Tuesday, June 23, 2015

Recharge Your Energy With Less Stress

Recharge Your Energy With Less Stress

Nurses know stress.
In a job that is often 24/7 and requires the most technical and most empathetic skills to be used simultaneously and at a moment’s notice and often in less-than-ideal and sometimes dangerous conditions, a nurse’s job is hardly peaceful.
But Amiee Bernstein, author of Stress Less. Achieve More. and president of Open Mind Adventures, says you can use that ramped-up adrenaline to actually get more done. If you can stop fighting against the constant demands, you can actually get into a healthier zone where you can be more productive and more centered.
There’s a difference between stress and pressure, says Bernstein, and understanding how each impacts your typical day is important. “Webster defines pressure as a force or a power or energy that comes in contact with a surface, fluid, or object,” she says. “I use pressure as energy. Pressure is our energy, our life force, and the energy of change.”

Pressure vs. Stress
But stress is something entirely different and most of us want less stress. “Pressure is good,” she says. “Stress is not good. When you are open to pressure, your capacity increases and your perception is enhanced.” Stress is the opposite – it depletes your energy.
As an example, Bernstein says no matter how tired you are, when there’s an emergency at work, your body provides that rush of energy to help you do your job. “As a nurse, if you are open to it, you will perform very well,” she says. “If you resist it, you will feel discomfort and distress.”
You can use these tips for deciding what’s pressure in your life and what causes you stress and how you can choose to change how you react.

Bernstein says is helps to become aware of your own stress triggers. A coworker might thrive under a huge list of expectations, while that same task list makes you feel resentful. No one is right or wrong about a trigger, but it helps to know what makes your stress rise. If you know your triggers, says Bernstein, you then have the power to choose how you will let it affect you.

Bernstein refers to this as “hereness,” which is how you assess before you react. Workers in stressful roles – nurses, physicians, military personnel – act from their bodies in an emergency. Being present means you listen to your intuition first, often before you have time to think through a scenario. You react based on experience. But your intuition isn’t just guessing. “You have to practice it,” says Bernstein, so you can determine if your attention is focused within yourself (only on what you are feeling), out of yourself (only on what others are feeling), or a balance of both (when you can attend to others’ needs while recognizing your own).
Wherever your attention is, that’s your center,” says Bernstein. Once you are aware and present, controlling the stress and opening to pressure so you can function at your best means noticing when there’s an imbalance so you can find your center.

You don’t have to be tension free to function at your best, she says, but you do have to work so that the tension doesn’t overtake your energy. How can you tell is you need less stress? Is your back tight? Are your shoulders hunching? Is your stomach in knots? If that’s happening, taking deep breaths (Bernstein even recommends holding your breath for just a bit to break out of the cycle) and realizing the source of stress and how it’s beginning to impact you is necessary. “That’s your yellow light flashing,” Bernstein says.

No one can have a life free of stress and pressure, but you can learn how to manage them. “When you are working without pressure, there’s no motivation or drive,” says Bernstein. “That’s when you fall into complacency.”
Instead, notice when you react negatively and respond in ways that make you feel better. You can’t strike a yoga pose in the middle of the ER, but you can notice how you feel and train your body to react differently and your experience, although pressured, will be less stressful. You can even talk about individual triggers as a team so there’s more awareness at work of what might affect the team.
You will turn pressure into a positive force in your life,” says Bernstein.

Julia Quinn-Szcesuil

Thursday, June 11, 2015

Molly’s perspective: How I applied No. 4 of Cindy’s ‘Five RITES’ Part Three

Molly’s perspective: How I applied No. 4 of Cindy’s ‘Five RITES’
Or, What I learned in my first job after nursing school. Part Three of three-part series.
By Molly Clark

During my years as a nursing student, civility was not formally addressed in our classroom or clinical settings. It was implied that we were to treat professors and fellow students with respect, but we were not taught skills to deal with matters of incivility. It is important that nursing students and recent graduates recognize incivility and learn skills to deal with these issues because, although it can be very challenging to confront professors, co-workers, and managers about such matters, it is crucial to successful practice of our profession.
Although our professors did not teach us about civility, I talked with my mom [Cindy Clark, creator of Clark’s Five RITES of Civility] about the importance of civility and why it matters. And as I matured as a nursing student and began my career as a young nurse, I felt equipped to recognize incivility and address the problems I encountered.
I had proven I could talk to my manager about important matters without succumbing to intimidation or fear.
After graduating from nursing school, I started my first job as a psychiatric nurse, working with troubled adolescents. After three weeks of general orientation, I was on my own and, within four weeks, had become a charge nurse on the unit. For a new graduate, this was a lot of pressure. At times, I was left in charge of 24 teens, while supervising five staff members. This was stressful enough, but we were working with some adolescents who were violent and seriously mentally ill. The unit could change from complete calm to mass chaos in a minute, and it was my job to prevent that from happening.
I remember very vividly the first day I cried on the job. The morning started out quietly but, just before lunch, the calm was shattered with screams, shouts, and threats. What had been a relatively quiet setting suddenly crumbled around me and, to my surprise, I found that it was prompted by my manager’s actions. For some unknown reason, he purposely antagonized some of the patients, then walked off the unit and left me to deal with the aftermath.
In that moment, five seasoned staff members looked at me, expecting me to handle the volatile situation. I had to make some very difficult decisions that day, not black-and-white decisions but ones that required me to use all the critical thinking skills I had developed in nursing school and, up to that point, on the job. Throughout the entire episode, I was running on pure adrenaline, and it wasn’t until I was reporting to the next shift that I broke down. Yes, I was upset about what had happened, but mostly I was very frustrated.

After leaving work that day, I called my mom to talk about what had happened. I realized that most of my frustration boiled down to my manager’s involvement in the situation, topped off by my lack of training and experience in making difficult decisions. Mom and I discussed ways to address this particular situation to prevent it from happening in the future—not only for myself but also for other new graduates and, especially, for the patients.

Rite No. 4: Engage and commit to personal and organizational change
The next day, I asked my manager if I could talk with him about what happened the day before. I was very nervous going into the meeting, because I did not know how he was going to react to what I had to say. During our meeting, I talked about his involvement in the situation and how I felt as though he had walked off the unit at the very time we needed his help. Surprisingly, he completely accepted responsibility, and we discussed what he could have done differently. We spoke candidly and talked about how we would handle future situations. I expressed concern about my inexperience as a charge nurse and shared how my lack of training hampered my ability to make immediate decisions amidst a crisis situation.

I left that meeting feeling a lot better about myself and better prepared to deal with similar situations that may occur in the future. I had proven I could talk to my manager about important matters without succumbing to intimidation or fear. From that point on, I talked to my manager about ways to improve my work, and it made my transition much smoother. I was able to voice my concerns and stand up for myself and other new nurses.
Shortly after my meeting with my manager, the hospital implemented a “new-graduate meeting” every other week in which we are encouraged to discuss concerns, fears, and issues we are facing. I soon realized that several other new grads had the same concerns I did, and we now had a voice to make changes.

Looking back, if I had not talked with my manager about my concerns, my first work experience would have been very different. Instead, I was able to address the problem early and not let it fester. Yes, it takes courage to meet with a manager and express your true feelings, but it’s worth it. That’s why it’s important for nursing students to learn how to handle acts of incivility during their academic education and to learn skills needed to address issues they will face during their nursing education and throughout their career as nurses.
Students and new graduates are nursing’s future. If we can teach them about civility and how to advocate for change, the nursing profession will be in excellent hands. RNL
Part Two: Cindy’s ‘Five RITES’ for fostering student-driven civility (article by Molly Clark's mom)
For another article by Cindy Clark on civility and nursing students, see What students can do to promote civility.  
Molly Clark, BSN, RN, a 2011 graduate of Carroll College School of Nursing in Helena, Montana, USA—she played soccer for the Fighting Saints!—was recently commissioned as an ensign in the U.S. Navy Nurse Corps. After completing Officer Development School in March, Clark will be stationed at the Naval Medical Center in Portsmouth, Virginia.

Friday, June 5, 2015

Fostering Professional Relationships and a Productive Workplace Environment

Fostering professional relationships in research
Chapter from Business Administration for Clinical Trials, an STTI book.
By R. Jennifer Cavalieri and Mark E. Rupp

This chapter from Business Administration for Clinical Trials: Managing Research, Strategy, Finance, Regulation, and Quality is about cultivating good relationships with colleagues and research subjects. Authors Cavalieri and Rupp discuss the "people part," one of the most rewarding and challenging parts of research. The chapter explains how to take unique perspectives and needs of colleagues and subjects into consideration to overcome barriers to finding common ground.

Chapter 4: Fostering Professional Relationships and a Productive Workplace Environment

Book: Business Administration for Clinical TrialsThe most rewarding and challenging part of research is the “people part.” An intimate understanding of human nature is at the heart of good practices for managing professional research relationships between supervisors and staff. There are, of course, many other factors influencing the research professional’s work relationships, including institution policies, the scope of practice, and state and federal laws, but it’s the “people part” that is meaningful and memorable. This chapter explores ways the research professional can foster relationships with colleagues and research subjects, as well as provides some suggestions on creating firewalls.
Finding common ground and understanding
Working with colleagues and research subjects is required. Doing it well is an art. If you take the unique perspectives and needs of each of your colleagues and subjects into consideration, you have overcome the biggest barrier to finding common ground.
Research subjects
Research subjects have a relationship with research professionals that is similar to their relationship with their medical providers. There is a fundamental similarity between a patient and research subject in the healthcare setting because both are involved in activities and testing within a medical environment. But there are also a host of differences.
Table 4.1 shows these similarities and differences
TABLE 4.1 The Similarities and Differences Between Patients and Research Subjects
Both Groups Are...
Research Subject
Illness and care requirements may be creating stress and disruption of their normal lives.
They may feel too weak or ill to question or comparison-shop for medical services.
They may need to use preferred medical providers due to the requirements of their medical insurance plan.
They may feel stressed by their medical condition and care.
They may be desperate for treatment options.
The subject may not understand the difference between standard of care or optional research activities.
They need professional medical treatment.
They may have exhausted available approved medical therapies.
Interacting With You Over a Period of Time
Outpatient clinical care is usually intermittent and ongoing.
Inpatient care is usually a short-term situation until the patient is medically stable and released from the hospital.
The relationship between research professionals and research subjects is based on the research protocol and last for a day, a week, or years.
Treatment may take place in a medical clinic, hospital ward in an acute care hospital, or a longterm care facility. Medical professionals may provide services in the patient’s home.
The study may take place in a clinic, hospital ward, long-term care facility, or community-based ward, medical office, or in the community.
Simply put, patients need clinical care, but research subjects do not need to participate in research. The importance of establishing rapport and a positive working relationship with research subjects cannot be overstated.
Why do patients agree to participate? Despite strict research regulations to the contrary, some patients may feel pressured to participate. They may want to “please” their physician or feel obligated to go along with their family’s wishes.
What are the direct and indirect benefits a subject may receive from participating in a clinical trial? Directly, they may be receiving access to innovative medications or interventions. It is important for research professionals to clarify the difference between clinical care and research participation. Therapeutic misconception is when a subject believes their research participation is medical therapy with a medical provider following a treatment plan with interventions and medications that have already undergone the scrutiny of the clinical trial process. Sometimes subjects choose to participate and lose sight of the research aspects of the study interactions and consider it a social relationship.


Family members were participating in a research study in which blood samples were collected for genetic analysis. The investigator used a group consent process to thoroughly explain the study and answer questions. Family members had as much time as they needed to consider participation, and those individuals who agreed proceeded from the conference room one by one to the clinic room, where a blood sample was taken.
In the clinic room, one consented subject told the research nurse how much he hated needle sticks and that, although he was perfectly willing to participate in the study, he did not want a phlebotomy procedure. “If I don’t do this, my family will be angry and keep trying to convince me to do it. They are going to know I didn’t do this.” The investigator spoke with the subject privately, supported the subject’s right to privately decline to continue participation, and provided the subject with an “out”—the option of placing a bandage on his arm so that he appeared to have had a blood sample collected.
Because all results were confidential, the family members did not find out that one of them did not participate. Could the investigator have re-explained the optional nature of research to the group? Sure, but some family members might have continued to pressure the person who didn’t want the needle stick.

It is not unusual for us to hear subjects say that they consider their study participation as beneficial from the standpoint of having an extra set of eyes looking over their clinical condition. Some patients and their families, facing teams of medical specialists, may see the investigator and his research team as a stable resource.


A clinical trial for osteoporosis was conducted over a 4-year period. The sponsor, wanting long-term efficacy and safety data, offered the participants the opportunity to continue on in a 2-year extension study. As the primary study neared completion, the subjects were offered information about the extension study, and the informed consent process was conducted. The investigator realized the subjects needed additional reminders and explanations about the research when he saw that the majority of participants had, over time, actually forgotten that they were participating in a clinical research trial and regarded their quarterly study visits as clinical care with a social benefit. They looked forward to their interactions with the research staff just as they looked forward to their aquatic exercise programs and their church activities.

Their decision to participate may be based on a desire for more medical attention. Because research visits can take much longer and happen at more frequent intervals than clinical care appointments, this extra time may mean additional education, reassurance, and encouragement.
These days, when clinicians are so busy, patients may want providers to slow down and explain (and re-explain) medical information in more detail or provide reassurance about symptoms. Time and attention may be the only “carrots” a research professional can provide.
Attaining access to medical caregivers and services in large hospitals and clinic systems can take considerable effort and time waiting for an open appointment time. During a research study, subjects usually have direct access to the investigator and his team because they are responsible for closely monitoring the subjects’ status. Subjects can become very dependent on the research staff to help them navigate the complex healthcare system and get quicker access to help.
Adverse events are assessed quickly, and the research team will intervene when the subject has concerns or symptoms of an adverse event.
When their study participation ends, patients and family members may still want to leverage their relationship with the clinical research team to help them cut through red tape and schedule quicker visits and medical attention. They may call to update the investigator on their medical progress, notify the investigator when they have been admitted, or simply drop by to visit. These actions can stem from a former subject’s normal desire for assistance and attention. We have done many studies and worked with wonderful research subjects, and we’re always sorry to see a study end. We do frequently run into former subjects, and they often ask about study outcomes.
Helping subjects to transition from their active to completed status in the research relationship will need to be handled respectfully and tactfully.
Strategies for working with subjects include: 
  • Regularly refer to their research participation and obtain and document their verbal assent to continue.
  • Use dedicated research telephone numbers and cell phones for all interactions. Never give out your personal cell phone or information about your residence.
  • Clearly identify what you can and cannot do for former subjects. For example, say, “I am sorry to hear that (former subject) was admitted to the hospital. The investigator is available if (former subject’s) medical providers have any questions about the research.”
  • Consider sending a study closure letter to subjects from the investigator. This provides a final formal thank you to the subject for their involvement in the study, clearly closes the formal study relationship, and gives them a route to contact the investigator and research personnel within the confines of study follow-up.
  • Research offices and clinics should maintain controlled access at all times in order to protect the integrity of the research records. Front desk personnel should not grant access to these areas without scheduled appointments or calling the research personnel to the front desk. 
Sponsors and their representatives
One of all sponsors’ cardinal priorities is to understand what is happening at their research sites and make sure they are in compliance with GCP and the research protocol (International Conference on Harmonisation, 1996). It is the sponsor’s goal to develop a positive working relationship with the investigator and the investigator’s research staff. The days when they were permitted to bring in refreshments and provide small gifts such as tote bags and office supplies to research personnel are long gone due to federal anti-kickback statutes (Burgess, 2014).
Industry sponsors and their representatives, contract research organizations (CROs), may use standard business practices to provide incentives and reward their own employees by using gifts of products, financial bonuses, and paid expenses, but this is not the case for the research sites. Sponsors and their representatives must build rapport with the investigators and their research personnel without gifts. They rely on establishing a firm connection with site personnel in order to understand how the research site operates and will provide feedback and liberally praise achievements in order to encourage performance.
Sponsors are in the business of developing products. Investigators are in the business of providing medical care, teaching, and publishing, but there is common ground between the two. Sponsors have business goals, and the investigators have professional goals. The common ground is that both want subject safety, to reach study enrollment goals, to maintain protocol compliance, and ultimately to have the research question, the purpose of the study, answered.
Building a positive and productive relationship with the study sponsor makes good business sense, but the integrity of the research data must be maintained and the results must avoid any appearance of influence from the sponsor.
Here are some important strategies you can put into practice:
  • Use caution when the sponsor or their CRO offers to provide direct support for site activities.
    • Do not allow the sponsor or CRO to prepare local IRB documents. The IRB submission process is the investigator’s responsibility.
    • Refrain from releasing any prescreening information about the investigator’s patients because these persons have not signed consent. It would be a Healthcare Insurance Portability and Accountability Act (HIPAA) violation to even report the sex or age of patients who were evaluated for eligibility.
    • Providing colleagues’ contact information for the sponsor to use for study communication may seem like a supportive suggestion, but the investigator’s IRB will need to be informed that this is part of the study recruitment plan. Remember, after the contact information is provided to the sponsor or CRO, there is nothing to stop them from sending study-specific information as often as they choose to busy colleagues who may view this as spam at best. In addition, there is nothing to stop the sponsor from using the contact information for their own purposes.
  • Use caution when the sponsor or their CRO requests participation in surveys comparing their systems with the systems other sponsors are using. Investigators are required to maintain the confidentiality of their studies.
  • Use the dedicated research addresses, telephone numbers, and cell phones provided as a part of the investigator’s institution for all interactions.
  • Check your institution’s and IRB’s policies on recruitment bonuses and gifts. Expect them to be prohibited and be thoroughly familiar with the institution and IRB policies. The IRB’s interpretation of bonuses may include more than prohibiting direct payments. It may also prohibit “educational grants” and “finders’ fees” for clinical personnel.
  • Keep study documents in secure cabinets and maintain confidentiality with all study information. Monitors know better than to ask for details about other study commitments, but especially those who are industry-sponsored will be keeping their eyes and ears open for evidence of competing commitments at the sites.
  • Keep meals and coffee breaks Dutch treat. Make sure the monitors know where the cafeteria and restrooms are located.
  • There is no need to establish the expectation of continuously being together during their entire visit. Their goal is to establish rapport, and they will be maintaining a file with notes about the investigator and site staff. Your goal is to establish a positive working relationship. Always remember that you are in control of how much personal information you want to share about yourself. 
Clinical stakeholdersThe support and engagement of clinical stakeholders who oversee the clinical and ancillary areas in the institution are critical to the success of a study. They will likely want to know about the results of the data collection long before the research analysis is complete. Their clinical world moves at breakneck speed, and their priority is the use of the data for their reports and initiatives. 


An investigator conducted a clinical trial for an investigational device that evaluated levels of bioburden (essentially dirt, debris, and germs) in patient rooms over a 2-year period. Although the clinical staff was fully informed of the study plan and activities, over time, they made assumptions about the reliability of the device’s data for the cleaning status of the room. The investigator had to explain and re-explain that the study results were not yet available—the study data had not yet been analyzed and could not be used to make clinical decisions (Smith et al., 2014).

Here are some strategies for working with clinical stakeholder:
  • Include clinical stakeholders in planning, updating, and sharing results.
  • Include support for them in a study budget where appropriate, especially when the research disrupts their workflow or consumes some of their resources such as staff time.
  • Let them know that their involvement is appreciated and that long-term success of the organization’s mission depends on their goodwill and support. 
Research colleagues
Adults are free to choose whether to establish personal relationships with co-workers, when this is going to happen, and how much of their life outside of work they are going to discuss. Colleagues have a natural interest in each other and getting to know new employees. New employees may be anxious to fit in as they start in their new position. Co-workers will almost certainly ask them to talk about themselves and their interests. A proactive strategy is to prepare an “elevator speech” of some very general comments about yourself to use for these early meetings with your new colleagues.
Matters can become very personal if family members are employed at the same institution or research professionals are receiving healthcare services at the institution where they work. Family may work at the same institution; however, there are usually policies that prohibit their working in the same department or supervising relatives.
Research professionals may work and receive healthcare services at academic medical centers. Their privacy is protected by HIPAA privacy laws, and there are strict policies on how and when medical records can be accessed. Surveillance and audits are conducted to ensure every patient’s, employee or not, privacy.
It is not uncommon for clinical personnel to participate in clinical research. Clinical personnel may have a better fundamental understanding and, in general, a greater trust of research. They may be curious and altruistic and see their participation as an avenue to contribute to medical knowledge. Strive to maintain the employee–subject’s confidentiality, especially during testing and study visits.
Expect the employee–subject to experience some role confusion. They may be uncomfortable with the role reversal. Do not assume that the employee–subject already knows anything at all about the disease process under study or the mechanics of daily research activities.
Often investigators and institutions have policies prohibiting family members or direct employees from participating in their clinical trials in order to avoid or avoid the appearance of coercion and breach of privacy. Research protocols may also include enrolling family members or employees as exclusion criteria.
Strategies for working with colleagues include: 
  • It is important to block potential conflicts of interest or breaches in confidentiality before they happen. Check your institution for policies related to enrolling relatives into trials. Institutional review boards (IRB) and the principal investigator’s research enterprise usually have a standard operating procedure (SOP) and policies in place addressing issues related to members of the research team or their family members participating.
  • If such policies do not exist, draft a policy for the research enterprise to address this. 
Facing the grim realities of life
The mission of research professionals is to find answers to treat and mitigate the effects of illness, better understand ways to prevent illness, and provide a measure of hope that what we learn can help ease the suffering of others. The passion and compassion of research professionals can lead to the very real effects of sadness, depression, and feeling burned out over time as they face the needs and loss of so many medically ill people.
Because a significant number of waking hours are spent with colleagues, these relationships are important and valuable and can be a source of tremendous joy and pain. The change in relationships with our colleagues due to career moves, retirement, or illness is inevitable. These changes can also lead to feelings of sadness and loss.
Here are some strategies you can use for taking care of yourself:
  • Appreciate today. Remind yourself that today, what you are working on now, and the people you are working with are a part of “the good old days” you will look back on in the future.
  • Work on the coping skills necessary for facing death and dying. We should recognize the signs of burnout in ourselves and colleagues and take steps to cope.
  • A change in research specialty may be in order. Not all clinical trials are working with seriously ill subjects. There are many research roles, and some involve no patient contact. 
Be (almost) indispensable
The people within a research enterprise, like people in any business, need to work at building productive working relationships. Productive research relationships are grounded in communication, team effort, and compliance, and this chapter has presented some research-specific ideas to consider. How are productive relationships built? One way to look at working relationships at an academic research site is to recognize that everyone, even the principal investigator, has a boss and is expected to contribute to the success of the research enterprise. Adopting the strategy of becoming (almost) indispensable to your boss and your colleagues benefits everyone on the team.
Why is indispensable status risky? First, you should never be truly indispensable because this can hold you back from developing and taking on new opportunities. People may also ask you to do unreasonable things because you are the supposedly the only one who can do them. Being indispensable is a sign of poor planning on the part of all parties involved. Having indispensable people will backfire when they have an illness or family emergency, as everyone does at some point. Finally, people with “indispensable” labels can get a falsely elevated impression of themselves.
No one is indispensable.
That said, here are some ways to be (almost) indispensable: 
  • Consider ways to work collaboratively and build a strong study team. Mentoring the less-experienced members of the research team or coaching a colleague through the research certification process helps to reduce the frequency and seriousness of mistakes and improve efficiency. Supporting and advising a peer while they prepare for research certification creates a sense of shared accomplishment and fosters the spirit of teamwork.

Research professionals can contribute to developing orientation processes and tools, create an intranet site for research resources, or hold periodic meetings for education and fellowship.
Helping a new colleague can be as simple as an experienced coordinator taking a new coordinator under her wing and mentoring her through her first weeks and months as a study coordinator. Explaining, identifying references, and listening in these early days can be the difference for successfully acclimating to the new position.  


If the principal investigator needs some backup on study activities, having the secondary investigator assume responsibility from beginning to end on the next subject being enrolled is an excellent orientation to the study. It will become much easier for them to step in and out of the process for backing up the study activities going forward. 
Recognize that recruitment and retention of subjects is everyone’s job. Subject recruitment and retention are prime examples of the value of teamwork. Each member of the research team has a part to play, from the investigator administering informed consent to the research coordinator handling the logistics and education to the research assistant who efficiently collects and processes specimens. If a subject doesn’t understand what they have consented to, if parking or finding the research office is too frustrating, or they have to return for a repeat blood collection, study retention is in jeopardy. 


Consider the impact of a friendly receptionist, a research assistant who provides clear directions to the study visit location, and the value of updates on study progress to clinical personnel in ancillary areas. Your subjects as well as the study coordinator and investigator will have regular interaction with them. Completed subjects and even patients who do not qualify for study participation can become ambassadors. We consider it high praise when qualifying medical professionals choose to participate in our clinical trials.

Thorough pre-study and ongoing targeted education makes a difference in retaining research subjects. Telling a subject that there are 13 study visits as a part of the informed consent discussion may be honest, but he may consider this too much of a commitment. If the information is presented as five study visits and eight telephone study visits over 3 months, the subject may find this less daunting. With so many visits over several months, providing a simple calendar with appointments plotted out or a list of appointments can help the subject stay organized.
At each study visit, be sure to remind the subject of where they are on the study timeline. For example, reference the study visit calendar and tell the subject, for example, that today is study visit three, and that his next study visit is a telephone visit that should be done either Thursday or Friday. Ask if it would be convenient for you to telephone him in the morning on Thursday, for example. 
  • Go the extra mile. Successful research professionals look for ways around, over, or through obstacles. 


Interactive systems (historically called interactive voice-recognition systems or IVRS) are commonly used in research for managing investigational product and supplies. They have been in place for more than a decade and have evolved from telephone and fax to web-based systems. These systems efficiently track inventory and study milestones such as screening visits and may be a tool for implementing the randomization process of subjects for multisite trials. Research professionals receive training on how to use the system, but should be prepared to think and work through logistical glitches.
During the final months in a recent clinical trial, the remaining amount of limited investigational product was being redistributed among sites and several boxes were removed from our site’s stock. Shortly after this transfer, a system error in the IVRS was discovered at an early morning study visit. One of the redistributed boxes of investigational product was still listed as our site’s stock, and the IVRS assigned it to our subject. Our dilemma was to reschedule the subject’s study visit or attempt to work around an automated system.
Rescheduling subjects for study visits is a risk to their compliance. Will the inconvenience cause the subject to consider withdrawing from study? Will the subject return for a repeat study visit within the protocol-mandated schedule? Will the delay result in a delay of the study drug start or a protocol deviation due to the timing of doses?
The study visit was scheduled for 7:00 a.m. Central time because the subject and her parent needed to get to school and work on time. Telephone calls to the IVRS are usually done after a subject arrives for the visit because this centralized system is working with dozens of study sites and is designed to take global and site variables into consideration for study drug assignment.
The study sponsor was based in the Pacific time zone. The investigator was in route and unavailable by telephone. Calls to the IVRS help line and study monitor were unanswered. With minutes left to decide whether this issue could be resolved to salvage the study visit or reschedule the study visit, the research coordinator made a call to the sponsor’s project leader. This person was available and had the authority to provide immediate authorization to assign an alternate investigational product kit, and the study visit was completed.
The take-away message is that technology is great, but clinical trials call for sharp critical-thinking skills to keep subjects engaged and maintain protocol compliance. Technology will keep up with the clinical trial needs, but cannot always anticipate all of the real-life challenges that arise. Several years have gone by, and our latest clinical trial IVRS system has an automated choice for kit replacement to address lost or damaged kits.



Study monitors, the sponsors’ representatives, are responsible for supervision of the overall conduct of the trial. Their visits to the study site are part of these responsibilities. They will send confirmation letters for scheduled study visits and provide a description of what they plan to review. The monitor will interact with the investigator and study coordinator during the visit and works to clarify and resolve any data discrepancies. They may also provide additional protocol and GCP-related education.
Our investigators rely on email or verbal updates on the progress of a site visit from the research coordinator. Emails are a handy documentation tool for the research coordinator to use. Formal meetings with the investigator are customarily done toward the end of the monitor’s visit. By remaining in close contact with their study staff, the investigator can intervene in a more timely manner and as needed.
Monitoring visits are a significant investment of coordinator time. The coordinator will prepare for the visit, making sure that the items listed in the monitor’s confirmation letter are ready for their review.
Action items presented at the final meeting with the investigator and listed in the follow-up monitor letter will need to be addressed.
The dilemma for the research professional is that the monitor’s follow-up letter may be 4 to 6 weeks in coming. The solution for the research coordinator is to use the investigator’s update emails to create a short summary of the activities and create a punch list (a to-do list of items commonly used in construction or project management) so that the needed items are not forgotten. Site personnel should carefully review the monitor’s follow-up letter to make sure all of the noted items are addressed. On the rare occasion that the monitor’s letter does not arrive, is misdirected, or is very tardy, the investigator can rely on their documentation.

It is essential that research professionals understand their study responsibilities and regularly review GCP guidelines to ensure compliance (U.S. Department of Health and Human Services, 1996). 
  • Understand that research professionals on the front lines often have the best perspective on improving operations. 


A clinical trial for a new drug to treat osteopenia (low bone-density) needed participants. Because most women have never had a bone-density measurement (a low-risk radiology procedure), their bone density was usually unknown.
Because the investigator had been conducting these types of trials for many years, the experienced team of research professionals at an academic research site had efficient processes in place for conducting outpatient osteoporosis clinical trials.
Their standard recruitment plan was to inform potential subjects of the study and then filter qualifying subjects from a large pool of interested women. The dedicated recruitment nurse was responsible for managing all outreach efforts, including giving community-based presentations, arranging the advertising and public relations messages, phone triage, and scheduling screening visits. The recruitment nurse frequently used staggered advertising strategies to achieve 50 to 75 telephone calls per week and, of these, an average of 10 screening study visits were scheduled, with the goal of scheduling them within a few days of the telephone call. The research nurse coordinator was responsible for conducting the screening visits, enrollment, and study visits.
As enrollment steadily increased, the research coordinator’s schedule was quickly filled, and the processes needed improvement. The original thinking was that a positive working relationship between the research coordinator and a subject is established at the time of the screening visit. When we analyzed our screen-fail ratio, it became clear that only one to two subjects out of every 10 scheduled visits qualified for the study. The 30-minute screen visits for the other eight screen failures were a poor investment of the research nurse coordinator’s limited time. She needed to spend her time working with the subjects who qualified and chose to continue on in the study.
The recruitment nurse and research nurse coordinator re-examined their usual tasks and formulated a process change to let the recruitment nurse assume responsibility for the conduct of the screening visits. After study eligibility was confirmed, the research nurse coordinator stepped in to complete the visit and move forward with the study activities. The recruitment nurse completed the screen visits for the subjects who, based on their bone-density results, did not qualify to participate. After a brief trial, the investigator agreed to this plan. Subjects were more accepting of this process than we had anticipated. 
  • Strengthen your research team by understanding your weaknesses and working together to bridge the gaps.
Teaching and sharing educational resources can help make the research team well rounded. Investigators who make an educational investment in their staff by explaining the medical condition and related testing will reap the benefits of personnel who are better equipped to support the screening, recruitment, and study visit processes. They have a better understanding of what to report and can identify options and solutions for process improvements.
Colleagues can use “teaching moments” to explain software programs and share documentation tools and tips. It can be uncomfortable to admit that you aren’t an expert at creating graphs or aren’t familiar with the medical symptoms or tests associated with the study’s disease process. Keeping abreast of dynamic regulations and the latest ethical issues is a challenge every research professional faces. Subject safety is promoted in a work environment where research professionals are encouraged to ask questions and share mistakes. 
  • Understand that knowledge and information is power.
  • Operations can be slowed or halted when key personnel are absent or knowledge is hoarded by insecure members of the team. 


All of the members of the research team can contribute to centralized references for resources such as organizational charts listing key contact personnel, detailed standard operating procedures (SOPs), policies, and crisis plans. This is essential for both a small research enterprise and the campus-wide research community. 

  • Maximize available resources. Research teams may have limited surge capacity, ability to suddenly handle significant increases in the workload such as multiple eligible subjects at the same time, as investigators balance funding and personnel logistics. There are times when redirecting efforts and working as a team can make a significant impact on recruitment efforts and coverage for personnel illness and family events. For example, investigators may work collaboratively with other investigators within their department or other specialties. Their research coordinators may serve as secondary personnel for multiple investigators. It is critical to clarify delegation and define the expectations and SOPs for this collaborative work.
  • Set and reach stretch goals. When the question is, “How much effort is enough?” the answer becomes, “Just a little bit more.” Setting a study enrollment goal is a good idea. Setting a stretch goal, one that requires extra effort, is a standard performance practice that supervisors implement. The research professional may be able to enjoy some flexibility with their schedule, which can sometimes translate into a little downtime during an investigator meeting in Miami during January, or coming into the office a little later or leaving a little early to balance out some unavoidably long days.


It is common for a sponsor to designate the date when study enrollment will close. At that point, the priority focuses on a final push to enroll subjects. For a recent study, the final enrollment date was on a Friday. A potentially eligible subject was contacted on Thursday afternoon, and a message was left using the call-back phone number for the dedicated research cell phone instead of the research office phone.
When the potential subject returned the call at 6 p.m., the research coordinator was walking from the office into the parking garage. The potential subject was willing to come in the following morning for a screening visit to learn more about the study, qualified for participation, consented, and was the final subject enrolled in the study.

  • Recognize that appreciation, optimism, enthusiasm, and the willingness to take on new challenges can be as infectious as pessimism. We are human and need recognition for our ideas, contributions, and achievements. The best recognition doesn’t have to be a trumpet fanfare. 
A handwritten note is a quiet acknowledgement of a job well done or milestone achieved and can go a long way toward building morale. A “wall of fame” in the research offices can display certificates for milestone service anniversaries, the names of certified research professionals, and internal publications. Employee-of-the-month awards may not be appropriate for very small research enterprises and may result in unintended consequences such as resentment and disappointment for those who are not recognized. Customizing ways to recognize and reward team effort makes sense in most settings.
Quality Connection
So let’s look at a risk the investigator might identify, which involves a scenario of working with multiple personnel at multiple research sites: 
What exists: An experienced investigator has just learned that a federal research proposal has been funded. This multiyear, multisite protocol will involve more than a dozen specialized team members.
The risk: Assuring regulatory compliance and maintaining required documentation across three study sites. 
First, the investigator can create some quality objectives to address the risk: 
1. Assign study regulatory responsibilities and accountabilities for supporting the approval and reporting processes.Assign study regulatory responsibilities and accountabilities for supporting the approval and reporting processes.
2. Assure compliance with sponsor-mandated progress and financial reports and regulatory approvals from federal and local IRB groups.
3. Create and conduct surveillance and monitoring plans.Create and conduct surveillance and monitoring plans.
Next, fill in the details of how these quality objectives will be measured and the set up the QC processes:
1. Assign study regulatory responsibilities and accountabilities for supporting the approval and reporting processes.
  • The regulatory specialist is responsible for daily document and file management. Quality indicators include checking the contents of the files against a standard checklist of “essential file documents,” dated communication demonstrating study activities such as meetings and instructions from the investigator, and evidence that the documents are maintained securely, such as document storage in rooms accessible only to the investigator’s designated personnel. 
2. Assure compliance with sponsor-mandated progress and financial reports and regulatory approvals from federal and local IRB groups.
  • Under the direction of the principal investigator, the regulatory specialist is to create schedules, report templates, and checklists. Quality indicators include a comparison of the schedule and report submissions.
  • The regulatory specialist is responsible for drafting reports and correspondence for the principal investigator. Quality indicators include investigator and sponsor satisfaction with report contents.
3. Create and conduct surveillance and monitoring plans.
    • A written monitoring plan will be included in the study-specific manual of procedures (MOP) and the research enterprise’s SOPs. Quality indicators include verification of the presence of the MOP and SOPs.
    • Principal investigator oversight will consist of formal and informal contact with all participating research sites on a quarterly, monthly, weekly, and as-needed basis with the hospital and research personnel at each participating research site. Quality indicators include review of the documentation of written, electronic, and notes to file on telephone conversations between the principal investigator and the site personnel.
    • The principal investigator will visit each participating research site to conduct a site monitoring visit on a quarterly schedule. Quality indicators may include a review of the monitoring report for each visit.
    • The principal investigator will conduct “for cause” visits without prenotification as needed. Quality indicators may include a review of the documentation of the circumstances associated with triggering the visit.
Again, these objectives contain some very general descriptions of the QC activities and quality indicators for a typical clinical trial scenario.
Key take-aways
  • The research environment is not immune to the dynamics of unprofessional behavior, personal differences, conflict, and ambition.
  • General principles of managing people are relevant to the research environment.
  • Research professionals can benefit from firewalls
  • Quality control and quality assurance activities are directly connected to the work performed by multiple members of the research team. RNL
If you liked this article, you may also want to read:
International Conference on Harmonisation. (1996, June). ICH harmonised tripartite guideline: Guideline for good clinical practice. Retrieved from http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/

Smith, P. W., Beam, E., Sayles H., Rupp, M. E., Cavalieri, R. J., Gibbs, S., & Hewlett A. (2014). Impact of adenosine triphosphate detection and feedback on hospital room cleaning. Infection Control and Hospital Epidemiology, 33(5), 564-569.
U.S. Department of Health and Human Services, HRSA. (2014). Guidance on the federal anti-kickback law. Retrieved from http://bphc.hrsa.gov/policiesregulations/policies/pal199510.html
U.S. Department of Health and Human Services, U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Center for Biologics Evaluation and Research (1996, April). Guidance for industry E6 good clinical practice: Consolidated guidance. Retrieved from http://www.fda.gov/downloads/Drugs/Guidances/ucm073122.pdf

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 http://www.mc.vanderbilt.edu/root/pdfs/nursing/center_lateral_violence_and_

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