1. Jackson, Christina PhD, APRN, AHN-C

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Years ago, one of my RN to BSN students came to me after class and asked if she could speak with me in private. She appeared to be very upset, and as we settled into my office, she explained to me that during her shift at the hospital that day she had recommended a book to one of her patients, and she was seriously second-guessing her action, thinking that she had overstepped her scope of practice boundaries. She was a staff nurse on a busy oncology floor at a local community hospital, and the book was Andrew Weil's Spontaneous Healing, which was one of the assigned readings for the class. This book contains much information that would be helpful to folks diagnosed with cancer, as it supports the reader in taking greater responsibility for one's health through a variety of evidence-based strategies that stimulate innate healing mechanisms.

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As we talked, she shared that her greatest fear was that the patient would tell her oncologist that she (my BSN student) had recommended the book and that the oncologist would then confront the nurse in anger, asking her "Who she thought she was" suggesting this book to the patient without asking him first. She agonized over whether she should have asked the oncologist's opinion before recommending the book. This nurse was having an obvious fight or flight response just telling me about her concerns, and her fear was palpable. We discussed her situation and summarized it in the following way: she, as a registered nurse, had determined that specific bibliotherapy would be helpful for this particular patient at this particular time, and had made a recommendation based on her clinical expertise in oncologic nursing, her assessment of the book as being an appropriate educational resource, and her knowledge about the patient. We agreed that this was within the scope of her nursing practice and role as an educator, and that she should relax knowing that her rationale was sound, and could be easily justified. Not only that, we agreed that reading the book might give the patient a different perspective that could facilitate her healing process.


This experience, though it happened more than 10 years ago, has stayed with me because it illustrates something that has been profoundly wrong about our health care system. It depicts what it is like to feel afraid, disempowered, and "less-than" in a hierarchical environment. This fear has held nurses and the nursing profession back-slowing progress that would strengthen health care in general. For nurses to function with this limiting mindset does them no good-but more importantly, it does their patients and colleagues no good. Health care environments are systems-interdependent parts that affect each other, and that must work together to function effectively. And we know that most systems are only as effective as their weakest component. So a strong, educated, fearless, empowered nurse is the kind of nurse we want to have in any role. This is the type of person who will have the energy and the confidence to advocate, innovate, and renovate.


The Institute of Medicine just released a report titled "The Future of Nursing: Leading Change, and Advancing Health." The essential messages embedded in this report suggest that nurses should achieve higher levels of education (whether increasing the number of BSN prepared nurses or doubling the number of nurses with doctoral degrees) and an improved education system that promotes seamless academic to clinical practice progression through nurse residency programs. With attention toward improving the quality and completeness of educational programs, nurses should practice to the full extent of their education and training, and should commit themselves to lifelong learning and development to meet the needs of diverse populations. They should develop the requisite leadership skills to be full partners, along with physicians and other health care professionals, in redesigning health care in the United States. Nurses should also be prepared to participate in planning and policy making using improved data collection and information sharing processes.


In this report, a great deal of attention is paid to the need for nurses to be well-educated, to continue their educations throughout their careers, and to fully use what they know in their professional lives. Upon further reflection, it is apparent that this type of actualization requires a great deal of courage. The type of courage needed can be bolstered through content and socialization processes in prelicensure nursing education programs, strategic orientation, and nursing residency programs that enhance role development, continuing education (both formal and informal), and through sound and supportive management and leadership systems within health care environments. Exactly how can these factors influence the development of courage?



As I remember my own nursing educational experience and how I developed a sense of courage, I hear echoes of wisdom shared from a few key faculty persons, and will share these here:


"Do what you know how to do until someone tells you to stop."


This was said to remind us that we had a body of knowledge, and that we should feel free to apply it within the scope of our practice. It also implied that there may be some who would try to limit us or at least that we may be tempted to limit ourselves!! I took this as a call to be a strong and knowledgeable advocate, and to do my due diligence and preparation to make sure I was knowledgeable. This meant reading journals, attending continuing education, and taking risks to apply what I knew even if it seemed "outside the box". It also meant that I needed to get any formal credentials necessary to establish credibility.


"Know the rationale for the things you do and say."


Again, this statement called me to become a lifelong learner, and to be reflective about my practice. I could appreciate the necessity of self-study and continuing education to practice in a fashion that was based on various types of evidence. So, I might use results of formal research as a rationale, or a deep understanding of my patient, or a grasp of my own particular strengths or limitations as a rationale for taking a particular approach.


"Do not practice with fear-you have insurance, and it is there to enhance your freedom to practice fully."


As an educator within an RN-BSN environment for many years, there is no statement that upsets me more than to hear nurses say "It's my license that's on the line" as a justification for anything and everything. Mostly I have seen nurses use this statement as a way to limit themselves-though I am sure they are not consciously aware of this!! Sadly, this is the tiresome refrain that I have heard the most often over the years. It just sounds so reactive, and seems to me to be a potent source of diffuse, unfounded fear. Not only is it reactive, but it also seems that by making this their mantra, nurses are buying into a way of looking at things that is self-limiting and self-perpetuating. In other words, when people are afraid, they can be controlled and kept down. They are not strong and creative when they are afraid-they are in a defensive mode, and their energies are drained. They may view situations in more negative ways and may become more adversarial with others as they seek to defend their licenses. We know from research that the way to protect our licenses is to cultivate positive relationships (with patients, family members, and colleagues across disciplines), practice mindfully, communicate carefully and clearly, and follow up whenever we are in doubt. So we must teach our nursing students how to be mindful, communicate, and collaborate.


Currently, only 36% of new nurses graduate from BSN programs. This is a significant restraining factor in promoting graduate education for nurses. So many nurses must first complete a BSN to prepare for graduate work. Often this process takes the starch out of them, wearing them down and taxing personal and material resources-in other words, it is inefficient and unfair. This may leave many feeling depleted and less willing to go on for graduate education. This provides another driving force to require the BSN as entry level so that people should not have to keep going back to school and interrupting their lives.1


In general, we as a profession need to have the courage to decide how nurses will become nurses. To continue to have 3 entry levels into practice perpetuates confusion within our ranks as well as in those who view us from the outside. Let us have the courage to make the decision now-to use the shortage as an excuse is no longer a viable argument. To claim our right to be at the table is facilitated when we at least have a college degree as a foundation. It is empowering for the individual nurse to have that degree. I have seen it in hundreds of registered nurses over the years-the healing power of getting that bachelor's degree and the amplification of courage that goes with it.


The suggestion has been made that community colleges with associate degree programs be accredited to offer the BSN so that more nurses can be prepared at the bachelor's level. This may be a solution to our ongoing entry into practice dilemma that honors these programs and facilitates the preparation of only bachelor's-prepared nurses for entry into the workforce.



Nursing residency programs could contribute to the development of courage in new graduates. By creating transitional places where the new nurse is able to continue learning and socialization in supportive environments, threats to self-esteem can be minimized, and risk taking can be encouraged. Strengthening the preceptorship role of practicing nurses and rewarding this with clinical ladder points or financial remuneration makes sense.



The recent trend toward systemic approaches to safety can be used as an example of building courage in nurses-or not. The nursing literature reflects this trend toward looking at antecedents that allow mistakes to be made in health care environments. All of the many parties/departments/systems that are involved play an equal role in patient safety. This is intended to move us away from a more punitive approach whereby an individual (nurse) is blamed for an incident. In theory, this makes so much sense and is a much more reasonable way to approach these kinds of situations. It is also encouraging for nurses (and other health care professionals, for that matter). However, the reality is that nurses are still afraid to report errors; they are still feeling blamed and punished, even when a systemic approach is touted within their work environment.


Ten years ago, a colleague of mine helped a national health provider endorse a culture of safety that started very successfully by establishing a nonpunitive error-reporting system. Today, she is hearing from seasoned nurses who work in hospital systems that there is "lip-service" given to error reporting being nonpunitive in their organization, but that is not what the institutional actions support. In actual fact, nurses report an error and either do not hear back or are made to feel inferior, which has been shown to be dangerous and can lead to near misses and withholding knowledge of errors. In some cases, staff members are reprimanded for an error even in hospitals that have achieved magnet status-hospitals with administrators who should understand the relationship between quality outcomes and the importance of maintaining an open culture (Francie Halderman, personal communication, December 12, 2010). This goes against creating a work culture dedicated to a holistic understanding of human error and process redesign. It goes against enhancing safety and transforming health care environments because it discourages people-that is to say it robs them of courage.


If we want nurses to feel courageous, we must provide ample support for them as they take the necessary risks. To provide administrative backup for a nurse who has a rationale for her/his actions is essential. To make sure that nurses are at the table whenever appropriate, nurse administrators are required to pay attention and look for opportunities.


It seems to me that this Institute of Medicine report says nothing that would indicate we should maintain false hierarchies within the health care system. Rather, it says everything about empowering all members of the health care team to function as fully as possible, and that the voice of nurses-their concerns, opinions, and visions-should be clearly heard. Every day, nurses in all job descriptions make Herculean efforts to provide quality and safe care under difficult conditions. And although the report suggests that nurses should have more authority in leading us out of the maelstrom that is our current health care system, the Institute of Medicine clearly acknowledges that the power to change these conditions does not rest primarily with nurses, regardless of how well-educated or able to lead they are. Rather, it is shared with governmental organizations and leaders, the insurance industry, health care institutions, professional organizations, and professionals in other health care disciplines. A more fully empowered nursing workforce (3 million strong) working together with these groups may actually be able to transform our health care system in meaningful ways that increase quality of care and improves health outcomes. At least this is how it looks through my holistic lens. How does it look through yours?




1. Larson J. Major Changes Proposed in Nursing Education. Published January 10, 2011. Accessed January 11, 2011. [Context Link]