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Culture of Nursing: A Factor in Nurses


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 – PowerPoint PPT presentation

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Title: Culture of Nursing: A Factor in Nurses

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

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

  • 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)

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

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
  • Nursing home and union focus groups easier to
    enroll participants
  • Some differences in perceptions related to risk
    between managers and workers

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

Status of Nursing
  • Discrepancy between society and healthcare
  • 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?

Historical Context
  • Long history of disempowerment and economic
  • 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

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)

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

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.

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
  • 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)

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.

Significant Re-Definitions in Restructuring of
Health care
  • Healthcare Agencies a business manufacturing
  • 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

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

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

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)

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.

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.

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!

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

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)

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)

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

Unions as Bulwark Against Culturally-Defined Role
  • A complex socioeconomic issue like health care
    restructuring cannot be addressed by individuals
  • 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)

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

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
  • Note this material is not to be copied without
    permission of the authors