Thursday, May 14, 2015

Do Associate Degree Registered Nurses Fare Differently in the Nurse Labor Market Compared to Baccalaureate-Prepared RNs?

This is an important discussion I couldn't pass on posting!

David I. Auerbach, PhD, Peter I. Buerhaus, PhD, RN, FAAN, Douglas O. Staiger, PhD
Nurs Econ. 2015;33(1):8-12.

Abstract and Introduction


Unlike most other countries, there have long been multiple routes toward becoming a registered nurse (RN) in the United States. For decades, RNs have been prepared via three main pathways; a 2-year associate's degree program, a 3-year hospital-based diploma program, and a 4-year baccalaureate program leading to a bachelor's degree in nursing (BSN). Diploma programs have all but disappeared, leaving roughly equal numbers of RNs obtaining their initial preparation toward becoming an RN via the associate's degree programs (ADN) or the BSN. According to the National Sample Survey of Registered Nurses (n.d.), of RNs completing their initial RN education between 2005 and 2008, approximately 3% were prepared via a diploma program, 57% via an ADN, and 40% via a BSN.
Not apparent in those figures, however, is a recent apparent shift in basic entry nursing education away from the ADN and toward the BSN (Buerhaus, Auerbach, & Staiger, 2014). Beginning roughly a decade ago, the American Nurses Credentialing Center (2013) began designating hospitals as Magnet® institutions based on certain quality and other benchmarks, one of which is that by January 2011, 75% of nurse managers must have at least a BSN. Then, building on a series of research studies over the last decade beginning with Aiken, Clarke, Cheung, Sloane, and Silber (2003) who indicated the risk of inpatient mortality is lowered in hospitals employing a greater share of BSNprepared RNs, the Institute of Medicine (2010) recommended 80% of RNs be prepared at the BSN level by 2020. States and institutions appear to have taken up the call; by 2014, 80% of California hospitals require new RN staff to have a BSN (Bates, Chu, Keane, & Spetz, 2014).
These forces may be having important implications for the nursing workforce. Kovner, Brewer, Fatehi, and Katigbak (2014) recently comparing a cohort of roughly 1,000 newly licensed nurse graduates (2010–2011) and found 82% of new BSN graduates were em ployed in hospitals within 18 months of graduation compared to 67% of ADN graduates. In contrast, in an earlier similar cohort graduating in 2004–2005, 83% of new ADN graduates found hospital jobs in the same time frame after graduation. Kovner and colleagues (2014) cited "anecdotal re ports that hospitals are preferentially hiring RNs with a BSN and that if they do hire associate's de gree grad uates, they are requiring those nurses to get a BSN within a specified period" (p. 32). In fact, in 2010, while there were roughly 80,000 ADNs and 50,000 BSN nursing degrees awarded among newly licensed RNs, another 22,000 RNs completed RN-to-BSN programs, converting their ADN preparation to a BSN (Bates & Spetz, 2012).
With the exception of the study by Kovner and associates (2014), however, it is unclear if this apparent preference for BSN-prepared RNs has markedly changed the labor market outlook for a RN who has completed an ADN. These programs have proliferated (along with BSN programs) in the largest expansion of undergraduate nursing education in recent history (Auerbach, Buerhaus, & Staiger, 2013). If this preference for BSN-prepared RNs is truly widespread and universally accepted, one might expect ADNs to be shifting to other employment settings and/or receiving lower wages. In this article, recent employment and earnings data from the American Community Survey is examined to determine whether any of these expected changes are occurring in the nurse labor market.

Data and Methods


The primary data used in the analysis are from the American Community Survey (ACS) (King et al., 2010). The ACS, which began reporting data in 2001, is modeled after the long form of the decennial census (U.S. Department of Labor, 2014) and obtained responses from approximately 12,000 RNs each year from 2001 to 2004 and roughly 30,000 RNs per year thereafter (after the sampling frame was expanded). The ACS identifies RNs by allowing respondents to select their occupation and obtains additional data on respondents' age, educational level, income, industry sector, and other demographic information and has been used extensively by our team to analyze the nursing workforce (Auerbach, Buerhaus, & Staiger, 2011).
Data on RNs between the ages of 21 and 64 were used in this analysis for the years 2003–2013; RNs reporting working fewer than 30 hours in a typical week were recorded as 0.5 full-time equivalents (FTE). RNs reporting a master's level of education or higher were excluded to focus specifically on RNs working as an RN (rather than as a nurse practitioner, for example, which requires a BSN typically followed by an advanced degree). Although the ACS data were first collected in 2001, this analysis begins with 2003 because of a change in the education questions between 2002 and 2003. The final sample included 217,815 RNs across all years.

Identifying Nursing Education

To our knowledge, the ACS has not been used to distinguish ADNs from BSNs in peer-reviewed research. ACS respondents report whether their highest level of education completed is an associate degree, a 4-year college degree, or one of various types of higher degrees such as master's or doctorate. As a simplification, we classified all RNs reporting a bachelor's degree as a BSN-prepared RN and RNs with less-reported education as ADN-prepared RNs (RNs with at least a master's degree were removed from the sample). The reported degrees in the ACS are not nursing-specific, although respondents could indicate a field for baccalaureate degrees starting in 2009. (This information was not used for purposes of consistency with the time period before 2009.) Thus, RNs prepared with diploma degrees (of which there are very few in recent years) would likely be unsure how to classify their education in the ACS. More importantly, RNs with bachelor's degrees in non-nursing fields but no higher than an ADN in nursing would likely select a bachelor's degree as their highest degree and we would be unsure whether they were a BSN or ADN-prepared RN.
To validate the ACS-based assignments, data from the National Sample Survey of Registered Nurses (NSSRN) from 2008 were analyzed and compared to the reported education of RNs to the educational categorization of RNs from the ACS in that same year. The NSSRN, discontinued in 2008, asked RNs directly about their initial and any subsequent nursing degrees as well as other non-nursing degrees. In 2008 NSSRN data, just 5% of respondents had a non-nursing baccalaureate degree but also a highest nursing preparation of an associate's degree. (Another 8% of RNs had baccalaureate degrees both in nursing and in a non-nursing field, but these individuals would be correctly classified in the ACS as BSN-prepared RNs). Overall, after excluding all RNs with a master's degree or higher, our assignments in the ACS yielded 41.3% of RNs with an ADN as their highest nursing degree and 58.7% with a BSN. This is similar to the comparable figures of 43.8% and 56.2%, respectively, in the NSSRN. Other characteristics of ADN-prepared RNs and BSN-prepared RNs were compared between both surveys – patterns were identical. In both surveys, the BSN-prepared RNs were more likely to be male, non-White, unmarried, higher household income and nursing income, foreign educated, and working in hospitals (data available upon request).

Other Labor Force Measures

Labor market outcomes were recorded from direct questions asked in the ACS survey. Unemployed RNs were defined using variables constructed within the ACS based on detailed questions concerning the respondent's employment status (looking for but unable to find employment). Respondents were asked to report their income from wages and salaries in the previous 12 months; this dollar amount was used as an estimate of earnings from nursing employment. Earnings figures were reported only for RNs who work full time, as defined by those reporting working more than 30 hours per week. Finally, all ACS respondents were asked to identify their industry setting from a list that we consolidated into hospitals, offices of physicians and other health professionals, nursing homes and other long-term care settings, other health care settings, and settings unrelated to health care.
To make estimates representative of the U.S. noninstitutionalized population, observations were weighted by sampling weights provided by the ACS. In several instances, statistical significance of differences between ADN and BSN RNs are reported. These tests were conducted using two-tailed tests, with 0.05 as the level governing statistical significance.


Differences Between ADN-prepared RNs and BSN-prepared RNs

Differences in the rate of unemployment among both types of RNs are shown in Figure 1. Though historically quite low, the unemployment rate has diverged between RNs prepared with a BSN and those with an ADN in recent years.

Figure 1. Unemployment Rate of RNs, by Ultimate Degree Type, 2003–2012
While fluctuating between 1% and 1.5% from 2003 to 2009 for both ADNs and BSNs, the unemployment rate for two groups then began to differ significantly, growing to 1.9% among ADNs in 2013 compared to 1.2% among BSNs in that year (p<0.01). With roughly one million RNs in each group in recent years (excluding RNs with master's degrees or higher), an unemployment rate of 2% represents roughly 20,000 RNs.
The trends in FTE employment suggest a fairly dramatic divergence in hospital employment by type of basic nursing education (see Figure 2 and Table 1). In 2003, a similar percentage of RNs with each degree type worked in hospitals. A few years later, a gap in hospital employment had started to materialize, and, by 2013, more than 10 percentage points separated the two groups, with 72% of BSN graduates employed in hospitals compared to 61% of RNs whose highest degree was an ADN. These data are consistent with a growing preference for BSN-prepared RNs on the part of hospitals.

Figure 2. Percent of Full-Time Equivalent RNs Employed in Hospitals By Ultimate Degree Type, 2003–2013
A further breakdown of trends in work settings of ADN and BSN-prepared RNs outside of the hospital is shown in Table 1. The data provide insights into alternative settings that appear to have drawn the ADNs who might have otherwise been employed in hospitals. It appears roughly 10% of ADN-prepared RNs have shifted from hospitals to long-term care settings over this period. For example, in 2003, 13% of ADNs were employed in long-term care settings – a percentage that grew to 18% by 2013. In contrast, the proportion of BSN-prepared RNs working in long-term care settings remained at roughly 10% throughout the period. The percentage of ADN-prepared RNs employed in offices of physicians and other professionals hovered around 10% throughout the period where as the percentage of BSN-prepared RNs employed these settings decreased from 9.1% in 2003 to 7.7% in 2013.
Finally, trends in overall earnings and earnings among hospital-employed RNs over the same time period are shown in Figure 3. In contrast to the trends shown in Figures 1 and 2, the data shown in Figure 3 do not indicate a divergence over the 10-year time period. If anything, the wage gap between ADNs and BSNs, which has been relatively constant over the last decade at roughly $10,000 for RNs in hospital and other settings, has shrunk slightly in the last 2 years.

Figure 3. Overall and Hospital-Employed Earnings of Full-Time Equivalent RNs by Ultimate Degree Type, 2003–2013

NOTE: Earnings figures exclude those of RNs working fewer than 30 hours per week.
Labor market outcomes can be expected to differ for newly graduating RNs who are seeking their first jobs compared to more experienced RNs. The sample of RNs was limited to those under 35 years of age to test for possible differences from the trends noted previously. Among younger ADN RNs, the rate of hospital employment dropped from 70% to 63% between 2010 and 2013. Unemployment rates for ADN-prepared RNs were double those of their BSN counterparts in 2013 (1.9% vs. 0.9%), but figures were more jumpy in earlier years. Similarly, as with all RNs, the earnings gap did not change significantly over time.


In two of three labor market outcomes analyzed using data from the ACS, there was a divergence of the experience of AND-prepared RNs compared to BSN-prepared RNs. ADNs are more likely to be unemployed (though unemployment rates are still extremely low) and increasingly less likely to work in hospitals than their BSN counterparts. These findings are consistent with hospitals' expressing a preference for BSN graduates in recent years. On the other hand, although BSN earnings are greater than ADN earnings in every year of the sample, there does not appear to be a widening divergence in the earnings between BSN and ADN-prepared nurses.
As with any labor market evaluation, it is difficult to discern whether the observed differences in unemployment rates and hospital employment by level of nursing education reflect the RN's education itself, or whether other characteristics of the RN who may obtain different degrees could also be related to these labor market outcomes. With regard to the latter possibility, it is unlikely in the short time frame of these observations (2003–2012) that characteristics of RNs who obtained an ADN or a BSN have changed substantially. Rather, the timing of the divergence in unemployment rates between ADN and BSN-prepared RNs, and to some extent, the increased employment of BSNs in hospitals found in this analysis, appears to have occurred several years before the 2010 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health was released. In the middle part of the decade, hospitals were becoming aware of a growing body of evidence indicating the association of lower mortality and higher BSN-educated RNs. Moreover, in 2008 the Centers for Medicare & Medicaid Services and several states began to link hospital payment to performance on avoidable inpatient outcomes, some of which were sensitive to nurse staffing (Kurtzman & Buerhaus, 2008) Later, the IOM (2010) report was released. The IOM emphasized the need for a more highly educated nursing workforce, and its wide dissemination more than likely provided "tipping point" information that influenced employers' decisions to prefer the more highly educated BSN.
Finally, it should be noted our estimates of RNs by level of educational preparation are imperfect. As noted previously, the educational categories in the American Community Survey are not designed specifically to identify nursing education. Also, individuals in the ACS are identified as nurses by their answers to the occupation questions. Yet, in both cases, findings from the ACS have been validated against data from the NSSRN and workforce and educational estimates are very similar.

Policy Implications

The IOM set a goal of 80% of newly graduating RNs having a BSN by 2020. This call has been echoed by others who have suggested a BSN-level preparation is needed for the increasing complexity of care (American Association of Colleges of Nursing, 2014). Supported by the Affordable Care Act, health care delivery organizations are placing increasing emphasis on quality metrics, care coordination, population health management, and prevention and education. Accountable Care Organizations, expanding rapidly in the last several years, have strong financial incentives to manage care of their enrollees. These organizations seek to reduce total costs and improve quality by requiring health care professions to eliminate care duplication, coordinate and manage care received at home and among fragmented providers, and reduce hospitalization.
Our results indicate, as did Kovner and colleagues (2014), ADN-prepared RNs appear to be experiencing diverging labor market outcomes from BSN-prepared RNs. Yet, at the same time, there has been a rapid increase in ADN educational programs over the last 10 years (Buerhaus et al., 2014). This growth may be helping to fill what would otherwise be a potential new nursing shortage as the baby boomer RNs begin to exit the workforce? Even if ADN-prepared RNs are not always finding the hospital positions some of them expect upon entering nursing school, the widespread availability of RN-to-BSN programs provides a relatively easy step for conversion to a BSN. Ultimately, it is unclear whether ADNs are shifting away from hospital settings out of necessity because hospital jobs are unavailable, or if their skill set is better suited for less-acute nonhospital patients.
Thus, the increasing percentage of ADN-prepared RNs employed in nonhospital settings, just as demand for RNs in these settings appears to be increasing, is a finding that requires close monitoring (Spetz, 2014). Most studies of care outcomes differences between ADNs and BSNs have focused on hospital care; there is no evidence to suggest any quality differences in nonhospital settings. ADN programs may find it in their interest to specialize in, and focus on, the kinds of skills increasingly critical to enhanced ambulatory settings such as care coordination, communication, teamwork, population health, and education and prevention (Pittman, 2014). Ultimately, a robust, integrated, complex and efficient health care system requires a diverse nursing workforce and the schools that prepare nurses for this new world ought to anticipate these needs and graduate nurses with the skills and competencies required.

Tuesday, May 5, 2015

Cindy’s ‘Five RITES’ for fostering student-driven civility Part Two

Cindy’s ‘Five RITES’ for fostering student-driven civility
Second of a three-part series.
By Cynthia Clark

Some readers may know I am a professor in the School of Nursing at Boise State University. In June 2010, an article I co-authored with one of my nursing students, titled “What students can do to promote civility,” was published in Reflections on Nursing Leadership (RNL) as part of a five-part series on civility. As I mentioned in the first installment of this present series, nursing students are our promise and our hope. They are the Jedi Knights who will lead our noble profession to a bright future where personal and organizational civility reign. To frame this article, I have developed the Five RITES of Civility:
  • Raise awareness and expose effects of incivility.
  • Inspire action and catalyze change.
  • Take responsibility for creating civility.
  • Engage and commit to personal and organizational change.
  • Sustain results and generate more change.
Raise awareness and expose effects of civility
Raising awareness with students about the power of civility and the negative consequences of incivility in academic and practice settings is an important and vital endeavor. Students at the very beginning of their nursing education need to know what is expected of them regarding professional behavior and what they can expect from others. Schools of nursing can raise awareness in a variety of important ways. As a result, students will better understand what civil, respectful, and professional behavior is; how to promote it; and how to integrate civility into their daily lives.

Consider raising civility awareness for incoming students during general student orientation. This is an excellent venue to introduce a number of ways for students to thrive in their academic pursuits. In our institution, our Statement of Shared Values (SSV), which includes academic excellence, caring, citizenship, fairness, respect, responsibility, and trustworthiness, is woven into the fabric of student orientation. Students learn from the very beginning of their college experience what being a member of the campus university means, why civility matters, and how the SSV provides a touchstone for all members of the university.

One of my favorite activities is to have students participate in slicing the “civility pie.”
In the school of nursing, we also conduct a formal student orientation. Before classes officially begin, newly admitted nursing students participate in a full-day program where we specifically address what it means to be a nurse, professionalism, ethical conduct, and the importance of civility. I am responsible for conducting the civility portion of the orientation process, though all faculty members and administrators in the school of nursing reinforce and extend the message in a variety of interesting and creative ways. I also facilitate a second civility workshop during Week 6 of the students’ first semester, where we reintroduce the concepts of civility, professionalism, and how students can promote a safe and civil teaching-learning environment.

In the initial orientation class, I present an overview of the state of the science on civility and incivility in nursing and engage students in activities focused on what they can do to promote civility throughout their nursing program. One of my favorite activities is to have students participate in slicing the “civility pie.”
I provide students with a large index card that is blank on both sides. With the students working independently, I ask them to draw a large circle on one side of their index cards. This is the civility pie. Next, I ask each student to slice his or her pie into three pieces—representing students, faculty, and school administrators—according to what he or she believes is the approximate amount of responsibility each group has for promoting civility. After the students divide their pies, I ask them to turn their cards over and provide a rationale for why they sliced their pies the way they did. Most of them divide the pie into three equal parts. I love it when students draw three circles around the perimeter of the pie and comment that all three groups—students, faculty, and administrators—are 100 percent responsible for fostering civility. Awesome!

One of the most enjoyable aspects of this exercise is discussing the students’ rationales for why they sliced—or didn’t slice—their civility pie the way they did. My favorites include: “Civility is a shared responsibility; we are equal partners.” “Civility helps grow and strengthen relationships.” “Leaders are the drivers of civility—and we’re all leaders.” And “Civility starts from the inside out.” In other words, “It starts with me.”

Inspire action and catalyze change
Raising awareness and actively discussing civility and incivility are crucial, but insufficient. We must also inspire action and engage students in making a commitment to create a civil academic environment. In addition to having students share how they slice their civility pie and their rationale for doing so, I ask them specifically what students can do to promote civility. This often results in a spirited and enlightening discussion where students identify specific actions, such as respecting others, being inclusive and collaborative, using open communication, being honest and nonjudgmental, and making a positive difference.

We also identify additional ways students can promote civility, which include engaging in stress-reducing behaviors, assuming personal responsibility for co-creating classroom and clinical norms, and conforming and abiding by those norms. We discuss the importance of modeling civility; engaging in respectful social discourse; and participating on teams, committees, and governance councils. We also reinforce the importance of attending class, being on time, being prepared, avoiding side conversations, and not using media devices in disruptive ways.

One of the new activities I will be using with students is the Clark Academic Civility Index for Students (below). This tool encourages students to think deeply about civil and respectful interactions with others and to engage in thoughtful self-reflection to improve their civility awareness and to identify strengths as well as areas that need improvement. It is important that educators who adopt the Clark Academic Civility Index instruct students to dedicate sufficient time and space to complete it. 
Students need to find a quiet place, void of distractions, to carefully consider the behaviors listed in the index and respond truthfully and candidly by answering yes or no regarding each behavior. Once students have completed the index and their civility score has been determined, I ask them to consider their score and identify areas of satisfaction as well as areas for improvement. I also urge students to share their index responses with a classmate, colleague, or mentor and to ask that person to compare the student’s response to the index with his or her assessment of the student. Are there similarities between how the student sees himself or herself with how he or she is viewed by others? Are there differences or gaps? Discuss with your students ways to maintain the positive aspects of their “civility index” and identify strategies to address those areas they wish to improve.

The Clark Academic Civility Index for Students
 Ask yourself the following questions, responding either “Yes” or “No”:
 Do I, the majority of time (80 percent or more) …
  1. Role-model civility, professionalism, and respectful discourse? Yes/No
  2. Add value and meaning to the educational experience? Yes/No
  3. Communicate respectfully (by email, telephone, face-to-face) and really listen? Yes/No
  4. Avoid gossip and spreading rumors? Yes/No
  5. Avoid making sarcastic remarks or gestures (staged yawning, eye-rolling)? Yes/No
  6. Pay attention and participate in class discussion and activities? Yes/No
  7. Use respectful language (avoid racial, ethnic, sexual, gender, and religiously biased terms)? Yes/No
  8. Avoid distracting others (misusing media devices, side-conversations) during class? Yes/No
  9. Avoid taking credit for someone else’s work or contributions? Yes/No
  10. Co-create and abide by classroom and clinical norms? Yes/No
  11. Address disruptive student behaviors and promote a safe, civil learning environment? Yes/No
  12. Take personal responsibility and stand accountable for my actions? Yes/No
  13. Speak directly to the person with whom I have an issue? Yes/No
  14. Complete my assignments on time and do my share of the work? Yes/No
  15. Arrive to class on time and stay for the duration? Yes/No
  16. Avoid demanding make-up exams, extensions, grade changes, or other special favors? Yes/No
  17. Uphold the vision, mission, and values of my school? Yes/No
  18. Listen to and seek constructive feedback from others? Yes/No
  19. Demonstrate openness to other points of view? Yes/No
  20. Apologize and mean it when the situation calls for it? Yes/No

Add up your “yes” responses to determine your Civility Index score:

  • 18-20 (90 percent or more “yes” responses)—Very civil
  • 16-17 (80 percent)—Moderately civil
  • 14-15 (70 percent)—Mildly civil
  • 12-13 (60 percent)—Barely civil
  • 10-11 (50 percent)—Uncivil
  • Less than 10—Very uncivil
Take responsibility for creating civility
The activities described above are just a few of the initiatives that can be implemented to encourage students to take responsibility for creating civility. There are a number of other ways to reinforce the positive focus achieved during orientation. However, I highly recommend collaborating with students to co-create classroom and clinical norms to foster a safe teaching-learning environment and to consistently and intentionally discuss with students the imperative of fostering civility.
One of the most effective ways to foster civility is to co-create behavioral norms. I contend that any organization devoid of norms (including the classroom) is a rudderless ship. Thus, co-creating classroom and clinical norms is essential to successful teaching and learning. In classes I teach, we begin co-creating classroom norms by describing the institution’s vision and mission, defining civility, and discussing the university’s Statement of Shared Values (SSV). With regard to the latter, we discuss how each provides a foundation upon which the vision of our college and school of nursing is based. We also co-create classroom norms by asking the following questions: “What behaviors do we want to see in class? What behaviors do we not want to see in class? And, once we determine and agree upon expected behaviors, how will we monitor their effectiveness?”
We also co-create norms in our clinical groups and involve our community partners (preceptors) in the process, so they have a voice in how we behave together in our clinical groups. It is everyone’s responsibility to reinforce and monitor adherence to the norms. At midterm, we conduct a formal evaluation of how the norms are working.
Classroom and clinical norms must be reviewed periodically, revised as needed, and reaffirmed throughout the course of the semester. Norms are living documents that provide a civility touchstone for students, faculty, and clinical partners. They provide a framework for working, collaborating, and learning with and from one another.

Engage and commit to personal and organizational change
To engage students in civility initiatives and encourage their commitment to personal and organizational change, I believe that we, as members of nursing faculties, must “begin at the beginning” with faculty members intentionally preparing students to identify and effectively address incivility in academic and practice settings. In a policy statement on lateral violence and bullying, the Center for American Nurses (2008) addressed the “reality shock” that new graduates experience and made several recommendations for eliminating disruptive behavior, including 1) disseminating information to nurses and students that addresses conflict and provides information about how to change disruptive behavior in the workplace, 2) developing educational programs on how to recognize and address disruptive behavior, and 3) implementing curricula to educate nursing students on ways to address and eradicate such behavior.

In response to these recommendations, I began to integrate, several years ago, civility content into my senior-level leadership course. We use a Problem-Based Learning (PBL) scenario with live actors (standardized patients, or SPs) to portray incivility among nurses in the workplace. Students prepare by reading specific articles on the topic before coming to class. In class, before we observe a “live” scenario, we engage in an interactive didactic presentation and large-group discussion. In the past, students from our university theater department portrayed the scenario, but last semester, I asked three student volunteers to enact it.
It was a rousing success! Two of the students acted out a situation in which a staff nurse was extremely uncivil to her co-worker, and a third student played the part of the nurse manager who used an evidence-based framework to address the conflict. After observing the enactment, students analyzed the scenario, developed and practiced specific ways to address the situation, and debriefed the encounter in a whole-class discussion.
I asked students about what they had observed, including how the scenario helped them learn about dealing with incivility in nursing practice. The majority of students viewed the enactment as realistic, believed the role of the nurse manager was crucial in addressing incivility, and identified the importance of teamwork, effective communication, and directed education—readings and group discussion, to name two. Students also commented that the scenario raised their civility awareness, provided them with specific ways to prevent and address incivility, and helped them to be more cognizant of their own behavior and how they treat others.

In small-group sessions, I asked students to consider specific ways they could foster civility in nursing education. They came up with some excellent suggestions, including 1) taking an active role in integrating civility into the nursing curriculum, 2) participating in candid discussions and open forums on the topic of incivility, 3) holding themselves and others accountable for uncivil actions, 4) rewarding civility, and 5) identifying helpful phrases to use when incivility occurs. The latter, an excellent suggestion based on the work of Martha Griffin (2004), is discussed briefly below.

Sustain results and generate more change
To counter uncivil behaviors and empower new nurses to address and confront uncivil co-workers, Griffin (2004), drawing upon cognitive rehearsal strategies, suggests identifying phrases to use when incivility occurs. Accordingly, after students observe a live PBL scenario, I have them generate and practice specific responses they can use to address uncivil co-workers in the workplace. The following are two examples of student-generated responses: 1) “It takes teamwork and support to care for our patients, and your behavior toward me is getting in the way. What can we do to resolve our differences?” 2) “I have noticed a conflict between us, and it is affecting our working relationship and caring for our patients. I would like to discuss the situation and resolve our differences.”

Once students have identified potential responses, we practice them and discuss their impact. Students write their responses on an index card, which they keep with them for use when and if a situation calls for it. This helps sustain results and generate more change. Time after time, student feedback reveals a vital need for integrating civility content into courses. More importantly, by adopting civility training into the nursing school curriculum, students are better prepared to foster civility in the academy, in the practice setting, and in life. RNL
Part Three: Molly’s perspective: How I applied No. 4 of Cindy’s ‘Five RITES (article by Cindy Clark's daughter)
For another article by Cindy Clark on civility and nursing students, see What students can do to promote civility.
Cynthia “Cindy” Clark, PhD, RN, ANEF, FAAN, professor at Boise State University School of Nursing and founder of Civility Matters, is a psychiatric nurse/therapist with advanced certification in addiction counseling. She is the author of “Musing of the great blue,” a blog written for Reflections on Nursing Leadership.
Center for American Nurses. (2008). Lateral violence and bullying in the workplace (Policy Brief). Retrieved from

Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. Journal of Continuing Education in Nursing, 35, 257-263.
Nurse educators: For more ideas on ways to promote civility in the classroom and in clinical environments, see Clark’s newly released book, Creating & Sustaining Civility in Nursing Education, from Sigma Theta Tau International

Wednesday, April 8, 2015

Students, Jedi Knights and the promise of civility Part One

Students, Jedi Knights and the promise of civility
First of a three-part series on fostering civility in nursing education and practice.
By Cynthia Clark

Some readers may know I am a professor in the School of Nursing at Boise State University and a fellow in both the American Academy of Nursing and the National League for Nursing’s Academy of Nursing Education. I am also the founder of Civility Matters. For more than a decade, I have studied incivility in academic and practice environments to develop evidence-based strategies to create and sustain cultures of civility. Very often, I am asked how I got involved in this topic. Here’s my story.
Before I accepted my faculty position at the university, I worked for more than a dozen years as a psychiatric nurse, specializing in adolescent and family mental-health issues. I was blessed to be a member of a hotshot crew of adolescent mental-health workers who treated teenagers living with a variety of mental-health and substance-abuse disorders. Many of our patients were gang members, adjudicated youth with a long history of violence and addiction-related problems.
Using a primary prevention approach, we helped teenagers settle disputes and disagreements with words and other nonviolent means, instead of resorting to weapons and physical violence. We also considered protective factors and resilience measures to equip our patients with effective ways to deal with stress and to recover from traumatic life events, including trauma resulting from exposure to violence. My clinical work with aggressive and violent youth has fully informed my program of research on preventing personal and organizational violence and continues to fuel my passion for creating communities of civility, not only on college campuses but everywhere.

Just me?
After leaving my clinical practice and assuming my role as a university professor, things were fairly status quo—in the beginning. Students seemed to focus on learning, and faculty, for the most part, enjoyed teaching. However, in the early 2000s, I began to witness a shift. I noticed attitudinal and behavioral changes in our nursing students. Some of the changes were subtle, but they set off alarm bells in my “gut,” because they reminded me of my earlier experiences with angry youth. Although my college students weren’t outwardly hostile, I noticed more and more rude and disruptive behaviors, and I wondered, “Is it just me?” I also wondered if my observations were even accurate; perhaps they were colored somewhat by my previous clinical work.
Armed with a probing and curious mind, I began my quest to learn all I could about this troubling phenomenon. I started asking other professors, reminiscent of a man- or woman-on-the-street interview. I engaged in some very provocative conversations, and what I discovered was fascinating. Several professors were witnessing disruptive student behaviors, such as students consistently being late for class, holding distracting side conversations, misusing cellphones, challenging faculty knowledge and credibility, and making harassing and demeaning comments. Some professors told me they were retiring or moving on to other employment opportunities, because the toxic classroom behavior and these uncivil encounters were psychologically and physically impacting their lives.

“I know where you live!”
About the same time, two major events happened that forever changed my life and set the course for my program of study on incivility. One event involved a very angry nursing student who failed a nursing course and, for some reason that still perplexes me, held me responsible for the failure. Another faculty member had issued the failing grade but, because I was the course coordinator, I had to make the final decision about the grading outcome. I upheld the failure, but the student grieved the grade.

My clinical work … continues to fuel my passion for creating communities of civility, not only on college campuses but everywhere.
Over the course of the student’s attempts to appeal the failing grade, he made personal threats that, to this very day, make my heart race. In his anger and rage, he threatened me with statements such as, “You need to change my grade to a passing grade because I know where you live, I know where you park your car, and I know where your kids go to school.” It was a terrifying experience and, in retrospect, after a decade has passed, I see how far we’ve come in being able to deal with these situations and prevent them from happening in the first place. Fortunately, this situation was safely resolved, but it left me a bit shell-shocked and questioning if I should stay in my faculty role.
The second event, which happened about the same time, was much more chilling. It involved the killing of three university nursing professors, two of whom were shot in cold blood in a large lecture hall while students were taking their midterm exam. A third nursing professor was later found dead in her office. The shooter, a disturbed nursing student, was apparently enraged over being barred from the exam. After killing the three professors, he turned the gun on himself and took his own life. Prior to the killings, the shooter mailed a lengthy manifesto to an area newspaper, detailing his plan to pull the trigger. I knew then that I was on to something, and I began to study this very important issue in earnest. Eventually, my interest extended beyond student behaviors to include faculty incivility and our potential contribution to this incivility problem.
My work encompasses student perceptions of academic incivility and garners student opinions on ways to address and resolve the problem. Incivility is an issue that, to some extent, all of us face in American society. Whether it’s road rage, desk rage or just plain rudeness, we are impacted by these behaviors. Incivility is an affront to human dignity and an assault on a person’s intrinsic sense of self-worth. The effects can be devastating and long-lasting. Exposure to uncivil behaviors can result in physical symptoms, such as headaches, interrupted sleep and intestinal problems. They can also cause psychological conditions, including stress, anxiety, irritability and depressive symptoms. Thus, it is important to raise awareness about the importance of fostering a civil and healthy academic work environment.
A little bit of cancer?
Sometimes, people make statements such as, “You know, Dr. Clark, in our organization, incivility isn’t really a problem because only one or two individuals are uncivil to or bully others.” Here’s my response: “Imagine you are a patient sitting with your primary care provider after undergoing a series of tests, and he or she says to you, ‘No worries. You are one of the lucky ones; you only have one or two malignant cells circulating in your body.’” Yes, of course, this is a ridiculous response, but I suggest to you that the same level of absurdity relates to incivility in the workplace.
It is my fervent belief, and the evidence bears this out, that one or two toxic employees can devastate an organization. For example, Pearson and Porath (2009) report that managers and executives of Fortune 1000 firms spend as much as 13 percent of their total work time—seven full weeks per year—addressing problematic employee relationships or replacing workers who leave the organization because of incivility. The authors cite one example where a hospital spent more than $25,000 dealing with just one uncivil episode.
The costs of incivility are vast. Uncivil behavior adds to employer and employee stress levels, erodes self-esteem, damages relationships and threatens workplace safety and quality of life (Forni, 2008). Incivility also lowers morale, causes illness and leaves workers feeling stressed, vulnerable and devalued. Therefore, creating and sustaining communities of civility is an imperative and a call to action for all of us. It is also my life’s work.
Civility does matter!
My primary thesis is this: If we identify and address lesser acts of incivility before they escalate into aggression or violence, we are far better off and, in the end, quality of life on all levels will be improved. And here’s what I believe to my very core: Civility does matter! It’s worth fighting the good fight to create and sustain healthy academic and practice workplaces where respect is highly regarded and where benevolence carries the day.
Healthy workplaces do not occur by accident. Creating them requires intention, purpose and bold leadership from all levels of an organization. Incivility takes a tremendous physical, emotional, spiritual and financial toll on everyone. We must do better. One of the most-read articles in Reflections on Nursing Leadership in 2010, the fourth of a five-part series, was one I co-authored with one of my nursing students, titled  What students can do to foster civility.
In the next installment of this three-part series, I will readdress what students can do to foster civility in nursing education. Nursing students are our promise and our hope, the Jedi Knights who will lead our noble profession to a bright future where civility reigns and respect rules the day. I am excited to share their suggestions for a civil tomorrow. RNL
Part Three: Molly’s perspective: How I applied No. 4 of Cindy’s ‘Five RITES’ (article by Cindy Clark's daughter)
For another article by Cindy Clark on civility and nursing students, see What students can do to promote civility.  
Cynthia “Cindy” Clark, PhD, RN, ANEF, FAAN, professor at Boise State University School of Nursing and founder of Civility Matters, is a psychiatric nurse/therapist with advanced certification in addiction counseling. She is the author of “Musing of the great blue,” a blog written for Reflections on Nursing Leadership.
Forni, P.M. (2008). The civility solution: What to do when people are rude. New York, NY: St. Martin’s Press.
Pearson, C., & Porath, C. (2009). The cost of bad behavior: How incivility is damaging your business and what to do about it. New York, NY: Penguin Group.

Monday, March 23, 2015

How healthy a nurse are you?

Healthy Nurse

ANA defines a healthy nurse as one who actively focuses on creating and maintaining a balance and synergy of physical, intellectual, emotional, social, spiritual, personal and professional wellbeing. A healthy nurse lives life to the fullest capacity, across the wellness/illness continuum, as they become stronger role models, advocates, and educators, personally, for their families, their communities and work environments, and ultimately for their patients. Nurses at 3.1 million strong and the most trusted profession, have the power to make a difference! By choosing nutritious foods and an active lifestyle, managing stress, living tobacco-free, getting preventive immunizations and screenings, and choosing protective measures such as wearing sunscreen and bicycle helmets, nurses can set an example on how to BE healthy.
Accessible to all registered nurses and RN students, ANA is providing a comprehensive health risk appraisal (HRA) in collaboration with Pfizer Inc, free of charge. This HIPAA-compliant HRA gives nurses real-time data on their health, safety, and wellness, personally and professionally. Nurses can compare their results to national averages and ideal standards. Eventually, nurses will be able to compare their results to those of other nurses in specific groupings such as age or nursing specialty, when statistically relevant numbers are reached. Upon completion of the HRA, nurses are directed to a web wellness portal, filled with interactive quizzes, games, and pertinent resources. The HRA builds nursing data, inclusive of all ages and both sexes.
Visit now to take the HRA!
Just think, if all 3.1 million registered nurses increase their personal wellness and that of just some of their family, community, co-workers and patients, what a healthier world we would live in!
ANA has demonstrated its commitment to "HealthyNurse™" and safe and healthy work environments through our Nursing Practice and Work Environment department. We are here to assist you on your wellness journey, increasing safe and healthy personal and professional practices.

Friday, March 20, 2015

A Bit of the Right Kind of Selfishness...Self Care

Self-care and screenings

ANA, others encourage nurses to take that ounce of prevention

Like the long-running ad campaign that urges women to use a certain product because they are “worth it,” the American Nurses Association (ANA) is encouraging all nurses to view their own health, safety and wellness as a priority and not something that falls last on their to-do list.
More than a year ago ANA launched its HealthyNurse™ initiative to provide nurses with educational programs and online resources to become, or remain, healthy by eating nutritious foods, participating in physical activity, getting enough sleep and managing their stress ( Another key part of this health-focused initiative centers on nurses receiving the immunizations and preventive care and screenings they need — just like the general population they advise.
“A healthy work environment, health promotion activities and preventive care contribute to nurses’ overall health and well-being,” said Suzy Harrington, DNP, RN, MCHES, director of ANA’s Department of Health, Safety and Wellness. “We know nurses lead busy lives and are doing the best they can. But they — as we all — have a right to be healthy too, and that means prioritizing self-care and taking time to support their own healthy choices and preventive care.”
Other nurses expressed a similar perspective on RNs and self-care.
“We often talk about women being the health managers of their families,” said Catherine Ruhl, MS, CNM, director, Women’s Health Programs at the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN), an organizational affiliate of ANA. “A side effect of that is we manage others until something happens to us that gets our attention. And then a whole lot of things that seemed so important before, aren’t.
“I’d love to say women and all nurses are getting better about looking after their health. But it can be a challenge — even for us as health care professionals — to keep up to date with the various preventive care guidelines.”
Betty McGinty, MS, RN, CGRN, HSA, president-elect of the Society of Gastroenterology Nurses and Associates, Inc. (SGNA), sees generational differences in nurses’ approaches to managing their health.
“My experience is that generations X and Y and younger nurses tend to not work when ill and take better care of themselves,” said McGinty, also an ANA member. “And that’s a good trend.”
The following is a general overview of some of the preventive care activities that nurses should consider on their road to better health.
Starting with the heart
“As an advanced practice nurse with cardiology expertise, many nurses share with me their concern of developing heart disease,” said Joanna Sikkema, DNP, ANP-BC, FAHA, FPCNA, a member of the Preventive Cardiovascular Nurses Association (PCNA) Board of Directors and Florida Nurses Association member. “They often request information for cardiovascular disease risk reduction and request consultation for hypertension management.
“Nurses are so busy multitasking and taking care of others that finding the time to exercise and eat a healthy diet can be difficult, especially for those who are working odd shifts. Often due to work demands, nurses will skip meals or eat fast foods, which in general are high in cholesterol and sodium.”
These unhealthy practices, as well as not getting enough sleep, place nurses at risk for cardiovascular disease.
Sikkema noted that shift work and rotating shifts contribute to nurses getting less quality sleep, and those same work practices disturb their sleep cycles. That interference can set up inflammation in the body that can lead to cardiovascular complications, including hypertension and metabolic syndrome.
Cardiovascular risk increases with age, particularly in women who are peri- or post-menopausal, and many nurses are in this age group, she said. And although nurses are generally active in their daily work routine, the role of many is changing. They may be more sedentary in their work responsibilities, such as sitting and performing chart reviews, telemetry monitoring or telephone triage. These nurses can face a risk of hypercoagulation if they are sedentary for long periods of time, and at added risk if they are on birth control pills, she pointed out.
To promote cardiovascular health, Sikkema advises nurses to engage in the same traditional methods of preventive care that they frequently advise to their patients: maintain a healthy blood pressure, weight and BMI, and avoid tobacco use. One strategy to achieve appropriate levels includes eating a heart-healthy diet — not one based on extremes often found in many fad diets.
“I cannot overemphasize the benefits of daily exercise for collateral and coronary circulation and general heart health,” she said. “Stress management is also extremely important for nurses. Techniques such as guided imagery, relaxation breathing and yoga have been shown to lower blood pressure and improve overall health. Nurses need to take a few minutes daily to care for themselves.”
When it comes to screening, Sikkema said, routine cholesterol and blood pressure checks are critical.
Sikkema and PCNA, also an ANA organizational affiliate, are calling for more workplace-based healthy lifestyle initiatives which, she said benefit both the nursing workforce and employers. (PCNA offered a free live webinar examining these workplace initiatives May 15 to launch their “Walk the Talk” campaign. To view the archived webinar, “Creating a Heart-Healthy Workplace: The Job Begins with Us!,” go to:
“Like most busy people today, nurses spend a lot of time in the workplace,” Sikkema said. “These simple, daily lifestyle initiatives help promote a healthier and more stable workforce and can decrease costly emergency room visits and diagnostic testing.”
Other screenings
Although there are some slight — and controversial — differences in some preventive guidelines, AWHONN’s Ruhl said nurses need to be proactive when it comes to addressing their own primary care needs.
For example, the U.S. Preventive Services Task Force (USPSTF) suggests that most women receive biennial breast cancer screening — mammograms — beginning at age 50; the American Cancer Society recommends yearly mammograms beginning at age 40.
“When considering which mammogram guidelines to follow, people need to be very thoughtful and talk over the decision with a trusted provider,” Ruhl said. “They need to look at their family history, personal history, whether they smoke, and what level of risk they are willing to take on. If they are going to sleep better at night by getting an annual mammogram after age 40, then get one.”
Even self-breast examination is a source of differing opinions. The American Cancer Society considers it an option for women in their 20s. Other groups talk about the importance of self-knowledge — having an awareness of one’s own breast tissue and the changes that can happen, which is a viewpoint that AWHONN supports, according to Ruhl.
Guidelines on cervical cancer and HPV screening have nuances based on the recommending group, as well.
The American Cancer Society, American College of Obstetricians and Gynecologists and USPSTF generally agree that women should begin cervical cancer screening at 21 years old. Further, from age 21 to 29, women should get a pap smear every three years. And although there are slight differences among these groups for women aged 30 to 65, who are not at high risk for developing cervical cancer, overall women in this range should have a pap smear every three years or every five years if accompanying it with HPV testing, Ruhl explained. Those over 65 should be screened only based on their health history.
Ruhl suggests other routine screening for all nurses, such as intimate partner violence, skin cancer and HIV status. They also might want to consider genetic testing for breast and ovarian mutations, if they have a strong family history of these cancers, and, if they are baby boomers, screening for hepatitis C.
Another huge area of prevention is immunizations. Ruhl encourages nurses to receive annual influenza immunizations and keep up to date on Pertussis, which is particularly important for nurses working with babies or who have young families themselves.
Controversy also surrounds screening for prostate cancer, specifically the use of the prostate specific antigen test (PSA).
The Centers for Disease Control and Prevention (CDC) and federal agencies promote following the recommendation of the USPSTF.
Based on comments received and up-to-date research, the USPSTF concludes that “many men are harmed as a result of prostate cancer screening and few, if any, benefit.”
Further the task force noted, “A better test and better treatment options are needed. Until these are available, the USPSTF has recommended against [PSA-based] screening for prostate cancer.”
The American Cancer Society recommends that men make informed decisions — based on learning the risks and benefits — with their providers about whether to be tested for prostate cancer generally beginning at age 50. The organization also recommends that African-American men or those who have a close family history of prostate cancer talk with their providers about the test beginning at age 45.
With their recommendation, the American Cancer Society notes: “Research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment.”
Looking at GI health
SGNA has a website that is rich in resources to keep nurses, and in turn their patients, healthy — from infection prevention strategies to healthful eating.
But a key message that gastroenterology nurses preach is the importance of colon cancer screening. SGNA has been advocating for a national health care measure that would ensure that everyone in this country has access to colon cancer screening at no cost or low cost, said McGinty, director of Gastroenterology Services for Northside Hospital system in Atlanta, GA.
“I know that some people are afraid of having a colonoscopy — or the preparation for it, or feel that it is too time-consuming,” she said. “But it is the gold standard for colon cancer screening. And an early diagnosis ensures a much higher percentage of recovery.”
For most people, colorectal cancer screening should begin at age 50 and be performed every 10 years, according to current recommendations.
McGinty said that there also are workplace practices that can affect the health of gastroenterology nurses.
“Many members have written in our journal about ergonomic-related issues that gastroenterology nurses experience, and equipment that is available or emerging to prevent or reduce musculoskeletal disorders,” McGinty said. “For example, many GI nurses have upper extremity injuries because they supply abdominal pressure with their hands to enable the passage of scopes.”
One preventive workplace strategy for nurses who work in GI labs and in ORs are anti-fatigue floor mats, which can automatically help shift nurses’ weight and prevent stasis of blood in the lower extremities, McGinty said. She added that there are many position statements that address nurses’ risks and strategies at the SGNA website,
And finally, RNs have an advantage over the general public in that they understand health promotion and disease prevention.
Said Harrington, “By participating in routine preventive care and healthy behaviors, nurses are in a strong position to not only be healthier themselves, but also to serve as real role models for their patients, families and communities.”
— Susan Trossman is the senior reporter for The American Nurse.


ANA’s HealthyNurse™:
United States Preventive Services Task Force (USPSTF) recommendations:
USPSTF mobile app:
Agency for Healthcare Quality and Research guidelines comparison:
American Cancer Society guidelines:
American Heart Association:
Immunizations: The Centers for Disease Control and Prevention: and American Nurses Association
“Creating a Heart-Healthy Workplace: The Job Begins with Us!” visit:

Thursday, March 19, 2015

What do you do with a PhD in nursing?

What do you do with a PhD in nursing?
I now view the question as an opportunity to educate.
By Tiffany Montgomery
Almost weekly, I am asked about my choice to pursue a Doctor of Philosophy in nursing. The frequency of this makes me wonder if the general public only sees nurses as bedside handmaidens who take orders from physicians. The more frustrating thing is when these probing questions come from other PhD students.
I was shocked the first time I was asked by a non-nursing PhD student, “What do you do with a PhD in nursing?” I’ve now grown used to hearing this question from my doctoral colleagues outside the school of nursing. Still, it’s quite bothersome, because the question usually isn’t framed as an inquiry about what area of research I’m interested in or what type of employment I plan to seek upon graduation. It’s more, “Why in the world would a nurse want a PhD?”
Before I became accustomed to the question, I wasn’t sure how to answer it. Oftentimes, it was difficult to decipher whether or not the person asking was trying to be sarcastic (especially if the question came from another PhD student). At one point, I became irritated by the question and started giving a pretty snappy reply: “The same thing you do with a PhD in anything else!”
After completing a year of doctoral studies, however, I now realize that the general public is unaware of all the wonderful avenues available to nurses. So, now I view the question as an opportunity to educate.
What do you do with a PhD in nursing? Whatever you want! There are PhD-prepared nurses who teach, conduct research, evaluate programs, write books, lead health care organizations and work for the government. With a doctoral degree, the sky is the limit. One thing I doubt most nurse PhDs want to do is work full time in direct patient care. At the doctoral level, nursing is less about hands-on patient care and more about the abstract thinking that helps move the profession forward. More than anything else, a nurse with a PhD has the training needed to conduct research and add to the body of available nursing research knowledge. While not all PhD-prepared nurses choose to work as researchers, all have been exposed to great amounts of research and have had to demonstrate their ability to conduct high-quality research on their own.
Three jobs I’ve noticed that most PhD-prepared nurses consider are listed below. The job descriptions provided are based on my observations of nurses employed in these positions, and they may vary from facility to facility:
Nursing faculty memberA nurse educator who works in an AS, BSN, MSN or PhD program as a classroom instructor. Nurse faculty members are also responsible for creating, implementing and evaluating program curricula and mentoring nursing students. Oftentimes, in addition to their teaching responsibilities, they are expected to conduct research. They typically disseminate this research in scholarly journals and at research conferences.
Director of nursing researcha nurse researcher who serves as administrator of the nursing research department of a health care facility or coordinator of the facility’s nursing research program. The director may supervise other nursing research employees, or he or she may be responsible for overseeing all nursing research projects conducted within the facility. The director of nursing research is typically the go-to person within the facility for questions regarding the design and implementation of a desired research study. He or she may or may not be responsible for dissemination of research findings.
Director of clinical servicesa clinical administrator who oversees daily operations of patient care departments in a health care facility. He or she is the liaison between upper management and department managers. Although the director is not involved in direct patient care, he or she is aware of the work flows in each department that promote optimal patient care. The director may generate or receive reports addressing the efficiency of departmental work flows, and this information is then given to each department manager in an effort to increase efficiency and patient satisfaction.
Other jobs available to PhD-prepared nurses include research or high-ranking administrative positions in pharmaceutical companies, research institutes, health advocacy organizations, health care information technology corporations and nursing or other health-related publishing companies. A nurse who has attained a PhD can practically work anywhere that research, education, or program evaluation takes place. The important thing to remember is that graduation from a reputable PhD program ensures that a nurse has received proper research training.
Reflections of Nurse Leadership