Developmental care is a philosophy utilized by the entire interdisciplinary team to coordinate medical, nursing, and parental interventions based on the developmental needs for a particular patient. This philosophy of care is to support the infant and their families with a focus on environmental influences affecting neurologic development. Developmental care encourages frequent assessment and responses to a baby’s needs. These responses are meant to decrease the stress of the preterm neonates in the neonatal intensive care unit (NICU), according to the Northern Neonatal Network’s guideline for family-centered developmental care.
Why use developmental care?
Neonatal medicine is an ever-expanding field. Babies born at progressively earlier gestational ages are able to survive due to advancements in modern medicine. Mortality rates have declined with the fast-paced achievements of neonatal medicine. However, evidence exists to suggest increased morbidity for neonates born prematurely or acutely unwell. Long-term studies have identified more subtle problems including neurosensory impairments such as cognitive delays and behavioral difficulties. “These can have a significant influence on a child and their families’ way of life.” Developmental guidelines for interventions, handling, inclusion of family and nursing protocols help to optimize neurodevelopmental outcomes for NICU infants and their families.
What is the goal of developmental care?
As caregivers, we want to protect the infant’s brain and create an environment suitable for neurobehavioral development of the infant. According to the Network, the outside environment now needs to mimic the inside environment, which is crucial for normal brain development. The inside environment provides containment and allows for the baby to maintain a supported flexed posture with limited noise and light exposure, as well as, protected sleep cycles with no separation from the baby’s mother. The goal is to support more positive experiences for the baby and thus achieve more positive outcomes for even the littlest of our patients.
How do we implement developmental care?
In the NICU, we use developmental care to support the infant and their families with individualized care which focuses on the environmental influences including handling, positioning, light, and sounds. The amniotic fluid serves as tactile sensory stimulus for the infant while in utero. When the infant is in the NICU, they are exposed to various touch stimuli versus constant tactile stimulus. Studies suggest that even routine handling during procedures can have adverse effects on the infant such as bradycardia, hypoxia, sleep disruptions, increased intracranial pressure and behavioral agitation.
One way to overcome this overwhelming tactile stimuli is to swaddle the infant. A systemic review published in Pediatrics found that swaddled infants have improvement in physiological and behavioral states such as lower heart rate, alleviates pain, prevents hypothermia and calms the infant. It also induces and prolongs sleep with fewer startles. The Network’s guideline suggests that these same benefits can also be achieved by the practice of developmental positioning utilizing positioning aids. Developmental positioning also provides the musculoskeletal support of flexed & midline postures, encourages self soothing behaviors and helps to conserve the baby’s body temperature and energy thus growth and weight are promoted.
Gentle human massage and touch is another intervention that can help decrease stress levels of premature babies. A Research in Nursing & Health study found that gentle human touch increases respiratory regularity, improves sleep cycles, motor activity and behavioral distress during periods of gentle touch. Gentle massages have been reported to help improve weight gain, improved pain alleviation, reduced postnatal complications, improved physiological and behavioral states, shorter hospital stay and improved performance in developmental scores.
The NICU is quite often an overstimulating environment. Behaviors, which should be modeled by staff and taught to the parents can ease the constant stream of auditory and visual stimulation. The NICU staff can control the lights and sounds of the outside environment. A 2013 study published in Indian Pediatrics recommends that we keep the infant on a schedule to allow for uninterrupted rest and decrease stress by using non-nutritive sucking, kangaroo care with parents, swaddling, and containment.
In summary, developmental care should be utilized for all preterm infants during their adaption to extrauterine life. Creating a positive environment and protecting neurobehavioral development is crucial to an infant’s long term outcomes. Implementing developmental care practices such as positioning, swaddling, nonnutritive sucking, gentle human touch and massage can help alleviate pain and provide better outcomes for the premature babies and their families.
Whether you’re dealing with bunions, blisters, plantar fasciitis, or bone spurs, foot pain is a common complaint among nurses. If you’re monitoring your steps each day with the latest fitness tracker or app, you probably already know you’re walking miles in your shoes each day. No wonder your feet hurt! Below are some do-it-yourself ways to reduce foot pain and help you keep moving–pain-free.
1. Replace your shoes every three to six months.
In an online interview, Dr. Michael Lowe, past president of the American Academy of Podiatric Sports Medicine, notes that a standard athletic shoe is made to last between 350 and 500 miles–which translates to a new pair of shoes about every three to six months. With the number of hours you’re on your feet every day, your mileage quickly adds up. Once a shoe breaks down, it no longer absorbs shock like it’s supposed to and can misalign your foot and cause pain.
2. Regularly stretch your calves.
Tight calves can exacerbate some types of foot pain. To improve the flexibility, mobility, and position of your foot, follow this simple stretch:
Stand about a foot away from the wall, and place your hands against the wall at shoulder height. Keeping your feet hip-width apart, step back with one leg until your foot is flat on the floor. Bend the front leg until you feel a stretch in your back, calf muscle; the stretch should be tolerable for you. Hold this position for 30 seconds and repeat on the other leg. Cycle through this stretch one or two more times.
3. Try an Epsom salt foot bath.
Epsom salt contains magnesium sulfate–the mineral that gives this home remedy its muscle relaxant quality. To create a foot soak, find a bowl or bucket large enough to submerge both feet (I use a bucket). Place one-half to one cup of Epsom salt into the bucket. Then, fill the bucket about two-thirds full with warm to hot water being mindful of the temperature level that is most comfortable to you. Let the salt dissolve and soak your feet for 20 minutes. Dry off your feet and follow up with a moisturizer if necessary. Routine foot soaks can help reduce the inflammation that leads to aching feet.
4. Roll out your foot pain with a tennis ball.
Place the bottom of your foot on the top of a tennis ball. Roll the tennis ball back-and-forth along the whole length of your arch. For a deeper stretch of your foot’s fascia, apply a decent amount of pressure as you roll the ball. If you encounter a spot on your foot that is extra sore, gently massage that particular area until you feel a release in muscle tension or the pain improves.
One final note: If you try these at-home treatments without benefit, consider talking to your doctor about seeing a physical therapist for a customized evaluation and treatment plan for your foot pain.
“History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again.”
The history of nursing used to be part and parcel of most nursing programs. However, due to a plethora of changes in health care, nursing, and technology, there is little room to include this important content. Today, many nursing programs provide a brief overview of nursing’s rich history because the curriculum is overladen with content. Most historians concur that learning about one’s past history provides one with a greater understanding and appreciation of the issues that inform their current and future practice and policies. The history of the nursing profession is closely intertwined with health care, medicine, society, and public policy. We can see a reciprocal influential relationship between current events and the role of the nurse. Throughout the years nurses have played a pivotal role in the health and welfare of the population across the lifespan, and around the world. Recognizing the significance of the past on our current and future profession, the American Association for the History of Nursing advocates for the inclusion of nursing history in nursing curricula.
Nursing’s history is replete with stories of healing, nurturing, hardships, heroism, discovery, ingenuity, caring, compassion, education, research, and leadership. Historical records demonstrate that nurses have been in existence since ancient times, and their roles have evolved from one of an informal caregiver to the untrained nurse to the professionally trained nurse of today. Although we have made significant advancements along the way when looking back on our history one can see that in some ways nurses of today are not that different from the nurses of the past.
Key Facts in Nursing and Medicine
- Records from ancient time periods demonstrate that nurses and midwives existed.
- Hippocrates is known as the founder of medicine.
- Galen is considered one of the greatest Greek physicians after Hippocrates.
- Some civilizations used slaves, the poor, or fallen women to serve as nurses.
- From the 1st to 14th centuries nursing care was provided by unskilled men and women.
- From the 14th to 17th centuries times were turbulent with unsafe conditions, quackery, plagues, and construction of hospitals.
- During the 18th century family members cared for most of the infirm.
- In 1732 an almshouse for the poor and infirm was opened in Philadelphia.
- Pennsylvania hospital was opened in 1851.
- 18th century nurses made the following contributions:
- bed warmers
- heating pads
- herbal remedies
- During the Revolutionary War, General Washington ordered many women to serve as nurses to the wounded soldiers.
- The Crimean War took place from 1853 to 1856.
- The American Civil War took place between 1861 and 1865.
- Florence Nightingale, who many consider the “Foundress of Modern Nursing,” made significant contributions during the Crimean War and influenced medicine and nursing.
- During the 20th centuries World War I, World War II, the Korean, and Vietnam Wars nurses served to care for the wounded
- Throughout the 20th century, numerous nursing theorists emerged and made significant contributions in the advancement of nursing science.
- Three notable 20th century pioneers in nursing education were Lavinia Lloyd Dock, Isabel Hampton Robb, and Mary Adelaide Nutting.
- Nurse training schools became more formalized after Nightingale opened her first school of nursing and there was rapid growth of nursing schools throughout the 20th century.
- Beginning in the 1950s, nurses sought to develop their own body of knowledge initially “borrowing theories from other disciplines” and eventually developing and testing their own theories.
- Throughout the 20th century, myriad professional nursing organizations were created.
- The 21st century has been a time of continued growth and development of the nursing profession, which is due in part to advances in technology, evidence-based practice, and reports such as the Institute of Medicine’s Future of Nursing.
Do you ever feel like you’re running on empty? Maybe you feel like your workload is taking a toll on your mental or physical health, and you’re just not able to bounce back as you had hoped? You’re probably already aware that compassion fatigue can happen to any nurse at any point along the career path. But when it happens to you, self-doubt and self-criticism can creep into your thoughts. When going through this profound state of stress, it’s valuable to remember there is no stereotypical profile of what a nurse with compassion fatigue looks like, and it’s not a reflection of how committed or competent you are in the profession.
Let’s take a look at some myths surrounding compassion fatigue so you can experience a greater sense of well-being when you’re at home or work.
Myth 1. Compassion fatigue is a character flaw.
This is simply not true. Although your self-identity may be intertwined with your role as a nurse, compassion fatigue isn’t the result of a character flaw in you. You are a hard worker, and you care for your patients with everything you’ve got. However, if your body is showing signs of physical and emotional exhaustion, anxiety and worry, depression, anger, irritability, lack of joy, or any other sign, it’s time for you pay attention to it. Your body is telling you to recharge your internal battery, and, perhaps, scale back on your workload.
Myth 2. You need to work harder to overcome compassion fatigue.
On the contrary. While working harder may be the default setting to get some people through the day, many nurses tend to put others’ needs above their own, further engaging in energy-draining activities. When compassion fatigue creeps up on you, it’s not telling you to do more. Rather, it’s telling you your work-life balance has gotten out of whack, and you need to reexamine it.
Myth 3. I still feel compassion for my patients, so compassion fatigue must not pertain to me.
In an online article, American Nurse Today noted that nurses reported feeling both compassion fatigue and compassion for their patients at the same time. “If anything, the more compassion a nurse feels, the greater the risk that she or he will experience emotional saturation or compassion fatigue,” the article said. Try to recognize the other areas where you may be showing signs of fatigue. Do you find that your colleagues are difficult to work with? Are you thinking about going home as soon as you get to work? Are you concerned you might make an error while on the job? These point to subtler signs that you’re experiencing compassion fatigue, even if you still feel empathetic when caring for your patients.
Myth 4. It’s my job to care for others first and myself second.
For many nurses, this idea seems like a selfless act while working within the health care community. In reality, when you implement consistent self-care practices, acknowledge what things make you feel overwhelmed, and cultivate the support you need both inside and outside of work, you reduce your risk of developing compassion fatigue. “Perhaps the most important way to prevent or reduce compassion fatigue is to take care of yourself. As nurses, we work hard and really need our breaks. We need to eat, and to take time for ourselves without being interrupted by alarms, patients, or colleagues. We also need our time off, for our mental and physical well-being,” stated American Nurse Today.
Bottom line? Understand that compassion fatigue can sneak up on you, and its symptoms vary from person to person. It’s not indicative of how skilled you are as a clinician, and there’s not a one-size-fits-all approach to finding your way back from it. It’s important to know recovery will likely require time along with some adjustments to your lifestyle.
Every year during the third full week in May, the American Association of Neuroscience Nurses (AANN) celebrates Neuroscience Nurses Week (NNW) to honor all nurses who work in the field. To get more insight, we contacted Allison Begezda, MPS, senior marketing manager of the AANN. What follows is an edited version of our Q&A.
Why was NNW started?
Neuroscience Nurses Week was started to celebrate the nurses who care for the most vulnerable patients and their families. During NNW, AANN thanks our nurses for providing the highest level of quality care to their patients. The week is all about highlighting neuroscience nurses’ influence on patient care to hospital administrators, allied health professionals, and the community.
What kind of celebrations/recognition are held for this week? Why?
AANN encourages hospital administrators to celebrate their neuroscience nurses by providing lunch, cake, a party, or other recognition. We provide an activity planning guide on our website with tips and ideas for planning a NNW celebration. We also have a NNW logo and poster hospitals can print and use.
Additionally, we offer a proclamation template that hospitals can use to alert the media or that their local officials can use to endorse the observance of NNW. Our journal, the Journal of Neuroscience Nursing (JNN), also offers the current issue for free.
AANN has partnered with Jim Coleman Ltd. to offer branded neuroscience nurses week merchandise for sale. Hospital administrators can purchase pens, tote bags, t-shirts, and more for their nurses as a NNW gift. Learn more at www.AANN.org/NNW.
What are the various kinds of neuroscience nurses? What kinds of training or education do they need to have in order to hold this position?
Neuroscience nurses assist patients with brain and nervous system disorders. They work to understand and treat illnesses and injuries that affect the nervous system. Neuroscience nurses work in diverse, challenging, and rewarding environments, such as hospitals, health care clinics, brain injury units, and intensive rehabilitation units.
As for their education, neuroscience nurses have a nursing diploma such as an Associate of Science in Nursing (ASN) or Bachelor of Science in Nursing (BSN) and then must pass the National Council Licensure Examination (NCLEX). After two years of practice (candidate must have at least two years of full-time experience or 4,160 hours in either direct or indirect neuroscience nursing practice during the past 5 years), nurses are eligible to sit for the Certified Neuroscience Registered Nurse (CNRN) exam and upon passing become a CNRN.
Stethoscopes dangled around the necks of nurses wearing navy NursesTakeDC t-shirts and big smiles. “Where are y’all from? We’re from Arizona!” More than 800 nurses from 40 U.S. states congregated at the NursesTakeDC Rally on May 5th in Washington, DC. The rally was to support legislation establishing federally mandated requirements for safe nurse-to-patient staffing ratios, while drawing public attention to the staffing crisis in many U.S. hospitals. This was the second such rally; last May, the inaugural event drew about 250 participants to the steps of the U.S. Capitol.
The rally was cosponsored by the grassroots nursing movement Show Me Your Stethoscope, a group that formed spontaneously on Facebook after nurse Janie Harvey Garner watched The View host Joy Behar ask why a nurse in the Miss America pageant was wearing “a doctor’s stethoscope” around her neck. That group now has more than 650,000 members. Other rally sponsors and supporters included the Illinois Nurses Association, Hirenurses.com, Nursebuzz, The Gypsy Nurse, Century Health Services, and UAW Local 2213 Professional Registered Nurses.
The NursesTakeDC rally was originally scheduled to take place on the steps of the Capitol, but thunderstorms and downpours forced the meeting indoors at a hotel in nearby Alexandria, Virginia. Although the setting lacked symbolism, participants still raised handmade posters and shouted rally cries. Rally organizers estimated the weather had an impact on overall attendance, but they were still encouraged by the turnout. After the speakers wrapped up, a group of about 150 nurses headed to the U.S. Capitol steps for photographs and final thoughts.
© 2017 David Miller, RN
Two, Four, Six, Eight, Patient Safety Isn’t Fake
“We aren’t laughing, we want staffing!” Cheers and whistles erupted out of the crowd. After 10 minutes of rally cheers and chants, the gathering turned its attention to the first of many speakers who would highlight issues faced by nurses in every specialty and across the profession. Actress Brooke Anne Smith began by reciting a moving poem about nurse warriors on the front lines.
Event organizer Jalil Johnson then took the stage, giving a keynote speech that addressed the challenges bedside nurses face every day. He spoke about nurses as the foundation of health care, and the unrelenting pressure to perform in deteriorating conditions. While discussing dire staffing situations, Johnson said that he fought every day, “making sure I didn’t give anyone a reason to come after the license I had worked so hard for.”
He discussed the paradox that year after year, nurses are rated the most trusted profession, yet no one trusts nurses when they say they are overworked, overburdened, and practicing in unsafe conditions. Nurses alone are not enough to fight this battle, he said. “To the public, we say: Trust us when we say the industry makes it nearly impossible to deliver the care you need. Trust us when we say we need your support.”
Other NursesTakeDC rally speakers included Katie Duke, Terry Foster, Deena McCollum, Linda Boly, Julie Murray, Catherine Costello, Kelsey Rowell, Leslie Silket, Dan Walter, Nicole Reina, Monique Doughty, Doris Carroll, Charlene Harrod-Owuamana, Debbie Hickman, and Janie Harvey Garner.
The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act
On May 4th, the day before the rally, Representative Jan Schakowsky (D-IL) and Senator Sherrod Brown (D-OH) reintroduced the latest iterations of the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (H.R. 2392 and S. 1063). The bills seek to amend the Public Health Service Act to establish registered nurse-to-patient staffing ratio requirements in hospitals.
In a press release, Rep. Schakowsky’s office writes: “This bill is about saving lives and improving the health of patients by improving nursing care—ensuring that there are adequate numbers of qualified nurses available to provide the highest possible care.” The press release acknowledges that study after study has shown that safe nurse-to-patient staffing ratios result in better care for patients. “It’s time we act on the evidence and the demands of nurses who have been fighting to end to dangerous staffing,” the release continues. “I’m proud to be a partner with nurses across the country in promoting this bill and working to ensure quality care and patient safety.”
Rep. Schakowksy attended last year’s event, but was unable to attend this year. The Nurse Staffing Standards Act is the latest in a string of bills that have been introduced to Congress every session. Previous bills S. 864 and H.R.1602 died in committee last session. S. 864 was first introduced in May of 2009; H.R. 1602 was first introduced in 2004 and has been sponsored seven times so far. Rally co-chair Doris Carroll explained why: “The legislation is reintroduced session after session, and it continues to die in committee because there is no bipartisan support.”
In today’s environment, politics can be touchy. The day before the rally, the House of Representatives passed the American Health Care Act of 2017. Among nurses there are very polarized viewpoints on health care, abortion, assisted suicide, and other controversial topics. In his speech, Johnson acknowledged that not all nurses think alike. “We are a profession divided,” he admitted. “But when it comes to safe staffing, we all agree. This is a movement devoid of partisanship. Staffing is not a partisan issue.”
The proposed text and ratios for the Nurse Staffing Standards Act are below:
A hospital would be required during each shift, except during a declared emergency, to assign a direct care registered nurse to no more than the following number of patients in designated units:
1 patient in an operating room and trauma emergency unit
2 patients in all critical care units, intensive care, labor and delivery, and post anesthesia units
3 patients in antepartum, emergency, pediatrics, step-down, and telemetry units
4 patients in intermediate care nursery, medical/surgical, and acute care psychiatric care units
5 patients in rehabilitation units
6 patients in postpartum (3 couplets) and well-baby nursery units
Rally speakers encouraged nurses to reach out to their representatives in Congress to show support for safe staffing legislation, and handouts for participants detailed how to find representative names and numbers for letter writing campaigns and phone calls.
Where Is Everybody?
When one of the speakers asked why there wasn’t more involvement in the grassroots movement, and why there weren’t more nurses present, several voices called back from the crowd. “Everyone’s working!” one shouted. Another called out, “They don’t have the money!”
“Really, where the heck is everybody else?” one rally participant said. She gestured to the conference room, which at the time held about 100 nurses. This nurse was part of a group attending from New Jersey, including Kate McLaughlin, a registered nurse and founder of NJ Safe Patient Ratios, a group dedicated to the support of safe staffing in New Jersey and promotion of ratio law S. 1280 in New Jersey’s Senate.
“In New Jersey, multiple bills have been introduced, every single session, and nothing ever passes,” McLaughlin said. “In California it was the same thing, and then the tenth year, they involved unions and patients and it finally worked.” She said she started to pay attention to safe staffing laws in her state, and launched a petition on change.org. “I stalked nurses on Facebook and found people that way,” she continued. “Each week, we organize and post the contact information for two state senators.” She is starting a movement in New Jersey, hoping to motivate others to show support for these bills. “It’s an election year,” she said. “Now is the time.”
McLaughlin said her state’s ratio law was first introduced in February 2016, but there has been no vote and no hearings, “which just feels disrespectful.” She was told the governor didn’t support the bill, and “that we might need to wait until there’s a new governor.”
The problem, according to several nurses at the rally, isn’t a lack of awareness. “I think it’s apathy,” McLaughlin said. “This is a profession of predominantly women, and we are taken advantage of. They know we don’t get breaks, but they’re okay with the labor law violations. We’ve somehow accepted that this is normal—this is not normal.”
Carroll also expressed discontent that no one seems to care about this issue. “Why has this taken so long? Why hasn’t California’s success spread like wildfire?” she asked. “Well, health care changed, and it became a multi-billion dollar business for hospitals and insurance companies.”
Dan Walter, another speaker, acknowledged that sometimes nurses do not report safety issues because they fear retribution. Walter is a former political consultant and publisher of HospitalSafetyReviews.com, a web site that he established for nurses to anonymously post about patient safety issues where they work. In his speech, he explained the inspiration for creating the site: “You are the activists and you know what needs to be done. I want people to be able to go there, post, and we will keep it as anonymous as possible so we can protect you.” He expressed hope that this web site will be a powerful platform to improve patient ratios.
How Bad Is Staffing?
Nurses from a hospital in downtown Washington, DC, expressed frustration with the lack of support and resources from hospital administrators. “The other day, we had so many critical patients in the department we ran out of monitors,” one said. Another said that 80% of the nurses who work in her hospital’s emergency department have less than two years’ experience. “The turnover is so high,” she said. “People get so burned out because of the short staffing.”
Just how short are units staffed? “In our ED [emergency department], someone the other night was taking care of seven patients,” one nurse from this group said. “And these were sick patients, people with LVADs [left ventricular assist devices], and ICU patients.” This is common all over the country. A medical-surgical nurse may be taking care of up to eight or more patients at a time.
Llubia Albrechtsen, a registered nurse and family nurse practitioner at the rally, said there have been times she has refused to take on additional patients in the emergency department where she works. “When I have five patients, I need to take a step back and pay more attention, because their conditions may worsen,” she said. “It’s hard, because we could be providing excellent care to many of our patients, but with limited resources we have to do the best we can and hope nothing bad happens.”
Albrechtsen said that although hospital administration makes an effort to listen to nurse concerns about staffing, through town halls or open meetings, not much has changed. “Many areas still work understaffed,” she said.
Why Does Staffing Matter?
A policy brief disseminated at the rally lists the effects of inadequate nurse staffing, including the overwhelming evidence that safe staffing saves lives. High patient-to-nurse ratios lead to poor outcomes and a demonstrated increase in patient morbidity and mortality. Inadequate staffing has been associated with an increase in hospital readmissions, falls, pressure ulcers, hospital-acquired infections, and medication errors.
Poor staffing is expensive. In addition to causing poor patient outcomes, nurse burnout causes injuries, illness, and contributes to the growing nursing shortage. Replacing nurses due to turnover takes between 28 to 110 days, and costs the average hospital $6.2 million per year.
“The health care industry generates $3 trillion annually,” Johnson said in his address. “We are living in an age of greed, where the health care industry measures patient satisfaction by a customer service model. This is prioritized over quality and safety. Reducing burnout, staff retention, and caring for your staff are at the bottom of the barrel of priorities.”
The grassroots movement behind safe staffing is fighting for environments that allow nurses to do their work in the way in which they were trained. “[A nurse’s] work has been diminished to defensive practices; it has been reduced to a list of tasks to complete,” Johnson said. “That is not nursing.”
In Johnson’s final remarks, he spoke to empower nurses to return to their states, hospitals, and colleagues with a message to inspire change. “We have to show up in person, put boots on the ground, and be ready to engage and pull more nurses into this movement,” Johnson said. “Most importantly, we have to believe that with over 3 million registered nurses and over 1 million licensed practical nurses, our profession can come together as one. We will take back our profession and regain control of our practice.”
Another rally is already in the works for next year. The organizers of NursesTakeDC will now direct their focus toward supporting any state that has pending policy and legislation aimed at improving nurse-to-patient ratios and safe staffing. Organizer Carroll said that this year is a learning curve for the organizers, and they hope that next year they will have something even better with an even bigger audience.
“We encourage all nurses, practicing at all levels and in all settings, to unify and support beside nurses in the fight for safe staffing,” said Johnson to a room full of applause and cheers. “We fight for recognition—we will not justify our existence! There is no health care industry without us, and we will determine what is best for our practice and for our patients.”