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Creating the Right Environment for Nurses

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Editor's Note: This piece is based on Rebecca Hendren's Feb. 16 online column, "Nurse Leaders' Role in Promoting Autonomy and Accountability."

Nursing issues have been in the news lately, and not all of the coverage has been good. First, AMN Healthcare released a survey that found nearly half of the nurses who responded want to make a career change in the next three years, and more than a third said they were dissatisfied with their job.

Then there was a piece in the New York Times' "Well" blog by Theresa Brown, RN, about the disturbing prevalence of bullying in nursing. And finally—some good news—Texas whistleblower Anne Mitchell, RN, was acquitted of all changes.

A thread runs through these stories: the lack of autonomy in nursing.

Brown quotes nurse researchers Cheryl Woelfle and Ruth McCaffrey's article "Nurse on Nurse" to speculate why nurses attack their own. "Nurses often lack autonomy, accountability, and control over their profession," they write. "This can often result in displaced and self-destructive aggression within the oppressed group."

More than 40% of the nurses in the AMN Healthcare survey were not satisfied in their positions, which may be due to a lack of control over the things that matter to them in their jobs. Mitchell lacked the autonomy in her hospital to do something about a physician she perceived as unsafe, so she went to the Texas Medical Board as her only option.

Eileen Dohmann, vice president of nursing at Mary Washington Hospital in Fredericksburg, VA, says nurse leaders must create an environment where nurses have autonomy—and are held accountable—for their behavior and practice.

"My responsibility is the environment that nurses practice in," says Dohmann. "That's my job: to create, reinforce, and ensure that nurses have the environment they need to safely practice."

Dohmann cites the example of productivity. Mary Washington Hospital has emphasized nurse-to-patient ratios and productivity targets. Dohmann has created an environment where nurses understand their parameters and what they have to work with to provide care.

"My job is to help them understand; it's not necessarily my job to help them like it," says Dohmann. "But my job is to help them understand and then give them the autonomy. I say to my nurses all the time, ‘Keep it legal and keep it safe. Those are the rules. So figure it out.' Nurses at the bedside in our hospital don't want me making decisions about how they practice nursing at the bedside. I don't do it. They do it. I see my job is letting them know what the confines are that they have to live within, and the rest of my job is making sure that I get any barriers out of the way so they can do what they need to do."

Nurses treating one another poorly is nothing new. Dohmann says nurse leaders play a huge role in creating an environment that does not allow bullying. Leaders have to set expectations and hold people to those expectations.


Rebecca Hendren is an editor with HealthLeaders Media. She can be reached at rhendren@hcpro.com.

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