as having a potential for physical violence

4. Answer: 1, 3 Rationales: 1. One of the first steps in violence prevention is to identify what contributes to violence and devise ways to control these things. 2. Allowing violence to escalate makes the situation worse. 3. Learning how much staff members know about handling episodes of violence is essential to preparing staff education programs. 4. Those who have a high potential for violence should not be given greater access to weapons.

If you do experience sexual harassment, you should do the following:

- Consult your employee handbook or online published policies You may find guidance on how to respond to the harassment, including how to record the incidents and how to report them in these documents. - Confront Indicate immediately and clearly to the harasser that the attention is unwanted. If you are in a unionized facility, ask the nursing representative to accompany you. - Report Report the incident immediately to your supervisor. If the harasser is your supervisor, report the incident to a higher authority and file a formal complaint. - Document Document the incident immediately while it is fresh in your mind—what happened, when and where it occurred, and how you responded. Name any witnesses. Keep thorough records in a safe place away from work. - Support Seek support from friends, relatives, and organizations such as your state nurses association. If you are a student, seek support from a trusted faculty member or advisor. - You can also contact the EEOC You have only 180 days to do this, so don't delay if you think this is the route you will have to take to resolve the problem. Its Web site has contact details.

Cultural Diversity

- Everyone, of all cultures, races, and ethnic groups, needs to examine his or her own assumptions and possible biases concerning people of different gender, age, culture, race, or ethnic group, or those having a disability. - Diversity in health-care organizations includes ethnicity, race, culture, gender, sexual orientation, lifestyle, primary language, age, physical capabilities, and career stages of employees. - Working with and caring for people who have different customs, traditions, communication styles, and beliefs can be rewarding as well as challenging. - An organization that fosters diversity encourages respect and understanding of human characteristics and acceptance of the similarities and differences that make us human.

Staffing Ratios

- Findings from 12 key studies cite specific effects of low nurse staffing on patient outcomes: incidences of failure to rescue, inpatient mortality, pneumonia, urinary tract infections, and pressure ulcers. - Effects on the nurses themselves include needlestick injuries and eventual burnout - Hospital length of stay and finances are affected as well. - The ANA recommends moving staffing decisions away from the industrial model of measuring time and motion to a professional model that examines the factors needed to provide quality care. - The effect of changes in staffing levels should be evaluated on the basis of nursing-sensitive indicators, including patient complexity or acuity, number of admissions and discharges from a unit, the number of professional staff and ancillary staff, the size and layout of the unit, and availability of technical support and other resources

Ergonomic Injuries

- Forty-two percent of nurses report they are at risk of an ergonomic injury, and 13% have actually had a serious injury. For some, the injury means they can no longer practice their profession. - Seventy-five percent actually have access to safe patient handling technology, yet only half of them use it on a regular basis - Why don't they use the equipment? There are several possible reasons: It may not be easily accessible, it may be too heavy or clumsy to use, or staff may not have been trained in its use. - Francis and Dawson note that appropriate safe patient handling equipment must be selected and made readily available to staff, staff have to be well trained in its use, and leaders have to monitor actual use.

Involvement in Decision Making

- Having a voice in the decisions made about one's work and patients is very important to healthcare professionals. - Many actions can be taken to empower nurses: remove barriers to their participation in decision making, publicly express confidence in their capability and value, reward initiative and assertiveness, and provide role models who demonstrate confidence and competence.

Professional Growth and Innovation: Encouraging New Ideas and Critical Thinking

- Intellectual curiosity is a hallmark of the professional, but an inquisitive frame of mind is relatively easy to suppress in a work environment. - Both patients and staff will quickly perceive a nurse's impatience or defensiveness when questions are raised. Their response will be to simply give up asking these questions. But if you are a critical thinker and support other critical thinkers, you can contribute to an open-minded work environment. - Participating in brainstorming sessions, group conferences, and discussions encourages the generation of new ideas. Although new nurses may think they have nothing to offer, this is rarely the case. It is important for them to participate in activities that encourage them to contribute fresh, new ideas.

Why Is Health Care a Stressful Occupation?

- Job-related stress is broadly defined by the National Institute for Occupational Safety and Health (NIOSH) as the "harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker." - Much of the stress experienced by nurses is related to the nature of their work: continued intensive, intimate contact with people who often have serious physical, mental, emotional, or social problems, and sometimes terminal conditions. - Efforts to save patients or help them achieve a peaceful ending to their lives are not always successful. Some patients return to their destructive behaviors. The continued loss of patients alone can lead to burnout. - In some instances, human service professionals also experience lower pay, longer hours, and more extensive regulation than do professionals in other fields. Inadequate advancement opportunities for women and minorities in lower-status, lower-paid positions may also contribute to job dissatisfaction.

5. According to NIOSH, a common reaction to latex allergy is: 1. Increased appetite 2. Allergic contact dermatitis 3. Increased falls 4. An increase in violent outbursts

5. Answer: 2 Rationales: 1. Increased appetite is not a frequent reaction to exposure to latex. 2. Allergic contact dermatitis is a frequent reaction to latex for those who are allergic to it. 3. Increased falls are not common allergic responses to latex. 4. An increase in violent outbursts is not associated with latex allergy.

Violence

- NIOSH defines workplace violence as "violent acts (including physical assaults and threats of assault) directed toward persons at work on duty" - Most of the incidents involve patients - Although a relatively rare occurrence, there is also the threat of an active shooter in the facility. - Most of these incidents have occurred in emergency departments (EDs) or patient rooms. - Although assaults that result in severe injury or death usually receive media coverage, most assaults on nurses by patients or coworkers are not even reported by the nurse. - Not only are episodes of violence underreported, but there are persistent misperceptions that assaults are part of the job and that the victim somehow caused the assault. - Underreporting may also be caused by a lack of institutional reporting policies or employee fear that the assault was because of negligence or poor job performance. - Actions to address violence in the workplace include (1) identifying the factors that contribute to violence and controlling as many as possible, and (2) preparing staff to prevent and manage violence

Needlestick (Sharps) Injuries

- Percutaneous exposure is the principal route for human immunodeficiency virus (HIV) infection as well as hepatitis B and C and other blood-borne pathogens. - The Needlestick Safety and Prevention Act went into effect April 18, 2001. The revised OSHA Blood Borne Pathogens Standard obligates employers to consider safer needle devices when they conduct their annual review Although much progress has been made in preventing sharps injuries, a recent consensus statement from the ANA and other groups calls for more attention to (Daley, 2012): ■ Greater safety in surgical settings ■ Sharps safety outside the hospital ■ Including nurses in selection of safety devices ■ Encouraging product design and development to fill existing gaps (e.g., in dentistry, use of longer needles) ■ Increased staff training

Managing Stress

- Psychologists noted more than 100 years ago (1908) that too little stress can cause a lackadaisical attitude, whereas too much hurts performance and eventually one's health. A moderate amount can stimulate high performance without deleterious effects. - A health-promoting lifestyle, including attention to exercise, adequate sleep, and spiritual concerns, is fundamental to caring for oneself. - Riahi suggests the following to maintain a healthy work life: self-reflect on your perceived role, develop hardiness through use of positive coping styles, and embrace various forms of prevention and stress-reduction actions. - Recent research suggests that mindfulness-based stress reduction (e.g., noting your physical response to stress) and cognitive behavioral training (screening out negative thoughts) are more helpful than earlier relaxation approaches, but they do require a substantial investment of time - Hoolahan and Greenhouse (2012) describe a "restoration room" that was created from a conference room for use by nursing staff as a safe place to go and calm themselves. Whatever it is called, the staff breakroom is essential in stressful work environments. - But Nejati and colleagues (2016) point out that this breakroom shouldn't be too far from the chaos outside for two reasons: The nurses and their colleagues need to know that they are close enough to the care areas that they can respond if a crisis arises, and nurses will not use the breakroom if it is too far away. - Ultimately, you are in control. Every day you are faced with choices. By gaining power regarding your choices and the stress they cause, you empower yourself. - People cannot live in a problem-free world, but they can learn how to handle stress.

Social Environment

- Team building, communicating effectively, and developing leadership skills are essential to the development of working relationships. - The day-to-day interactions with one's peers and supervisors have a major impact on the quality of the workplace environment. - In a supportive environment, people are willing to make difficult decisions, take risks, and "go the extra mile" for team members and the organization. - In a nonsupportive environment, members are afraid to take risks, avoid making decisions, and they limit their commitment to their coworkers and the individuals in their care. - Incivility contributes to a nonsupportive environment.

Reporting Questionable Practices

- The Code for Nurses (ANA, 2015) is very specific about nurses' responsibility to report questionable behavior that may affect the welfare of a patient. - If you become aware of inappropriate or questionable practices in the provision of health care, concern should be expressed to the person carrying out the questionable practice and attention called to the possible detrimental effect on the patient's welfare. - Use official channels if it becomes necessary to report these practices. - ANA's Code of Ethics further states that: When nurses become aware of inappropriate or questionable practice, the concern must be expressed to the person involved, focusing on the patient's best interests as well as on the integrity of nursing practice. When practices in the healthcare delivery system or organization threaten the welfare of the patient, nurses should express their concern to the responsible manager or administrator, or if indicated, to an appropriate higher authority within the institution or agency, or to an appropriate external authority. - When incompetent, unethical, illegal or impaired practice is not corrected and continues to jeopardize patient well-being and safety, nurses must report the problem to appropriate external authorities such as practice committees of professional organizations, licensing boards, and regulatory or quality assurance agencies. - Staff willingness to identify and report problems is essential to ensuring patient safety and improving outcomes. - Whistleblowers are sometimes ostracized (isolated or cast out), a painful experience for those who enjoy the comradery of nursing colleagues. - Whistleblower is the term used for an employee who reports employer violations to an outside agency. - You cannot assume that doing the right thing will protect you: Speaking up could actually get you fired unless you are protected by a union contract or other formal employment agreement. Your state professional organization may also be able to support you. - Case law, federal and state statutes, and the federal False Claims Act may afford a certain level of protection. Although these laws may offer some protection, the most important point is to work through the employer's chain of command and internal procedures. - You may also (1) make sure that whistleblowing is addressed at your facility, either through a collective bargaining contract or workplace advocacy program; (2) contact your state nurses association to find out if your state offers whistleblower protection or has such legislation pending; (3) be politically active by contacting your state legislators and urging them to support a pending bill or by educating your elected state officials on the need for such protection for all health-care workers; and (4) contact your U.S. congressional representatives and urge them to support the Patient Safety Act.

6. A common ergonomic occupational-related risk in the health-care environment is: 1. Indoor air pollution 2. Active shooters 3. Nosocomial infection 4. Back injuries

6. Answer: 4 Rationales: 1. The term ergonomic refers to the design of equipment and the use of equipment and other procedures in a safe and healthy manner. Indoor air pollution is concerned with exposure to toxic substances in the air. 2. Active shooters are human rather than equipment or procedural risks. 3. Nosocomial infections are not ergonomic risks. 4. Back injuries are a very common ergonomic risk in health care.

OSHA

- The goal of OSHA is to prevent injuries and illness and save the lives of employees across the United States - Employers are required to keep records of all occupational (job-related) illnesses and accidents such as chemical exposures, lacerations, hearing loss, respiratory exposure, musculoskeletal injuries, and exposure to infectious diseases. - Workplace inspections may be conducted with or without prior notification to the employer. Catastrophic or fatal accidents and employee complaints may trigger an OSHA inspection. - OSHA encourages employers and employees to work together to identify and remove workplace hazards before contacting OSHA. If the employer has not been able to resolve the safety or health issue, however, the employee may file a formal complaint, and an inspection will be ordered - The employer has the right to contest the OSHA decision. - The law also states that the employer cannot punish or discriminate against employees for exercising their rights related to job safety and health hazards or participating in OSHA inspections. - OSHA inspections of health-care facilities have focused especially on blood-borne pathogens, lifting and ergonomic (proper body alignment) guidelines, confined-space regulations, respiratory guidelines, and workplace violence. OSHA added protecting the work site against terrorism after the September 11, 2001, terrorist attacks.

Discrimination

- The laws that prohibit discrimination in the workplace are based on the 5th and 14th Amendments to the Constitution, mandating due process and equal protection under the law. - The federal EEOC oversees the administration and enforcement of issues related to workplace equality. - The Civil Rights Act of 1964 applies to employers of 15 or more people, including federal, state, and local government employers. - Although there may be exemptions from any law, it is important that nurses recognize that there is significant legislation that prohibits employers from making workplace decisions based on race, color, sex, age, disability, religion, or national origin. - The employer may ask questions related to these issues but cannot make decisions about employment based on them.

Indoor Air Pollution and Exposure to Hazardous Chemicals

- The list of potentially hazardous chemicals found in a health-care setting is a long one: hazardous drugs, disinfectants and sterilizing agents, pesticides, and an array of cleaning products. - OSHA (2018a) classifies hazardous chemicals as carcinogenic, corrosive, toxic, irritant, sensitizer, or target organ effector. - Employers are required by OSHA to clearly label all their hazardous materials and provide Material Safety Data Sheets (MSDSs) for them. - Employers are also required to train their employees to prevent hazards and provide PPE and immediate emergency treatment for potentially injurious exposure. - Inside air pollution is a more recently identified problem. Dioxin emissions, mercury, and battery waste are often not handled properly in the hospital environment. - Disinfectants, chemicals, waste anesthesia gases, and laser plumes that float in the air are other sources of pollution exposure for nurses. - Rethinking product choices, such as avoiding the use of polyvinyl chloride or mercury products, providing convenient collection sites for battery and mercury waste, and making waste management education for employees mandatory, are starts toward a more pollution-free environment - Better ventilation and air filtration can keep the air cleaner - Recycled paper and products, minimizing the use of toxic disinfectants, and waste disposal choices that reduce incineration to a minimum are needed. - Nurses as professionals need to be aware of the consequences of the medical waste produced by the health sector, supporting continued education for both nurses and patients as well as specific policy statements and advocacy efforts of our professional organizations, such as reduction of medical waste incinerator emissions, use of mercury- and PVC-free products, and non-incineration waste disposal.

Agencies Addressing Threats to Safety

- The modern movement for safety in the workplace began near the end of the Industrial Revolution. The National Council for Industrial Safety (now the National Safety Council) was formed in 1913. - The Occupational Safety and Health Act of 1970 created both the National Institute of Occupational Safety and Health (NIOSH) and OSHA. - Part of the U.S. Department of Labor, OSHA is responsible for developing and enforcing workplace safety and health regulations. - NIOSH, part of the U.S. Department of Health and Human Services, supports research, education, and training. - The National Safety Council (NSC) partners with OSHA to provide training. The NSC maintains that safety in the workplace is the responsibility of both the employer and the employee. The employer must ensure a safe, healthful work environment, and employees are accountable for knowing and following safety guidelines and standards - The journey to "world-class safety," says the NSC, is a process of continuous assessment and improvement

Sexual harassment

- The reasons are complex, but sex-role stereotypes, persistent societal tolerance of sexual harassment, and the unequal balance of power between men and women are major contributors. - The Equal Employment Opportunity Commission (EEOC) issued a statement in 1980 that sexual harassment is prohibited by Title VII of the Civil Rights Act of 1964, which prohibits discrimination on the basis of sex, race, color, national origin, and religion. Two forms are identified, both based on the premise that the action is unwelcome sexual conduct: 1. Quid pro quo Sexual favors are solicited in exchange for favorable job benefits or continuation of employment. The employee must demonstrate that he or she was required to endure unwelcome sexual advances to keep the job or job benefits and that rejection of these behaviors would have resulted in deprivation of a job or benefits. Example: An administrator approaches a nurse for a date in exchange for a promotion. 2. Hostile work environment This is the most common sexual harassment claim and the most difficult to prove. The employee making the claim must prove that the harassment is based on gender and that it has affected conditions of employment or created an environment so offensive that the employee could not effectively discharge the responsibilities of the job. An environment can be shown to be hostile or abusive, there is no further need to establish that it was also psychologically injurious. - If you supervise other employees, it is important to review your agency's policies and procedures and seek appropriate guidance from Human Resources if needed. - If an employee approaches you with a complaint, a confidential investigation of the charges has to be initiated. - Your employer (or the director of your program if you are a student) has a responsibility to maintain a harassment-free workplace. You should expect your employer to demonstrate commitment to creating a harassment-free workplace, provide strong written policies prohibiting sexual harassment and describing how employees will be protected, and educate all employees verbally and in writing.

Latex Allergy

- The two major routes of exposure to NRL are skin and inhalation, particularly when glove powder acts as a carrier for NRL protein - Reactions range from contact dermatitis with scaling, drying, cracking, and blistering skin to generalized urticaria, rhinitis, wheezing, swelling, shortness of breath, and anaphylaxis. - Allergic contact dermatitis (sometimes called chemical sensitivity dermatitis) results from the chemicals added to latex during harvesting, processing, or manufacturing. These chemicals can cause a skin rash similar to that of poison ivy. - Latex allergy should be suspected if an employee develops symptoms after latex exposures. - A complete medical history can reveal latex sensitivity, and blood tests approved by the U.S. Food and Drug Administration are available to detect latex antibodies. Skin testing and glove-use tests are also available. - Complete latex avoidance is the most effective approach. - Medications may reduce allergic symptoms, and special precautions are needed to prevent exposure during medical and dental care. - Employees with a latex allergy should consider wearing a medical alert bracelet. - Many employees in a health-care setting can use alternative gloves of vinyl or nitrile. - If an employee must use NRL gloves, gloves with lower protein content and those that are powder-free should be considered. - Good housekeeping practices should be used to remove latex-containing dust from the workplace. - Those with histories of allergies to pollens, grasses, and certain foods or plants (avocado, banana, kiwi, chestnut) and histories of multiple surgeries may be at greater risk. - The number of new cases of latex allergy has decreased because of improved diagnostic methods, improved education, more accurate labeling, and use of powder-free gloves. - Nursing staff should work closely with the pharmacy staff to follow universal one-stick-rule precautions, which assumes that every pharmaceutical vial may contain a natural rubber latex closure. In addition, the nurse should remain with any patient at the start of medication administration and keep frequent observations and vital signs for 2 hours

Repetitive Stress Injuries

- The use of computers continues to increase exponentially for all health-care personnel. - Repetitive stress injuries (RSIs) affect people who spend long hours at computers, switchboards, and other occupations where repetitive motions are performed. - The most common RSIs are carpal tunnel syndrome and mouse elbow. Badly designed computer workstations present the highest risk of RSIs. - Finally, those employees who have been injured at work need support and guidance when they return to work. They may also need some modifications of their work-related activities, explanation of policies related to their situation, and access to continued care for their injury.

Mandatory Overtime

- When nurses are routinely forced to work beyond their scheduled hours, they can suffer a range of emotional and physical effects. - As patient acuity and workloads increase, overtime puts both patients and nurses at greater risk. - The ANA opposes the use of mandatory overtime, stating that nurses should be allowed to refuse overtime if they believe that they are too fatigued to provide quality care. - In a 2006 position statement regarding nurses working when fatigued, the ANA takes the position that, regardless of the number of hours worked, each registered nurse has an ethical responsibility to carefully consider her or his level of fatigue when deciding whether to accept any assignment extending beyond the regularly scheduled workday or week, including a mandatory or voluntary overtime assignment - Rogers et al. (2004) found that nurses' error rates increase significantly during overtime, after 12 hours or after working more than 60 hours per week.

Responses to Stress

- Whether the stress you experience is the result of major life changes or the cumulative effect of minor everyday hassles, it is how you respond to these experiences that determines the impact stress will have on your life. - Some people manage potentially stressful events more effectively than others - A patient situation that one nurse considers stressful may not seem at all stressful to a coworker.

1. OSHA, a federal government agency, is responsible for: 1. Providing training to handle difficult clients and their families 2. Providing research and education training 3. Upholding the standards of nursing practice 4. Developing and enforcing workplace safety and health regulations

1. Answer: 4 Rationales: 1. The Occupational Safety and Health Administration (OSHA) focuses on safety, not on the provision of health care. 2. Many agencies provide training, not just OSHA. 3. OSHA does not focus on practice standards or nursing care. 4. This is the best, most specific description of the purpose and focus of OSHA.

Consider these factors in understanding cultural diversity:

1. Communication Communication and culture are closely bound. Not only is culture transmitted through communication, it influences how people express themselves. Vocabulary, voice qualities, intonation, rhythm, speed, silence, touch, body posture, eye movements, and pronunciation differ among cultural groups and vary among persons from similar cultures. Maintaining respect is central to building relationships. Everyone needs to assess communication preference of others in the workplace. 2. Space Personal space is the area that surrounds a person's body. The amount of personal space individuals prefer varies from person to person and from situation to situation. Cultural beliefs also influence a person's perception of personal space. In the workplace, an understanding of coworkers' comfort related to personal space is important. Often, this comfort or discomfort is relayed in nonverbal rather than verbal communication. 3. Social organization For some people, the importance of family supersedes that of other personal, work, or national issues. For example, caring for a sick child may override the importance of being on time or even coming to work at all, regardless of staffing needs or policies. 4. Time Time orientation is often related to culture. Some cultures are more past-oriented, emphasizing traditions. People from cultures with a future orientation may be more likely to forego current pleasure for later rewards, returning to school for a higher degree or earning certification, for example. Working with people who have different time orientations may cause difficulty in managing rotating shifts, planning schedules, setting deadlines, and even defining what "on time" means. 5. Internal or external control Individuals with an external locus of control believe in the primacy of fate or chance. People with an internal locus of control believe they can influence, even determine, outcomes. In the workplace, nurses are expected to operate from an internal locus of control. This approach may be different from what a person has grown up with

Federal Laws Enacted to Protect the Worker in the Workplace

1. Equal Pay Act of 1963 2. Title VII of Civil Rights Act of 1964 3. Age Discrimination in Employment Act of 1967 4. Pregnancy Discrimination Act of 1968 5. Fair Credit Reporting Act of 1970 6. Vocational Rehabilitation Act of 1973 7. Family Education Rights and Privacy Act—Buckley Amendment of 1974 8. Immigration Reform and Control Act of 1986 9. Americans with Disabilities Act of 1990 10. Family Medical Leave Act of 1993 11. Needlestick Safety and Prevention Act of 2001 12. Lilly Ledbetter Fair Pay Act of 2009

Ten Daily De-Stressors

1. Express yourself! Communicate your feelings and emotions to friends and colleagues to avoid isolation and share perspectives. Sometimes, another opinion helps you see the situation in a different light. 2. Take time off. Taking breaks, or doing something unrelated to work, will help you feel refreshed as you begin work again. 3. Understand your individual energy patterns. Are you a morning or an afternoon person? Schedule stressful duties during times when you are most energetic. 4. Do one stressful activity at a time. Although this may take advanced planning, avoiding more than one stressful situation at a time will make you feel more in control and satisfied with your accomplishments. 5. Exercise! Physical exercise builds physical and emotional resilience. Do not put physical activities "on the back burner" as you become busy. 6. Tackle big projects one piece at a time. Having control of one part of a project at a time will help you to avoid feeling overwhelmed and out of control. 7. Delegate if possible. If you can delegate and share in problem-solving, do so. Not only will your load be lighter, but others will be able to participate in decision making. 8. It's okay to say no. Do not take on every extra assignment or special project. 9. Be work-smart. Improve your work skills with new technologies and ideas. Take advantage of additional job training. 10. Relax. Find time each day to consciously relax and reflect on the positive energies you need to cope with stressful situations more readily.

Goliszek (1992) identified four stages of burnout:

1. High expectations and idealism At the first stage, the individual is enthusiastic, dedicated, and committed to the job and exhibits a high energy level and a positive attitude. 2. Pessimism and early job dissatisfaction In the second stage, frustration, disillusionment, or boredom with the job develops, and the individual begins to exhibit the physical and psychological symptoms of stress. 3. Withdrawal and isolation As the individual moves into the third stage, anger, hostility, and negativism are exhibited. The physical and psychological stress symptoms worsen. Up through this stage, simple changes in job goals, attitudes, and behaviors may reverse the burnout process. 4. Detachment and loss of interest As the physical and emotional stress symptoms become severe, the individual exhibits low self-esteem, chronic absenteeism, cynicism, and total negativism. Once the individual has moved into this stage and remains there for any length of time, burnout is inevitable.

Developing Workplace Safety Programs: Workplace safety programs should protect staff members from harm and the organization from any liability that could result.

1. The first step in the development of a workplace safety program is to recognize a potential hazard. OSHA (U.S. Department of Labor, 1995) requires employers to inform employees of any potential health hazards and provide as much protection from these hazards as possible. In many cases, initial warnings come from the CDC, NIOSH, and other federal, state, and local agencies. Employers must provide tuberculosis testing and the hepatitis B vaccine; protective equipment such as gloves, gowns, and masks; and immediate treatment after exposure for all staff members who may have contact with blood-borne pathogens. They are expected to remove hazards, educate employees, and establish institution-wide policies and procedures to protect their employees (Herring, 1994; Roche, 1993). If not provided with protective gloves, for example, employees may refuse to participate in any activities involving blood or blood products. Reasonable accommodations must also be made. For example, a nurse with latex allergies may be placed in an area where gloves of non-latex materials may be used. 2. The second step in a workplace safety program is a thorough assessment of the amount of risk entailed. Assessment of the workplace may require considerable data gathering. Formal committees are often formed to assess these risks. Staff from various levels and departments should be included. 3. The third step is to create a plan to provide optimal protection for staff members without interfering with the provision of quality patient care. 4. The fourth and final stage in developing a workplace safety program is implementing the plan. Educating the staff, providing the necessary safety supplies and equipment, and modifying the environment may be necessary. 5. Evaluate

2. A surprisingly dangerous job in the United States is working: a. In a coal mine b. As a window cleaner in New York City c. In a health-care facility d. As a police officer

2. Answer: 3 Rationales: 1. Coal mines are known to be dangerous work sites. 2. Cleaning the windows of high-rise buildings is known to present some risks to the workers. 3. Few people realize the many risks encountered by individuals employed in health-care facilities. 4. Likewise, police work is well known for the risks encountered.

3. A federal agency that partners with other agencies throughout the nation to investigate health problems, conduct research, implement prevention strategies, and promote safe and healthy environments is known as the: 1. FDA 2. IOM 3. ANA 4. CDC

3. Answer: 4 Rationales: 1. The Food and Drug Administration's policies are specific to food and drug safety. 2. The Institute of Medicine makes policy recommendations. It is not a federal agency. 3. The American Nurses Association is also not a federal agency and focuses on nursing-related issues. 4. The Centers for Disease Control and Prevention is a federal agency that does investigate a wide range of health concerns.

7. A suburban hospital recently announced that staff nurses could no longer choose their shift. Instead, they would be assigned to either a 12-hour day shift or a 12-hour night shift on an as-needed basis. An informal group of staff nurses met to discuss this new policy. They came up with several arguments against it. Which of the following suggestions would help to alleviate the deleterious effects of this new policy? 1. Allow self-scheduling by staff nurses in each unit. 2. Provide free dinner for nursing staff at the end of the night shift. 3. Allow staff members to request consistent days off. 4. End visiting hours before the day shift ends so that the night shift nurses do not have to deal with visitors.

7. Answer: 1, 3 Rationales: 1. Self-scheduling allows staff to consider both their personal needs and the unit's needs in assigning work shifts. 2. A large meal at the end of a night shift may make it more difficult to sleep after work. 3. Consistent days off reduce the circadian rhythm disturbance. 4. Adjusting visiting hours to end with the end of the day shift may prevent employed visitors from seeing their loved ones and places responsibility for consulting with them entirely on the day shift.

8. Which of the following are considered reasonable accommodations for an employee with a disability? Select all that apply. 1. Modification of the work schedule 2. Salary reduction to reflect lower output 3. Additional days off and extended vacations 4. Adjustment of work procedures

8. Answer: 1, 4 Rationales: 1. Modification of a work schedule is a reasonable accommodation. 2. Salary reduction would be discriminatory. 3. Additional days off or extended vacations would be costly and unfair to nondisabled employees. 4. Adjustment of work procedures to accommodate a person's disability is also a reasonable response.

9. Which of the following procedures and modifications contributes to reducing indoor air pollution? 1. Windows that may be opened by staff as needed 2. More powerful ventilation systems and air filtration 3. Selecti ofon products with more polyvinyl chloride (PVC) 4. Increased use of medical waste incinerators

9. Answer: 2 Rationales: 1. Windows that can be opened by patients or visitors may present a fall risk; outdoor air may not be less polluted. 2. Improved ventilation and filtration may reduce indoor air pollution. 3. Polyvinyl chloride (PVC) is a source of indoor air pollution. 4. Medical waste incinerators are also potential sources of air pollution.

Fair Credit Reporting Act of 1970

Job applicants and employees have the right to know of the existence and content of any credit files maintained on them.

Family Education Rights and Privacy Act—Buckley Amendment of 1974

Educational institutions may not supply information about students without their consent.

Title VII of Civil Rights Act of 1964

Employees may not be discriminated against on the basis of race, color, religion, sex, or national origin.

Equal Pay Act of 1963

Employers must provide equal pay for equal work, regardless of gender.

Immigration Reform and Control Act of 1986

Employers must screen employees for the right to work in the United States without discriminating on the basis of national origin.

Family Medical Leave Act of 1993

Employers with 50 or more employees must provide up to 13 weeks of unpaid leave for family medical emergencies, childbirth, or adoption.

Threats to safety

Health and safety threats include infectious diseases, physical violence, ergonomic injuries related to the movement and repositioning of patients, exposure to hazardous chemicals and radiation, and sharps injuries

Americans with Disabilities Act of 1990

Persons with physical or mental disabilities or who are chronically ill cannot be discriminated against in the workplace. Employers must make "reasonable accommodations" to meet the needs of the disabled employee. These include such provisions as installing foot or hand controls; readjusting light switches, telephones, desks, tables, and computer equipment; providing access ramps and elevators; offering flexible work hours; and providing readers for blind employees.

The American Nurses Association (ANA) surveyed 4,614 nurses in 2011 to learn about their primary concerns related to workplace safety. Their top concerns included:

Stress and overwork (74%) and ergonomic (musculoskeletal) injuries (62%). - Shift lengths have increased but mandatory overtime requirements have declined slightly, reported by 53% in 2011 compared with 68% in 2001. - An encouraging finding is that nurses reported the greater availability of effective devices to assist them in patient transfers and for reducing sharps injuries, fewer assaults, and less illness because of the work environment - When surveyed about factors considered essential to a healthy workplace environment, employees listed collaborative work relationships, good communication, empowerment, recognition, opportunities for growth, effective leadership, adequate staffing, and workplace safety. - All staff members have the right to be made aware of potential risks and to be provided with as much protection as possible. No worker should feel uncomfortable or unsafe in the workplace.

Sources of Workplace Stress

The nature of nurses' work creates the potential for experiencing stress, especially for younger, less experienced nurses. Some settings seem to generate more stressful situations than others. In the emergency department (ED), for example, nurses reported several sources of stress: ■ Inadequate staffing, shift work, and overcrowding ■ Aggression and violence on the part of patients and their families ■ The death of a young patient ■ High-acuity patients, especially those needing resuscitation - Outside demands such as family caregiving can also be a source of stress - Although most discussions emphasize the stressful nature of nurses' work, it is important to keep in mind that there are many sources of satisfaction in the work of nurses as well. Managing the stresses and capturing this satisfaction will be discussed in a later section on job satisfaction and joy in work

Assessing Your Risk for Stress and Burnout

• Do you feel more fatigued than energetic? • Do you work harder but accomplish less? • Do you feel cynical or disenchanted most of the time? • Do you often feel sad or cry for no apparent reason? • Do you feel hostile, negative, or angry at work? • Are you short-tempered? Do you withdraw from friends or coworkers? • Do you forget appointments or deadlines? Do you frequently misplace personal items? • Are you becoming insensitive, irritable, and short-tempered? • Do you experience physical symptoms such as headaches or stomachaches? • Do you feel as if you want to avoid people? • Do you laugh less? Feel joy less often? • Are you interested in sex? • Do you crave junk food more often? • Do you skip meals? • Have your sleep patterns changed? • Do you take more medication than usual? Do you use alcohol or other substances to alter your mood? • Do you feel guilty when your work is not perfect? • Are you questioning whether the job is right for you? • Do you feel as though no one cares what kind of work you do? • Do you constantly push yourself to do better, yet feel frustrated that there is no time to do what you want to do? • Do you feel as if you are on a treadmill all day? • Do you use holidays, weekends, or vacation time to catch up? • Do you feel as if you are "burning the candle at both ends"?

Signs That Your Stress Level Is Too High

• Dreading going to work • Thinking frequently about mistakes, failures • Avoiding patients, colleagues, assignments • Using alcohol or drugs to relax after work • Worrying about all of the above

Useful Relaxation Techniques

• Guided imagery • Yoga • Tai chi • Meditation • Relaxation tapes or music • Exercise • Favorite sports or hobbies • Quiet corners or favorite places

Behaviors Indicating a Potential for Violence

• History of violent behavior • Delusional, paranoid, or suspicious speech • Aggressive, threatening statements • Rapid speech, angry tone of voice • Pacing, tense posture, clenched fists, tightening jaw • Alcohol or drug use • Policies that set unrealistic limits

Behaviors That Could Be Defined as Sexual Harassment

• Pressure to participate in sexual activities • Asking about another person's sexual activities, fantasies, or preferences • Making sexual innuendoes, jokes, or comments; showing sexual graffiti or visuals • Continuing to ask for a date after the other person has expressed disinterest • Making suggestive facial expressions or gestures with hands or body movements • Making remarks about a person's gender or body

Steps Toward Increasing Protection From Workplace Violence

• Security personnel and escorts • Panic buttons in medication rooms, stairwells, activity rooms, and nursing stations • Bulletproof glass in reception, triage, and admitting areas • Locked or key-coded access doors • Closed-circuit television • Metal detectors • Use of beepers or cellular phones • Handheld alarms or noise devices • Lighted parking lots • Escort or buddy system • Enforce wearing of photo identification badges

Coping With Daily Work Stress

• Spend time on outside interests and take time for yourself. • Increase your professional knowledge. • Identify problem-solving resources. • Identify realistic expectations for your position. Make sure you understand what is expected of you; ask questions if anything is unclear. • Assess the rewards your work can realistically deliver. • Develop good communication skills and treat coworkers with respect. • Join rap sessions with coworkers. Be part of the solution, not part of the problem. • Do not exceed your limits—you do not always have to say yes. • Deal with other people's anger by asking yourself, "Whose problem is this?" • Recognize that you can teach other people how to treat you.

When an Assault Occurs: Placing Blame on Victims

• Victim gender Women receive more blame than men. • Subject gender Female victims receive more blame from women than from men. • Severity The more severe the assault, the more often the victim is blamed. • Beliefs The world is a just place, and therefore the person deserves the misfortune. • Age of victim The older the victim, the more he or she is held to blame.

Questions for Self-Assessment

• What does the term health mean to me? • What prevents me from living this definition of health? • Is health important to me? • Where do I find support? • Which coping methods work best for me? • What tasks cause me to feel pressured? • Can I reorganize, reduce, or eliminate these tasks? • Can I delegate or rearrange any of my family responsibilities? • Can I say no to less important demands? • What are my hopes for the future in terms of (1) career, (2) finances, (3) spiritual life and physical needs, (4) family relationships, (5) social relationships? • What do I think others expect of me? • How do I feel about these expectations? • What is really important to me? • Can I prioritize in order to have balance in my life?

With each additional patient assigned to a nurse, the following occurred:

■ A 30-day mortality increase of 7% ■ Failure-to-rescue rate increase of 7% ■ Nursing job dissatisfaction increase of 15% ■ Burnout rate increase of 23% ■ 43% of nurses surveyed suffering from burnout

The idea that personal hardiness provides a buffer against burnout has been explored for several years. Hardiness includes the following:

■ A sense of personal control rather than powerlessness ■ Commitment to work and life's activities rather than alienation ■ Seeing life's demands and changes as challenges rather than as threats - The hardiness that comes from having this perspective leads to the use of adaptive coping responses, such as optimism, effective use of support systems, and healthy lifestyle habits - In addition, letting go of guilt, fear of change, and the self-blaming, "wallowing-in-the-problem" syndrome will help you buffer yourself against burnout

What are your responsibilities related to preventing sharps injuries? You will need to learn how to use new devices and make certain that the current safety requirements are enforced:

■ Always use universal precautions. ■ Use and dispose of sharps properly. ■ Obtain immunization against hepatitis B. ■ Get involved in sharps selection. ■ Keep your training up to date. ■ Report all exposures immediately following your facility's protocol. ■ Comply with post-exposure follow-up procedures and policies. If you have questions about treatment for a needlestick, you can call the National Clinician's Post-Exposure Prophylaxis (PEPLine) number, 1-888-448-4911

Nurses in a pediatric intensive care unit reported some additional sources:

■ Bodily caring, especially when it was necessary to inflict pain on a child ■ Being "tethered" to their patients continuously for 12 hours ■ Dealing with inexperienced medical residents ■ Taking on others' work (e.g., therapy on the weekend, double-checking doctors' orders) without credit for it ■ Malfunctioning equipment

Developing a safety plan includes the following:

■ Distinguish real from imagined risks. ■ Consult federal, state, and local regulations and experts on work safety. ■ Seek evidence-based practices related to the problem. ■ Develop a plan to reduce risks. ■ Calculate the costs of the program or plan. ■ Seek administrative support for the plan.

The following are a few ways in which horizontal violence can be addressed:

■ Establish a zero-tolerance policy for these behaviors. ■ Develop a code of conduct that specifically addresses these behaviors. ■ Administrators, supervisors, and managers can model appropriate behavior. ■ Discuss strategies for handling such behavior in meetings with staff. ■ Report bullying behavior to your nurse manager. ■ Confront bullying and belittling behavior; express your concerns objectively.

The following will help to decrease the potential for latex allergy problems (CDC, 1998):

■ Evaluate any cases of hand dermatitis or other signs of latex allergy. ■ Use latex-free procedure trays and crash carts. ■ Use nonlatex gloves for activities that do not involve contact with infectious materials. ■ Avoid using oil-based creams or lotions, which can cause glove deterioration. ■ Seek ongoing training and the latest information related to latex allergy. ■ Wash, rinse, and dry hands thoroughly after removing gloves or when changing gloves. ■ Use powder-free gloves.

To assess the risk of violence, nurses must know their workplace. Ask the following:

■ How frequently do assaultive incidents, threats, and verbal abuse occur in your facility? Where? Who is involved? Are incidents reported? ■ Are current emergency response systems effective? ■ Are staffing patterns sufficient? Is the staff experienced in handling these situations? ■ Are post-assaultive treatment and support available to staff?

Instead of being preoccupied with the past or the future, acknowledge the present moment and say the following to yourself:

■ I choose to relish my days. ■ I choose to enjoy this moment. ■ I choose to be fully present to others. ■ I choose to fully engage in the activity at hand. ■ I choose to proceed at a measured, effective pace. ■ I choose to acknowledge all I have achieved so far. ■ I choose to focus on where I am and what I am doing. ■ I choose to acknowledge that this is the only moment in which I can take action.

Preventive measures to avoid RSI include the following:

■ Keep the monitor screen straight ahead of you, about an arm's length away. The top of the screen should be at eye level. ■ Align the keyboard so that your forearms, wrists, and hands are parallel to the floor. Tilt if needed to keep wrists in neutral position. ■ Position the mouse (if used) directly next to you and on the same level as the keyboard. ■ Keep thighs parallel to the floor as you sit on the chair. Feet should touch the floor, and the chair back should be ergonomically sound. Or use a stand-up desk to further vary position. ■ Vary tasks. Avoid long sessions of sitting. Do not use excessive force when typing or clicking the mouse.

Indications of an organization's diversity "fitness" include the following:

■ Minorities are represented at all levels of personnel. ■ Individual cultural preferences pertaining to issues of social distance, touching, voice volume and inflection, silence, and gestures are respected. ■ There is awareness of special family and holiday celebrations important to people of different cultures.

Preventing an incident is better than having to intervene after violence has occurred. The following are suggestions to nurses about how to participate in workplace safety related to the prevention of violence:

■ Participate in or initiate regular workplace assessments. Identify unsafe areas and factors within the organization that contribute to assaultive behavior, such as inadequate staffing, high-activity times of day, invasion of personal space, seclusion or restraint activities, and lack of experienced staff. Work with management to make and monitor changes. Consider the use of metal detectors, video surveillance, and increased use of security personnel, but remain aware of the need to maintain patient privacy. ■ Be alert for behaviors that precede violence, such as verbal expressions of anger and frustration, threatening body language, signs of drug or alcohol use, or the presence of a weapon. Evaluate each situation for potential violence. ■ Know your patients. Be aware of any history of violent behaviors, diagnoses suggesting potential for violent behavior, and alcohol or drug intoxication. Monitor those with a history of violence and alert staff members to take precautionary measures. This type of surveillance has been reported to reduce violent attacks by 92%. ■ Maintain behavior that helps to defuse anger. Present a calm, caring attitude. Do not match threats, give orders, or present with behaviors that may be interpreted as aggressive. Acknowledge the person's feelings. ■ If you cannot defuse the situation, then remove yourself from it quickly, call security, and report the situation to management.

There is much that your employer can do as well to reduce workplace stress and mitigate its effects. These actions include:

■ Provision of well-prepared preceptors and mentors for newly employed nurses ■ Sufficient staffing so that employees can take breaks and vacation time ■ Peer support groups ■ Debriefing after critical events have occurred ■ Well-developed employee-assistance programs (EAPs) for counseling when needed ■ Stress reduction training and workshops ■ On-site exercise rooms ■ On-site relaxation rooms

What if, in spite of all precautions, violence occurs? What should you do? You should:

■ Report to your supervisor. Report threats as well as actual violence. Include a description of the situation; names of victims, witnesses, and perpetrators; and any other pertinent information. ■ Call security. Nurses are entitled to the same protections as anyone else who has been assaulted. ■ Get medical attention. This includes medical care, counseling, and evaluation. ■ Contact your collective bargaining unit, your state nurses association, or OSHA if the problems persist. ■ Be proactive. Get involved in policy making

Suggestions for nurses who rotate shifts include the following:

■ Shorter (8-hour) shifts allow you to get at least 7 hours' sleep before returning to work. ■ Try to schedule the same shifts for an entire scheduling period instead of rotating different shifts within one scheduling period. ■ Try to schedule the same days off consistently. ■ If you become sleepy during the shift, try exercise (take a walk or climb stairs), bright light, a brief nap if possible, and a cup of coffee (not near the end of your shift). ■ If you work evenings or nights, do not eat a big meal or take caffeine or alcohol at the end of the shift as this interferes with sleep. Try to avoid using sleep medications. ■ If driving home in bright morning light, put on sunglasses. ■ Try to sleep a continuous block of time at regularly scheduled times instead of catching a few hours here and there. ■ Make sure the room you are sleeping in is a comfortable temperature and as dark and noise-free as possible. ■ Find time to maintain good nutrition and daily exercise. ■ Self-scheduling increases perceived control and may reduce the stress of shift work.

Some of the circumstances surrounding health-care work contribute to workers' susceptibility of violence, such as the following:

■ Units for treating violent individuals ■ Patients needing seclusion or restraint ■ Increased numbers of acute and chronic mentally ill patients being released without effective follow-up ■ Working late or until very early morning hours ■ Working in high-crime areas ■ Working in buildings with poor security ■ Treating weapons-carrying patients and families ■ Inexperienced staff who have not been trained to manage crises or handle volatile situations ■ Long wait times for service ■ Overcrowded, uncomfortable waiting areas

The surgical setting presents special challenges to prevent sharps injuries because of such factors as the intense pressures of the situation, open wounds susceptible to contamination, and extensive use of sharp instruments. Thirty percent of sharps injuries occur here, and the encouraging decline in injuries seen in other areas of the hospital has not yet been seen in the surgical setting. Some recommendations for addressing this risk include:

■ Use blunt-tip suture needles where possible. ■ Use safety scalpels, either sheathed or retractable. ■ Initiate the hands-free technique (HFT) or neutral passing zone (a container or sterile towel) instead of passing instruments hand-to-hand. ■ Double glove to increase protection from punctures. ■ Share information (educate) with staff about sharps injury prevention.