Culture of Nursing: A Factor in Nurses’ Health and Safety

1. Culture of Nursing: A Factor in Nurses’ Health and Safety Lee an Hoff, PhD, RN Barbara Mawn, PhD RN Ainat Koren, PhD, RN Karen Devereaux Melillo, PhD, APRN, BC Carole W. Pearce, RNC, PhD Kathleen Sperrazza, MS, RN PHASE in Healthcare Research Team. Supported by the National Institute of Occupational Safety & Health, Grant #R01-OH07381, “Health Disparities Among Healthcare Workers”

2. Session Objectives • Describe context of PHASE project revealing “culture of nursing data” as a factor related to health outcomes • Describe historical, sociocultural and economic milieu • Identify the implications of health care restructuring and commodification of nursing care • Identify implications for health and safety policy, nursing practice and education

3. Background • PHASE – 5 year multidisciplinary research project at UMASS Lowell that examined the health and safety hazards in health care workforce • Context included 2 hospitals, 2 nursing homes and nursing union members • Data included triangulated quantitative and qualitative methods • Epidemiological survey • Ergonomic observations • Qualitative case study methods: key informant interviews with managers, focus groups and open forums with workers, document review (media publications, OSHA logs, JCAHO reports, institutional policies and news letters)

4. Qualitative Data Sources • 2 community hospitals in Northeast MA • Key informant/manager interviews:29 • Total worker participants: 81 • Nurse Union members:7 focus groups • Nursing union participants: 50 • 2 nursing homes in Northeast MA • Key informant/manager interviews:25 • Total worker interviews:55

5. Data Sources: Methodological Challenges • Difficult to get workers to come to focus groups in the hospital setting! • Open advertised forum discussions on topics related to health & safety led to increased participation • Nursing home and union focus groups easier to enroll participants • Some differences in perceptions related to risk between managers and workers

6. Culture of Nursing: Definition • Encompasses values, beliefs, and behavioral norms that influence: • Nursing practice • Health team interaction • Self care • Vulnerability to abuse • Deeply rooted and passed through generations • Influenced by sociological designation of nursing as “semi-profession”

7. Status of Nursing • Discrepancy between society and healthcare industry • “Nurses have very high recognition in society but within health industry we’re not valued and our health is not valued.” (union nurse) • “I think the rate of injury and how it’s recognized and treated is very reflective of what the status [of nursing] is.” (union nurse) • Why the Discrepancy?

8. Historical Context • Long history of disempowerment and economic exploitation • This has crossed cultures and borders • Key references: • Ehrenreich, B. (1973). Middle Ages: Witches, Midwives & Nurses: A History of Women Healers • Ashley, J. (1976). Hospitals, Paternalism and the Role of the Nurse • Reverby, S. (1987). Ordered to Care: The Dilemma of American Nursing • Salvage, J. (1985). The Politics of Nursing (UK) • Holden & Littlewood. (1991). Anthropology and Nursing

9. Key Historical Themes and Areas of Dissent • Women’s work vs. Professional work • Historical role of nursing leaders in non-support of labor movement • Nurses as laborers vs. professionals • “The reason firefighters have better protection is because of solidarity...they use the political process to get better protection.” (union nurse) • “Until we stand up and say that our health is just as important as the patient’s, doctor’s and administrator’s health, it’s not going to change.” (union nurse)

10. Cultural Roots of Exploitation of Nurses • Hospitals as schools: students or laborers? • Nurses as housekeepers for the sick • Sexism in hospitals rooted in cultural division of labor between the sexes • Assumption of subservience and nurses (i.e. women’s) “proper” role in hospital “family” • Based on cultural norms, nursing shares economic disadvantages of other female-dominated occupations

11. Stories Related to Exploitation of Nurses • Hospital Nurse (discussing the satisfaction from the job yet…): “Right that’s life…and they come into the hospital and you’re there to serve them. And that's what they expect because that’s the way they were taught – that a nurse is there to meet your every whim and need.”

12. Health Care Restructuring Impact • The systematic “downsizing, reconfiguring and outsourcing” of nursing staff • “Extending nurses” by hiring cheaper aides • Relying on machines vs. nurses for ill patients • Moving home health patients to another agency with piecemeal billing - “patients get lost in shuffle” • “And when we say stop, you need to look at this person who needs more than you’re offering [they say] – ‘Get in the real world, this is not how we do things now.’ ” (union nurse)

13. Restructuring Impact • Hospital Nurse: “Even our orthopedic patients….they go to rehab…we don’t see them get better; we send them home in pain because we don’t have the beds. So it’s more of ‘Oh, ok you’re stable – see ya!’ and that’s what it’s become – a rotating door.”

14. Significant Re-Definitions in Restructuring of Health care • Healthcare Agencies: a business manufacturing model • Patients: “Widgets” treated as though every patient is in the same factory assembly line • “You never truly see that person get better like you did before.” (hospital nurse) • Nursing Service: a commodity for maintaining the bottom line and compensating high-paid executives

15. Key Results of Health Care Restructuring • The commodification of healthcare in which service and worker safety are secondary to economic incentives • Staff must “speed up, work faster and work smarter” to help keep patient numbers up in order to survive financially • Admission of dangerous patients minus adequate security and protection – leading to increase in violence and abuse from patients and families

16. Restructuring Stories • Hospital Nurse: “In the OR time is money, time is money. The faster you work, a lot of doctors say ‘Hurry up, hurry up. I have office hours at one o’clock. What’s taking you so long?’ They don’t realize that we have just a lot of cleaning to do while the patient is waking up, need to set up for the next case…a lot of pressure to go, go, go…maybe a little faster than you should have and then you get hurt and you say I’m not going to do that again. But the bottom line is money sometimes I guess.”

17. Cultural Norms in Current Health Care Industry • Abuse and injury seen as “part of the job” • Long hours, double shifts and short staffing accepted despite increase risks associated • Uneven reporting of injuries traced to negative management and co-worker attitudes – blaming the victim mentality • “Why are you making out these incident reports just because someone got punched in the face? What’s the big deal?” (union nurse speaking of manager’s attitudes) • Worker’s Compensation feels like “re-abuse” by the system…it’s easier to just take Motrin and keep on working.” (union nurse)

18. “Part of the Job” Stories • Hospital Nurse who sustained a fractured ankle and a dislocated kneecap from patient care work: “When I returned back to work…lifting very heavy patients, turning and repositioning…I cannot do it (reposition correctly) because if I bend it, it will dislocate. So I am putting myself at risk, I understand…but I love nursing so I would not change anything.”

19. Concerns about Reporting • Hospital Nurse: “There is resentment. I will tell you firsthand. I’m not telling you everyone but there can be resentment when the person coming back loses his abilities. Not everyone is always ok.”

20. Concerns about Reporting • Hospital Nurse: “If you’re on the floor and you’re seeing the same patient, you might be filling out a report that he swung at me 25 times during the course of his admission because you are going to face that patient the next day and the next. You’d be doing nothing but filling out reports!”

21. Concerns about Reporting • Hospital Nurse: “ I don’t think people report because they have to work with these people. You have to go back into that department and you don’t know how you’re going to be dealt with. It’s not always good.”

22. Cost to Nursing in Restructured Health Industry • Economic “bottom line” favored over investment in adequate equipment for injury prevention • Nurses’ experience and wisdom mostly ignored by management in regard to purchase of equipment and imposed computer documentation programs • Nurses too busy or exhausted to consider “upstream” roots of injury and stress • Diversity issues: ethnic minority workers in system pay highest price in injury and disempowerment (mainly CNA’s)

23. Restructuring and Impact on Nurse Managers • Nurse managers co-opted to implement top-down management decisions • Little input from direct care staff • Managers, nurses and CNA’s often pitted against each other • “We’ve been sold out by those nurses who became business managers who apply the “widget” manufacturing model” (union nurse) • Victim blaming or rebukes from reporting injuries • [They send in a nurse educator to]… “teach somebody what they did wrong, implying you don’t know what you are doing or you must have psychiatric problems.” (union nurse)

24. Nurse Manager’sConflicting Role Nurse manager: “Patients with alcohol withdrawal – I don’t want to put my staff at risk so I will take those patients. I can take a hit. I’ve taken many hits. I do know that it is a risk of the job, And most of the time it’s not an intentional thing. They don’t know. So it does go unreported unless they break skin or something that you have to be tested for. But it is a hazard of the job. Most nurses know it going in when they go to nursing school.”

25. Unions as Bulwark Against Culturally-Defined Role • A complex socioeconomic issue like health care restructuring cannot be addressed by individuals alone • Cynicism and apathy combine in reality • “The norm is we don’t speak up because you don’t bite the hand that feeds you…the women are much more apathetic the longer they’re in the system and new people who don’t’ tolerate it just leave.” (union nurse) • “We put ourselves in harm’s way…adaptation is a terrible thing, you do it because it’s expected of you. And eventually you don’ t even realize how bad it is for you.” (union nurse)

26. Implications: Nursing Education • Essential health and safety content inadequate in nursing curricula • Need to include gender issues and sociocultural norms affecting practice and strategies for social change • Need to stress importance of self-care in balance with professional duty

27. Implications for Policy and Practice • Management and Nursing role in preparing workers regarding health and safety • NIOSH Guidelines for Health and Safety • Worker’s Comp and Return to Work policies • Elimination of disempowerment and economic exploitation – redefining a new “culture of nursing” that does not accept injury and risks as inevitable and does not implicitly or explicitly penalize those who report adverse conditions and injuries Note: this material is not to be copied without permission of the authors