Americans seeking nursing care in the Northwest may be about to get some relief. The highly successful Canadian Nurse Next Door home health care business is expanding into the US, coming to Washington state sometime in the next 12 months.

Nurse Next Door has been spreading across Canada like wildfire. It started in 2001, and has built itself up. Just a little more than two years ago, NND had three locations; it now has 27. One of the founders is quoted as saying they could have had 150, but they wanted the right partners. That statement refers to the fact that aspiring NND partners have to prove the capacity to cope with upfront costs of $125,000 in the first year, put up $35,000 in advance, and make a five-year commitment to royalties of five percent on gross income.

Nurse Next Door is an interesting concept. It’s a targeted home care service, working, if you can stand the cultural shock, on client budgets, not operator budgets. The clients pay what they can afford, not the usual lucky dip on fees.

That’s more than slightly interesting, because it also seems to fit NND’s business model, which is apparently based on “what works” and not an off the rack business model like all the others that can fall to bits in the real market. One of the really intriguing things about NND is that it has the business structure of many highly successful businesses: A small administration based on much larger operational organization. That means NND has comparatively low non-operational costs.

That business model would mean a lot to people in the US home health care industry. It could also mean a lot to US nurses who are more than slightly tired of the on again-off again cycle of accountancy in the industry, which means they have to play “spot the viable home care provider” as a career option.

Most impressive is the fact that Nurse Next Door is a 24/7 operation. In Toronto, NND got a lot of attention when it started up, and it seems that one of the reasons it’s so popular is the low rates: $21 to $28 an hour for anything from companion care to complex care. As you can see, this improves the affordability equation considerably for families looking for a minder of their loved ones.

America’s long suffering aging population could benefit a lot from a nursing service that recognizes the realities of costs to clients, and a good business model for those providing the services. It could be a real shot in the arm for the US industry, where the costs for businesses and clients seem to have been worked out in the early Jurassic times.

Looks like Nurse Next Door is open for business for anyone who meets their criteria. US nurses might want to give NND a thorough examination.

An exciting idea that could work out as a pilot program for big improvements in the nursing profession is now under way: $10,000 scholarships for the Accelerated Bachelor of Science in Nursing. These scholarships are granted as part of the New Careers in Nursing Scholarship Program through a collaboration of the Robert Wood Johnson Foundation (RWJF) and the American Association of  Colleges of Nursing (AACN). Nationally, 58 colleges out of 113 applicants were granted the new scholarships.

The Accelerated Nursing program allows applicants with an existing Bachelor’s degree to earn their nursing degree in 16 months. These scholarships add a much needed boost to funding for students at a time when nursing numbers are a big issue and meeting industry and public demand is a top priority.

The RWJF program aims to provide 1,500 scholarships to minority and disadvantaged students. This initiative is getting a very positive response from some of the nation’s top colleges, notably Duke. Duke University has been operating a scholarship program called Broadening the Community in the same field in its own Accelerated Nursing program, and received more applicants than it had funds to place.

The Accelerated Nursing Program and New Careers in Nursing Program have also uncovered a lot of information which is starting to define the real training needs of the profession:

1. Duke’s research indicates that entrants at Bachelor’s and Master’s levels are much more likely to remain in the profession. These are the core professional qualifications, and the good news is that these graduates, who will also be primary level trainers, will stay in the field. Sustainability of this professional core is vital to practical  nursing.
2. Nurses with good academic backgrounds are going to be required to deal with the steady deluge of scientific and technological inputs into medicine at all levels. This is a “learning hyperbola” where nurses return their upgraded skills to the workplace and can train and advise in their own work. It’s a very cost-effective result if the Accelerated Nursing program can deliver, and it looks like it can.

A criticism has been raised about the RWJF scholarships and other initiatives, however. There is concern that emphasis on demographics will miss promising students who need the money and don’t fit the criteria. The criticism is really a reflection of the need to support and motivate all nursing talent. The New Careers in Nursing Program has proven it’s the right mechanism to address this extremely important issue.

Many nurses want to be able to unionize. The Employee Free Choice Act, which would allow unionization, is moving through the Senate, but it’s looking like there are going to be some roadblocks as the idea of nurses being represented by unions seeps through to government and industry.

However, the situation for the profession is too complex for purely polarized, pro and con simplifications about the principle of unionization. There’s a lot more at stake here. The entire nursing profession has daily representation issues across the health care spectrum. The degree of difficulty ranges from national issues to infuriating local nuisances.

Any union has to be able to operate in real time with issues, represent its members effectively and must above all be able to deliver credible results. The nursing profession needs ultra-functional performance levels.

Nursing is a unique profession. It needs a unique methodology to make its unions work. The Employee Free Choice Act offers  some very positive possibilities here, if the union can do the job:

1. Giving nurses a working legal ability to deal collectively with issues, on site and elsewhere.
2. The chance to be represented effectively regarding health care policies and issues.
3. A problem solving mechanism where nurses don’t have to fight every battle that comes along individually on an ad hoc basis when they’ve got five minutes.

Representation is the major problem underpinning all nursing issues in the health care industry mainstream. The American Nurses Association, which is a national body with an affiliate structure, represents registered nurses, a total of 2.9 million members. The ANA is usually off the public radar, and not on the political screen at all. The ANA apparently has nothing to say about Employee Free Choice Act, or unionization, for example.

The question is, can unions fill the representation gap for nurses? Every other major profession has effective national representation at policy level in the government, and a strong public profile. Unionization does provide at least a partial fix to local issues. How these unions are organized, and the nature of their membership representation, is going to decide whether they can get nursing issues on the national radar.

Whatever happens with the Employee Free Choice Act, please let’s not assume that enough local band aids will equate to a national body cast. Representation is the issue that won’t go away.

A Medicare rate adjustment, combined with cuts in Federal and state spending, has started to have a deep impact on nursing homes. Medicare cuts alone are expected to average a $1.6 billion reduction in funding per year. 24 states have already cut funding. Further cuts are currently before Congress. There are currently 16,000 nursing homes operating in the US, with an estimated 1.85 million people in care.

The cuts are expected to force closures as well as layoffs, as the juggling act of compensating for reduced funding begins in earnest. Industry sources state that inadequate funding through Medicaid has already forced some closures.

For specialist nurses in this area, the question is now how to dodge the cuts and stay in viable work. The common wisdom at this stage is that the upmarket nursing homes are in better condition to deal with the cuts. These homes, however, are a relatively small part of the sector. It’s unlikely the resized industry can absorb the staff losses directly.

An alternative job strategy would be to move into other forms of care like retirement homes and related areas. Nursing home skill sets apply to other areas of care, and the basic nursing roles are eminently portable, particularly in a nurse-starved employment market.

However, the reductions in the nursing home industry are a symptom of a major issue for nurses in the sector. The cuts show a structural weakness in the financial management system. This could result in many “nomadic” nursing jobs; traveling nurse work in a tight budgetary regime where spasmodic employment and arbitrary, time-based terms of employment replace regular full-time jobs.

That may mean a general move away from the sector into more stable employment, which inevitably would hit nurses remaining in the nursing home industry with heavier workloads and less qualified help. And we can assume salary rises aren’t on the agenda. This could cause a stampede of qualified nurses to better jobs.

“Nursing by spreadsheet” isn’t likely to be a viable option. The industry’s bottom line approach is understandable, but hardly a sustainable working proposition. The industry is about to receive the full blast of demand from the retiring baby boomers. This could be the wrong knee jerk at the wrong time. “Rent A Nurse” won’t appeal to the profession as a meaningful job option, either. Nor is it likely to be an effective solution to the obvious holes in the bucket.

There’s one common factor in all nursing careers: hard work, and lots of it. There are tough sides and good sides, explaining the reasons for 12-hour shifts to your feet, and laughing your head off at some little kid with a grin on her face.

The other side is making some space for yourself. All work and no play doesn’t make you dull (you don’t have the time and you’re in the wrong place for “dull” anyway), but there’s a mold effect, a conditioned state of mind.

You may not be able to go on holiday any time you feel like it, but you can create some personal time and space with a bit of planning. This is more time management than anything, just leaving some time free on the schedule. Time where you’re not committed to the work cycles, and out of the Instant Crisis Response mode.

The hard work, the constant filling in and attention to everything is so normal for nurses that it’s too easy to overlook the personal element. Few nurses give it a second thought, but there’s an underlying stress component if you forget you have an “off” switch and don’t use it occasionally.

There’s also an element of personal deprivation and neglect, as well as the physical pack mule effect. The personal element can be ignored to the point that a personal life is a memory, not an active thing. Remember that “rest and relaxation” is often prescribed as a cure for other people, to get them out of hyperactive behavior and allow them to recuperate physically from demanding situations. The same should be true for nurses.

If you can organize yourself into a work and play mode where you get enough time for some R&R on a reasonable, if not regular basis, you’re giving yourself a recharge. Quality of life outside picks up a lot, too. You can do some shopping, have some fun, enjoy your life and your home properly, and generally take yourself out of the Nursing Olympics training camp for a while.

Give it a shot, get back on speaking terms with your toaster oven,  and have a nice lazy day or two.

I’ve received a letter from one of my readers this week. I’m sure that every nurse can relate to her problem. This is what she said:

I’m a new graduate nurse working in a busy medical surgical unit in a large city in the Midwest. I really love my job except for one thing. I hate the gossip. I’m just plain sick and tired of the workplace gossip that I hear on an almost nightly basis. Not only is it just plain ignorant, but it can also be very hurtful. I have seen people who appear to be good friends, talk about each other behind their backs. It’s so cruel and unprofessional. What bugs me is if they are saying those things about their friends, I wonder what they are saying about me. It’s making me really upset. Do you have any advise?

Sincerely, Newbie Nurse.

I’ve worked in a community hospital as well as in a major trauma center in a large metropolitan city, and gossip is a common denominator in every health care setting. Since we can’t suture people’s mouths shut, nurses must forge ahead and do everything that we can do to curtail the demeaning effects that gossip creates in the workplace.

Gossip not only eats up time that should be devoted to patients, it’s a form of workplace violence. According to relationship coach Peter G. Vajda, Ph.D, gossip is any language that would cause another harm, pain, or confusion that is used outside of presence of another for whom it is intended. I’ve seen so many excellent nurses driven out of clinical settings because of gossip. Nurses generally feel powerless in their workplace environment, so they frequently engage in passive aggressive activities with each other. Hence, the rumor mill thrives at the nurses station.

Gossip is poison. It’s not harmless and in certain circumstances, it can lead to serious legal litigation for the employee and for the employer. If one employee is defaming another, in most states there is a potential claim if the employer does not try to change the false story that is circulating around the nurses station. Some companies are now creating gossip free work zones. That means you will be fired for gossiping about your coworkers.

Do you want to stop gossiping in its tracks? Here are a few tips that can help you break the cycle of gossiping in the workplace:

When someone comes up to you and says, “Did you hear about Dr. X and Nurse Y?” Respond with, “No, I didn’t. Let’s go ask him or her about that and find out if that is true.” You can also say, “I’m not comfortable talking about that,” or say, “I don’t like talking about other people because I don’t like them talking about me.”

When someone tries to gossip with you, walk away or change the subject.

Go to others when they are gossiping about you. Tell them what you heard, and ask them to come to you in the future about their questions or concerns. (Trust me on this one. I use this one a lot and it works.)

Don’t gossip yourself. What goes around comes around. Don’t set yourself up for trouble by backstabbing others.

Do you have any advise about how to break the gossip cycle at work? Come to Nursing Voices and tell us about it. We’re waiting to hear from you.

You interviewed for your new nursing job. It was a nerve-racking experience, but before you knew it, the nurse recruiter was calling you up and offering you a job that you couldn’t refuse. Now what do you do? There are some things that you can do that will help you make a smooth transition into your new nursing job.

Learn Everything You Can About Your New Employer

Going into a new work environment is always a challenge, so learn as much as you can about your new employer. Not all health care facilities are created equal. Learn about the health care services that they provide, their philosophies, and learn about their corporate culture. Call around to your friends before you go into work. Nursing is a small world. Maybe one of your friends knows someone that you’re going to be working with at your new nursing job. It’s always nice to see a familiar face when you walk into work.

Know The Lay of the Land

This is going to sound so simple, but a lot of people don’t think about this until it’s too late. Or should I say, until they are late. Here’s an example of what I mean.

It’s Nurse Jones’ first day of work. She’s really excited, and she’s looking forward to her first day of hospital orientation. She hops into her car after a quick breakfast and hits the freeway. Nurse Jones thinks she knows the route she is going to take to the hospital because she looked it up on Map Quest, but she really doesn’t have a clue. She is running into detours and roadblocks, and now she’s running late at the peak of rush hour traffic. Nurse Jones finally makes it to the hospital, but she can’t find a place to park. Parking is at a premium at most hospitals, and she drives around in circles for a long time before she finally finds the employee parking lot. Poor Nurse Jones arrives late for her first day of hospital orientation and doesn’t make a good first impression with her new boss.

Nurse Jones could have avoided a lot of her problems if she had taken a practice run to the hospital before her first day at work. A practice run is a simple thing that you can do that will help you make a good first impression on your first day on the job.

Know What You’re Going to Wear On Your First Day At Work

Again, this sounds simple, but knowing your unit’s dress code with save you from feeling like odd man out while saving you a lot of money at the same time.

Nurses use to have a universal dress code. We wore white dresses or pantsuits to work. Period! Now nurses wear all types of color combinations to work while other nurses no longer wear uniforms. They wear street clothes to work. Some employers have strict dress codes. They require nurses to wear specific colored uniforms that indicate which unit they work on within the hospital. Learn your institution’s dress code before you report to work. Uniforms are expensive, and you want to make sure you are buying the right outfits before you report for your first day at work.

There is a pervasive problem within the nursing profession. It’s been called nurse-to-nurse hostility, lateral violence, intergroup conflict, and eating our young. There are a lot of different names for it but whatever you chose to call the problem, it’s responsible for ruining a lot of nursing careers.

A Bully In Scrubs

There are many reasons why a nurse turns into a bully. Nurses have little autonomy in the workplace while being held accountable for everything that happens on our unit. We are also low man on the hospital hierarchy structure totem pole. Doctors and hospital administrators outrank us, and we work in a very intense environment. Throw in a few hostile patients and family members and you get the recipe for a bully in scrubs. Nurses who feel overwhelmed and oppressed at the bottom of the health care ladder engage in passive aggressive acts. Unfortunately, this type of behavior only perpetuates the cycle of lateral violence on the unit.

Lateral violence comes in all shapes and sizes. It can be verbal or non-verbal and either overt or covert. The most common forms of lateral violence include undermining, withholding information, sabotage, infighting, backstabbing, scapegoating, and undermining nursing colleagues. Bullying is a type of lateral violence that is generally associated with individuals at different levels of power and authority, but can also occur nurse to nurse. This type of behavior includes humiliation, intimidation, victimization, and verbal abuse.

It doesn’t take long before new nurses experience these types of destructive behaviors in the workplace. According to research conducted by Martha Griffin, RN, PhD, clinical specialist and program coordinator of nursing professional development at Brigham and Women’s Hospital in Boston, 60% of nurse new to practice leave their first positions within six months because of some form of lateral violence being perpetrated against them. Griffin’s research also shows that 20% of new RNs leave the nursing profession within three years due to lateral violence in the workplace. Even seasoned nurses can run into lateral violence when they chance jobs.

Bringing Down the Bully

It isn’t easy facing a bully, especially if you’ve been bullied in the past. However, you can transcend your fears and establish a healthier relationship with your coworkers by using a few simple techniques.

Improving the work environment starts with open, honest, and respectful communication. People must hold themselves and each other accountable for unacceptable behavior on the unit. Confront and address inappropriate behavior immediately as it occurs with the perpetrator. This is important because it shows that you will not tolerate the behavior. It is also helpful in some cases because the other person is not aware of their own behavior. Make “I” statements when you talk about your feelings. “I feel… when you.” Keep repeating yourself if the other person makes excuses, denies, or dismisses the incident. Keep records of incidents and communications if all else fails, and show them to your supervisor.

Patient care suffers when nurses can’t get along with each other. It’s time for the infighting to stop. Do you have stories about lateral violence in the workplace? Come to Nursing Voices and tell us about it. We’re waiting to hear from you.

Every nurse thinks about quitting their nursing job from time to time when they are having a horrendous day at work. Wanting to run for your life when you’re facing a stressful situation is normal, but it brings up a question posed to me by one of my readers. Super LPN wants to know when is it time to quit your nursing job. She writes:

I am thinking hard about quitting my present job, am attached to my resident patients, and some of my aides, and the Monday through Friday shift. But I have no unit supervisor. The whole operation is very “manage by crisis” oriented. I often work 10-12 hours a day, and I only want 8 hours a day. I have a life outside of work, and it has suffered badly. I am so sick that I cannot handle doctors over the telephone, and I forget things. I am staying home from work today. I have even lost my voice. I am afraid for my license. I was promised a very good nurse as my unit supervisor, but she was in a car wreck on her first day of work and we haven’t seen her yet. I am still all alone. I am responsible for narcotics that other nurses give, and I’m not a supervisor! Morale is very low, mine included, I have no control, and all the responsibility for people’s lives. I’m about over it. But, I get along fine with the DON. Any suggestions?

Dear Super LPN:

You are asking a very important question that every nurse faces during his or her nursing career. The nursing field is filled with nursing jobs like the one you are describing to me. I can’t tell anyone what to do, but I’m going to give you some things to think about to help you make your final decision about quitting your nursing job.

Can I Afford to Quit My Job?

I totally understand why you want to quit your job. You are working under tremendous pressure, and I’m sure that the stress that you are under is impacting your health. If you decide to quit your job, ask yourself if you can afford to be without a job while you are looking for a new one. If you need a steady income—and who doesn’t—don’t quit your job until you have a new job waiting for you when you walk out the door. Start looking for a new job now if you’re thinking about quitting your old job. You might get a better job offer somewhere else.

Can I Afford Not to Quit My Job?

I am really concerned about how your unit is being managed. Good facilities strive to provide excellent patient care. They will do anything to prevent a crisis from occurring on their units. It sounds like your unit is just one incident report away from a major lawsuit. Can you really afford to stay in a situation where you can lose your license? I understand how the people we work with become our extended family. Just remember that you can still visit your former patients and hang out with your friends when you leave your old job for a new one. Don’t let guilt and fear of the unknown hold you back. Personally, I’ve never kept a job that has made me miserable. Life is too short and I refuse to lose my sanity, or my nursing license, over a job.

Do you have questions or comments about working as a nurse? Come to Nursing Voices and tell us about it. We’re waiting to hear from you.

I’m sure that what I’m about to say will shock a lot of young people in the nursing profession. Nurses use to hold the same job for a lifetime. I’ve known many nurses who have worked their entire career where they attended nursing school. Now unit secretaries have to update their unit staffing roster every month because of the turnover. According to a recent report by the US Bureau of Labor Statistics, “baby boomers” held on average 10.2 jobs between the ages of 18 and 38, so that means that it’s time to prepare for your next exit interview. There’s a right way and a wrong way to say your goodbyes to your former employer. Here are some tips on how to make a graceful exit from your nursing job.

The Truth About Exit Interviews

Exit interviews seem harmless enough, but nothing can be further from the truth.
Responsible employers might use the information to improve their nurse recruitment and retention activities, but disreputable employers solely use exit interviews to gather information that they can use against former employees in case of future litigation. Be careful how you answer open-ended questions, and be especially careful if you are leaving because you can’t stand your old boss. Ranting during your exit interview can come back to haunt you. The notes from your exit interview are kept in your employee file, and your former employer will think twice about rehiring you at a later date if you burn your bridges as you are walking out the door. Remember that nothing you say is confidential. What you say during your exit interview can also be used against you in a court of law if you ever decide to sue your former employer.

How to Answer Exit Interview Questions

There is no rule that states that you must participate in an exit interview, however it could hurt you later on when you ask for a reference. Also be aware that you are not required to answer any questions during an exit interview. Keep your answers short, or just say, “No comment,” if you don’t want to answer a question. At the end of the meeting the HR rep may ask you to sign the notes that he or she has taken during your interview. Don’t sign anything! You will be signing away your rights if you end up in court.

Here are some commonly asked questions:

What is your primary reason for leaving you nursing job?
What was most satisfying about your job?
What would you change about your job?
Were you happy with your pay, benefits, and other incentives?
Would you consider working again for this company in the future?

The best way to say goodbye to your nursing job is to walk out the door calmly. Don’t make a noise at your exit interview. Shake hands, collect your last check, and look forward to the rewards and challenges of your next nursing job.

If you have any advice about exit interviews, come to Nursing Voices and tell us about it. We’d love to know what you think, and we’re waiting to hear from you!