Culture of Nursing: A Factor in Nurses

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

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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

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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)

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Qualitative Data Sources

• 2 community hospitals in Northeast MA
• Key informant/manager interviews29
• Total worker participants 81
• Nurse Union members7 focus groups
• Nursing union participants 50
• 2 nursing homes in Northeast MA
• Key informant/manager interviews25
• Total worker interviews55

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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

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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

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Status of Nursing

• Discrepancy between society and healthcare
  industry
• Nurses have very high recognition in society but
  within health industry were not valued and our
  health is not valued. (union nurse)
• I think the rate of injury and how its
  recognized and treated is very reflective of what
  the status of nursing is. (union nurse)
• Why the Discrepancy?

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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

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Key Historical Themes and Areas of Dissent

• Womens 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 patients, doctors and
  administrators health, its not going to
  change. (union nurse)

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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.
  womens) proper role in hospital family
• Based on cultural norms, nursing shares economic
  disadvantages of other female-dominated
  occupations

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Stories Related to Exploitation of Nurses

• Hospital Nurse (discussing the satisfaction from
  the job yet)
• Right thats lifeand they come into the
  hospital and youre there to serve them. And
  that's what they expect because thats the way
  they were taught that a nurse is there to meet
  your every whim and need.

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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 youre offering they
  say Get in the real world, this is not how we
  do things now. (union nurse)

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Restructuring Impact

• Hospital Nurse
• Even our orthopedic patients.they go to
  rehabwe dont see them get better we send them
  home in pain because we dont have the beds. So
  its more of Oh, ok youre stable see ya! and
  thats what its become a rotating door.

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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

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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

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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 oclock.
  Whats taking you so long? They dont realize
  that we have just a lot of cleaning to do while
  the patient is waking up, need to set up for the
  next casea lot of pressure to go, go, gomaybe a
  little faster than you should have and then you
  get hurt and you say Im not going to do that
  again. But the bottom line is money sometimes I
  guess.

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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?
  Whats the big deal? (union nurse speaking of
  managers attitudes)
• Workers Compensation feels like re-abuse by
  the systemits easier to just take Motrin and
  keep on working. (union nurse)

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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 worklifting very heavy
  patients, turning and repositioningI cannot do
  it (reposition correctly) because if I bend it,
  it will dislocate. So I am putting myself at
  risk, I understandbut I love nursing so I would
  not change anything.

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Concerns about Reporting

• Hospital Nurse
• There is resentment. I will tell you firsthand.
  Im not telling you everyone but there can be
  resentment when the person coming back loses his
  abilities. Not everyone is always ok.

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Concerns about Reporting

• Hospital Nurse
• If youre on the floor and youre 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. Youd be doing
  nothing but filling out reports!

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Concerns about Reporting

• Hospital Nurse
• I dont think people report because they have
  to work with these people. You have to go back
  into that department and you dont know how
  youre going to be dealt with. Its not always
  good.

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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 CNAs)

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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 CNAs often pitted against
  each other
• Weve 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 dont
  know what you are doing or you must have
  psychiatric problems. (union nurse)

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Nurse ManagersConflicting Role

• Nurse manager
• Patients with alcohol withdrawal I dont want
  to put my staff at risk so I will take those
  patients. I can take a hit. Ive taken many hits.
  I do know that it is a risk of the job, And most
  of the time its not an intentional thing. They
  dont 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.

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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 dont speak up because you dont
  bite the hand that feeds youthe women are much
  more apathetic the longer theyre in the system
  and new people who dont tolerate it just
  leave. (union nurse)
• We put ourselves in harms wayadaptation is a
  terrible thing, you do it because its expected
  of you. And eventually you don t even realize
  how bad it is for you. (union nurse)

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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

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Implications for Policy and Practice

• Management and Nursing role in preparing workers
  regarding health and safety
• NIOSH Guidelines for Health and Safety
• Workers 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