What student nurses learn and what they experience, either positive or negative, during their formation as a nurse will forever become part of their character. Horizontal violence is common among students for many reasons and perpetuated because they see themselves as powerless. Unfortunately, much research on violence and bullying in nursing usually excludes student nurses in sample populations, and there have been few studies done on the correlation of horizontal violence and nurse bullying and the effect on student nurses. Not only are student nurses victims of bullying, but they themselves become bullies as well. This impact must be addressed as well, because student nurses are our future in the health care system, and the lives of patients depend on the student nurse becoming a just and moral citizen.
Student nurses compete for entrance to nursing school; this pits them against their peers. Then, once in nursing school, they are often met with an instructor who says, “Look on either side of you; that student won’t be with you when you graduate.” This introduces fear of failure and adds to an already stressful environment. The degradation of students continues throughout their clinical rotations and classroom attendance. After graduation, they then must compete for intern placement, academic honors, and job placement. This struggle does not create a colleague, but rather a competitor against whom the student must win or face failure.
Student nurses suffer from lack of sleep, lack of a social outlet, intense worry, stress, and anxiety. Unless they have developed healthy coping mechanisms, this stress is turned outward onto fellow students, faculty, and family, resulting in negative comments and behavior and angry outbursts. Students may also face bullying from several different sources, including staff nurses, clinical and classroom instructors, patients, instructors, visitors, and fellow students.
The most common type of bullying against student nurses is verbal assault, and clinical instructors have been identified as the main source of bullying behavior towards students.
Bullying behavior experienced by student nurses includes: being excluded or alienated; receiving destructive criticism; experiencing resentment; being humiliated in the presence of fellow students, staff, or patients; having their work undervalued; being treated with hostility; being blamed for patient care incidents that were the fault of the staff; being ignored by staff or the preceptor; lack of communication; being threatened with a poor evaluation that may be the result of changing clinical expectations that were not communicated; and faculty who “mentally sabotage” them by not being clear about testing or clinical expectations.
All of bullying forces converge against the student, not allowing him or her to reach full potential. Bullying has a direct effect on the confidence level of the student and causes personal and professional outcomes similar to those of bullied staff nurses. This includes feelings of decreased self-esteem, lack of autonomy, decreased self-worth, anger, fear, low morale, frustration, anxiety, increased errors, stress, apathy, burnout, guilt, worry, sleep disturbances, and symptoms similar to post traumatic stress disorder.
It is the professional and ethical responsibility of faculty within schools of nursing and individual nurse educators to educate their students, beginning early in the process, to recognize signs of bullying from all persons with whom they currently interact or will interact with in the future, including patients, staff, fellow students, instructors/professors, and preceptors and to suggest strategies for a solution.
Nurse educators can help change how bullying is addressed in the following ways:
- Educate students on what bullying and horizontal and lateral violence are as well as their impact on patient care.
- Prepare students prior to entering their clinical area for bullying behaviors they may encounter and how to manage their behavior.
- Teach students prior to their graduation about the behaviors they may encounter at a new job and how to manage those behaviors.
- Allow students to freely express themselves about negative interactions they have encountered and how they dealt with the behavior.
- Acknowledge that role playing and conflict resolution should not be considered the “cure” for the bully or the victim. These strategies may actually encourage further bullying behavior if the school of nursing does not utilize other strategies to recognize and end the behavior.
- Ensure that those who precept students are educated in how to effectively precept.
- Teach students whom they need to inform if bullying or violence occurs. The school and health care facility policies and procedures regarding bullying reporting must be reviewed with the student. This includes witnesses to bullying.
- Make sure that students, in turn, feel safe in reporting to their instructor, faculty, preceptor, and later on, to a unit manager. They must feel that their complaints are taken seriously and will be acted upon and are held in confidence.
- All educators, including preceptors, should be knowledgeable in the methods to resist bullying and horizontal violence as well as to identify it.
- Educators in every venue, classroom, or clinical area must model behavior that includes effective methods for reducing hostility.
- Enforce a zero tolerance policy for abuse, bullying, or violence. Nurse educators should model that nothing but respect will be tolerated from any health care professional, student, patient, or visitor.
- Teach students that violence, bullying, and verbal abuse are not a part of nursing, and enduring them is not a rite of passage!
- Encourage all nurses to model professional behavior. What is seen by students is imitated by them. If students experience bullying and the bullying is condoned, they will become bullies and the cycle will continue.
- Clinical instructors should be knowledgeable in not only clinical skills but also in how to effectively communicate and interact with students and staff.
- All nursing schools and universities have a responsibility to define bullying, and to design and implement anti-bullying policies and procedures.
- Provide students with information of outside or university support for victims of bullying.
- Make students aware of the psychological effects of bullying and also coping mechanisms to deal with stress.
In honor of CRNA Week, our Nurses of the Week are two Columbia University nursing students who traveled to Ecuador on a surgical mission. Julian Piazzola and William Scott, both members of the Columbia Nursing Class of 2018, jumped at the opportunity to assist a surgical mission in Ecuador. As Certified Registered Nurse Anesthetist (CRNA) students, it was the perfect opportunity to participate in a clinical rotation while also getting to travel abroad.
The students were accompanied by Michael Greco, DNP, director of Columbia’s Nurse Anesthesia Program, on the week-long health mission with Blanca’s House to bring quality medical care to countries and communities in Latin America. Their clinical experience in Ecuador included setting up an operating room to provide anesthesia for total knee replacements and head and neck cases for local citizens.
Although the clinical hours they completed in Ecuador did not count toward their hour requirements for official CRNA licensing, Piazzola and Scott say their medical mission was an invaluable opportunity to volunteer their services to patients in need. Piazzola tells Nursing.Columbia.edu:
“Providing care in a remote location was extremely rewarding. I felt the impact we made on this community, and I left with such a positive feeling about the patient experience, which is integral to nursing care.”
To read Columbia Nursing’s full interview with Piazzola and Scott about their experiences volunteering on a surgical mission to Ecuador, visit here.
Bedside manner is a broad phrase used to describe a health care professional’s attitude towards a patient. At its core, it describes the doctor- or nurse-patient relationship, but the right approach to care goes much deeper than that. According to the David Geffen School of Medicine at UCLA, bedside manner is one of the most crucial parts of a patient’s recovery, as it helps build trust in the patient and leads to better care after the patient has left the hospital. In other words, universities are now emphasizing good bedside manner right alongside teaching CPR and how to use stethoscopes.
They’re Making Empathy a Priority
Today’s medical and nursing students are taught to put themselves in the patient’s shoes. As easy as it is for a health care professional to write off a patient’s concerns as routine, caretakers must remember that for many people, being in the hospital is one of the most stressful times of their lives. Why? Because being empathetic and courteous helps gain a patient’s trust and boosts their confidence, which can equal greater levels of success after discharge.
Med schools throughout the country have struggled with finding unique ways to help students understand the importance of empathetic medical care. But some have found success. At Virginia Commonwealth University, faculty members developed a unique program to help students delve into their ability to empathize: a collaboration between the school’s theater department and medical school. Internal Medicine students get a theater-based approach to learning empathy.
According to the pioneers of the program, the approach helps counter-balance the science-focused curriculum on medical school.
“Essentially, medical schools have crammed so much into four years of study that science has squeezed out the humanistic aspects of medicine. In theatre, we teach how to be authentically present in inauthentic moments. We thought we would see if we could take some of those skills and teach them to physicians,” said the vice chair of the school’s theater department, Aaron Anderson.
They’re Emphasizing Communication Skills
Communication is key to helping build a solid doctor-patient relationship. But you don’t only communicate with patients by the words you choose. You also communicate through what you wear. For example, you might choose to wear cute scrubs and accessories to convey a bright, cheerful disposition. The David Geffen School of Medicine recommends the following tips for good communication with patients:
- Use words that patients can understand, not medical jargon.
- Make eye contact with a patient while talking to them.
- Eliminate body language that demonstrates haste or dishonesty.
- Always introduce yourself every time you enter the room.
Good communication skills are achieved not only through what you do at the bedside, but also what you don’t do. A paper published by the University of Rochester Medical Center (URMC) links multitasking with poor bedside manner, suggesting that older medical professionals were taught to separate technical expertise from compassion. The paper highlights the significance of separating these two equally important care components in order to enhance bedside manner.
They’re Giving Students Real-Life Experience
There’s a reason why a big part of medical training is the residency or clinical hours. Health care professionals simply won’t understand the value of good bedside manner until they’re exposed to fieldwork, but many medical students don’t see a single patient until their third year. Real-life experience doesn’t have to come from traditional channels like residencies and internships. Some health care professors are working bedside manner training into students’ curriculum through volunteering and mentorship.
Second-year medical students at Florida International University in Miami are encouraged to go out into the community and help local families in order to help them interact with real patients sooner. Bedside manner curriculum is now starting to focus more and more on other channels to introduce students to real-life scenarios earlier. For example, students at URMC are trained in “mindfulness” — the center’s answer to the multitasking debate — through good mentoring.
They’re Teaching Continued Learning
So how do medical professionals address the issue of those well-established nurses and physicians who didn’t get their degree at a time when bedside manner was so strongly emphasized? It all comes down to continued learning. Like they do with medical advancements, clinicians must stay abreast of new approaches to bedside manner. Re-training established physicians to be more empathetic, caring and kind is possible, according to a study conducted by the Emory University School of Medicine in Atlanta.
The study sought to determine whether medical professionals who have been working in the field for years could be re-inspired to be more humanistic. In other words, it wanted to figure out whether you could teach old dogs new tricks, or re-teach them the ones they forgot. The results were promising: after 18 months of twice-monthly meetings on compassion, empathy, and other bedside manner skills, all the established physicians outscored their controls.
They’re Teaching Humor
Patch Adams may have been onto something. They say that humor is the best medicine, but is that actually true? When it comes to improving the patient-caretaker relationship, absolutely. Medical schools across the globe are gravitating towards new humor-focused approaches to bedside manner.
Students at Northwestern University’s Feinberg School of Medicine are taught ways to implement humor into their practice by taking improvisation theater classes to help them learn how to convey humor in a way that’s appropriate at the bedside.
They’re Using Technology and ‘Webside Manner’
When we think of bedside manner, we often think of a more holistic and polite approach — face-to-face time, minimal medical jargon, empathetic conversation, and no smartphones — but there are some situations where bedside manner can be improved through technology. For example, students may be encouraged to enter an interaction with a patient armed with a tablet that allows them to record or notate conversations, which will help them produce more humanistic, personalized care on the next visit.
And as most medical and nursing students know, more and more health care providers are offering “virtual visits,” where patients can message or video chat with their clinician so they don’t have to come into the office. These new technologies have sparked a whole new debate on bedside manner, dubbed “webside manner” in these scenarios. Can you practice good bedside manners over an app? Yes, according to the experts, and it should be covered alongside traditional bedside manner techniques in medical and nursing schools.
Thinking about going to nursing school? You’re headed for a great career, one that’s rewarding, challenging, and always exciting. But nursing school is notoriously difficult. Most nursing programs require high GPAs and impressive scores in math, chemistry, biology, psychology, and other demanding subjects. It’s also extremely fulfilling. These are things most people already know about nursing school, but what about the things no one ever tells you? Here are a few of those things.
1. You Will Pull All-Nighters
Nursing school isn’t for the faint of heart. In fact, it can be extremely challenging. Just take a look at the curriculum for the Johns Hopkins School of Nursing—a school that, by the way, is consistently ranked in the top three nursing schools in America. Master of Science in Nursing (MSN) candidates at Johns Hopkins must complete nearly 50 credits and 500 clinical hours to finish their master’s program.
Bachelor’s candidates take longer to graduate than ever before, with most nurses spending more than four years earning their undergraduate degree. Because nursing programs tend to be more demanding in terms of credits, many students are forced to fast-track their degrees by taking multiple hard classes at once. If you’re in nursing school, that means several of the most stressful mid-terms and finals at the same time.
Because of these factors, all-nighters are inevitable. But nursing students know better than everyone else that staying up all night to cram isn’t good for your health. Getting a good night’s sleep before a big exam will help you retain memory and stay focused. Make sure that when you go into nursing school, you don’t bite off more than you can chew. Try to alternate those tough classes so you don’t have competing exams.
2. You Will Experience Burnout
Nursing school burnout is real. But don’t take it from us. There have been numerous studies indicating that nurses-in-training feel burnout at a higher level than students seeking other career paths. One study found that nursing students in the U.K. felt increasing levels of stress and used negative coping methods as their programs progressed.
The same study found that as nursing programs got harder, students experienced physiological morbidity, meaning they developed health issues as a result of their stress. But don’t let the prospect of burnout deter you from pursuing a nursing degree. Researchers are working to develop new programs that deter fatigue and burnout.
With the risk of burnout and fatigue higher for nurses, how do they stay positive? It all comes down to focusing on the end goal. Nurses enjoy myriad benefits compared with other career paths, including greater job stability, stronger personal satisfaction, the ability for career mobility, and the potential for higher salaries.
3. You’ll Have to Spend Money Out of Pocket
With the average cost of a bachelor of nursing science (BSN) degree quickly creeping up well into six figures (the average cost of a BSN is somewhere between $40,000 and $200,000), it’s important to remember that nursing students also have to spend more out of pocket than many other students seeking a bachelor’s degree. In addition to the cost of tuition and housing, nursing students incur additional costs associated with licensure exams, text books, and medical supplies.
When you prepare for your clinicals, internship, or lab courses, you may also be required to invest in nursing scrubs or uniforms. This isn’t such a bad thing, though. Think of your scrubs, stethoscopes, and everyday equipment as an investment in your future. And when you look the part, you’re more likely to succeed. Make sure that you invest in high-quality medical uniforms and durable shoes (we recommend Dansko) so that your wardrobe will stay with you until you’ve graduated and passed your licensure exam.
4. You Will Become Cynical
Here’s the thing: nursing and nursing school are stressful, and part of that feels out of your control. When you’re doing your internship or certification hours, you’ll be faced with a wide range of scenarios that feel utterly impossible: a patient with an illness that has no clear treatment track, the notoriously difficult bureaucracy of hospital administration, the inequalities of health care. All these things can contribute to cynicism over time.
Another phenomenon among nursing students and professionals is the experience of becoming desensitized to people’s trauma and suffering. Ask any child of a nurse and they’ll tell you that their parent rarely panicked over a bloody injury or a particularly gross illness. That’s because the more you’re exposed to medical conditions, the more normalized they become. Over time, it may feel like nothing shocks you anymore.
Studies show that this phenomenon occurs because nursing students are forced to “compartmentalize” their emotions. In other words, they separate the natural human reaction to a person bleeding from their immediate need to provide life-saving care. Newer nursing pedagogies put a serious focus on empathy to help deter nursing students and professionals from becoming desensitized on the job.
5. You Will Make Friends for Life
Nursing school is a unique environment. There will be few times in your life when you’ll engage so closely with people of the same career path, especially in scenarios where you’re forced to work together and lean on each other so often. Making friends in nursing school isn’t inevitable for everyone, but it can certainly benefit those who prioritize friendships. Close friends will help you succeed when you study together, network together, and confide in each other.
But there’s a flip side to this, too. In any social situation, there’s likelihood for drama and disagreements. Small, insular nursing programs may require you to live, work, and study with your classmates, which can lead to an environment that encourages cliques and bullying. Going into nursing school with a friendly, positive, and focused attitude can help ensure that you stay on the outside of any distracting confrontations. It’ll also help you make friends that you’ll keep for a lifetime.
When Hurricane Irma hit Florida, Florida International University’s Florida Advance Surgical Transport (FIU-FAST) took action. After the Florida Health Department requested their assistance, the response was interdisciplinary, says Yhovana D. Gordon, EdD, DNP, ARNP, FNP-BC, who is Chair of the Program of Graduate Nursing, Florida International University Nicole Wertheim College of Nursing & Health Sciences, in Miami, Florida.
“Students and faculty from the nurse practitioner program at the FIU Nicole Wertheim College of Nursing & Health Sciences joined forces with FIU Herbert Wertheim College of Medicine physicians, as well as paramedics and others,” explains Gordon.
An all-volunteer response program, FIU-FAST is designed to rapidly deploy when requested. The volunteers add their skills and knowledge to existing health care professionals to help provide critical care following major disasters like Hurricane Irma.
An edited version of Gordon’s interview follows.
How many nursing students came together to work with Hurricane Irma victims? How long did they help? What kinds of things did they do? How were they supervised?
The mix of graduate nursing students (i.e., licensed Registered Nurses), faculty, and others on each FIU-FAST team varied as they were deployed to help hurricane victims at various locations.
For example, when the FIU student and faculty team of six physicians, six nurses, and a paramedic arrived at West Kendall Baptist Hospital on September 11, ninety-two patients were waiting in the ER. Less than three hours later, only 30 remained.
Thanks in part to the extra expertise, FIU also deployed an 18-member team of students and faculty members to assist at Jackson South Community Hospital. Two nurse practitioners and 10 registered nurses worked alongside three paramedics, two physicians, and one physician assistant to alleviate the patient backlog in the hospital’s emergency room.
What kinds of things did they learn? How has the FIU-FAST program gotten nursing students involved in natural disaster assistance like this in the past?
The participants learned how to respond quickly, communicate effectively, and help triage and treat people who arrived at medical centers needing care in the wake of Hurricane Irma. The team focused on treating less complex patient presentations like lacerations, the flu, and other ailments, freeing up the existing medical staff to treat more acute or complex cases.
FIU-FAST formed in April 2016 through a partnership with the Herbert Wertheim College of Medicine and the university’s Department of Emergency Management.
In terms of past deployments, the FIU-FAST team traveled to Puerto Barrios, Guatemala in February 2017. The mission was part of an ongoing project between the military and civilians led by the U.S. Southern Command. The goal was to provide medical and veterinary assistance.
In May 2017, the FIU-FAST team also set up a 10-bed critical care field hospital, this time much closer to home. The temporary health care facility was set up on Miami Beach to assist local responders working during the Memorial Day weekend.
Why is a program like this important? Why is it especially important to involve nursing students?
The FIU-FAST program is essential for providing medical assistance in the wake of disasters, times when needs often increase to a point that challenge existing resources. It’s important for nursing students at the FIU Nicole Wertheim College of Nursing & Health Sciences to be involved – part of our mission is to serve communities in need throughout the year, not just in times of crisis. Also, deploying nursing students to assist via FIU-FAST provides them with unparalleled experiences and teachable moments outside the classroom, giving them skills they can use throughout their careers.
What skills can nursing students glean from this experience? What skills have they learned in school that they could apply on the front lines?
Nursing students can learn to work on interdisciplinary teams, to think quickly, to communicate effectively, and, above all, to serve communities in need no matter what the circumstances. Our nursing students learn critical skills through education, clinical rotations, and simulation training, all of which they can apply in real-life situations as warranted.
The program underlines the essential roles nurses play on interdisciplinary teams, whether in day-to-day practice, during times of crisis, or when leadership skills are essential. The student participants also gained invaluable experience by working side by side directly with faculty and collaborating with them onsite. Although it’s difficult to predict when the next disaster will strike that requires a rapid response from the FIU-FAST team, but one certainty is they will be ready to move and make a difference at the community and patient levels.