(Author: Rashawn Montgomery-Woods)
For healthcare leaders, it is important to recognize the topic of job satisfaction, unionization and how the two are related to nursing strikes should be explored throughout the industry. However, this research excludes other healthcare professionals and focuses solely on Registered Nurses, their job satisfaction, and the power this group holds including the ability to cease operations of the healthcare industry by striking and other healthcare professionals are excluded. The scope of the related literature may be limited to articles, books, online survey’s, and interviews. The work will focus on Registered Nurses and, job satisfaction and their affiliation with unions during the last twenty-five (25) years in the United States. Research in the area of nursing job satisfaction related to union membership is a topic that has not been widely explored.
When we think of a nurse, we usually think of a caring woman in a white cap and uniform. They are often pictured as the group that was created to support physicians. That image is not true of today’s nurse. While they are still caring; gone are the white caps and uniforms and subservient demeanor.
Nursing has emerged as one of the hottest career choices today. That ranking, however, does not come without its fair share of challenges. The healthcare industry cannot operate without them, and they are a force to be reckoned with. They are a very powerful group as they are courted consistently by organizations, both in and out of healthcare. Because of the high demand for the services they provide, and the strength that comes with their union affiliation, nurses will no longer keep silent about their workload, work environment, perceived treatment by healthcare leaders and physicians, and most importantly the value they bring to the workforce.
Nurses are seen as hard to please and feel they should be provided more advantages than other healthcare workers. The fact is they do work hard, and their jobs are difficult. They are caught between hospital administration, physicians, and patients. They are usually thought of as caring and compassionate. However, union membership has empowered them to voice their disagreement with their work environment, wages, and health benefits openly. Their strong opinions in some situations cast them in a negative or unprofessional light.
This topic was chosen because nurses are an integral part of the healthcare industry, over the last decade, long waiting lists for nursing schools, the nursing shortage, and changes in regulatory requirements have impacted patient care significantly. Keeping them happy and satisfied with their jobs has become all-consuming for today’s healthcare organizations. The challenge increases with the introduction of organized labor unions.
The topic is important because this group of professionals impacts every aspect of healthcare. Unions, as well as employers, pursue them like no other group in the workforce. Not only do they impact the operations and finances of healthcare organizations, but the group is financially attractive to the unions that represent them. In my experience as Administrator of the Collective Bargaining Agreement (CBA), the average nurse pays 2-3% of her annual salary in union dues. Additionally, the group that represents them is able to share in the power they possess. Their involvement is limitless they are educators, direct care providers, patient care managers, administrators, and the list goes on.
This group of professionals is also an integral part of a hospital’s ability to provide quality patient care and directly affects the financial stability of an organization. They spend more time providing direct care for the patient than physicians. Therefore it is critical to address nurse job satisfaction because they have the ability to impact quality patient care and satisfaction scores directly.
Additionally, per state regulatory requirements, nursing units must be adequately staffed at all times so that nurses are equipped to provide patients the safest care possible. The healthcare industry also must make sure units are properly staffed to avoid nurse fatigue and stress, which could result in an unsafe work environment and dissatisfied nursing staff. When nurses are not satisfied with their jobs, patient care is jeopardized, and the quality of care may be impacted as patients complain about unanswered call lights, inattentive or abrupt nurses, etc. A happy nurse equals happy patients which impact hospitals in a positive way.
All said it is critical to the survival of health care to identify and understand how to address their job satisfaction and the role unions play in that satisfaction. The subject relates to NCRP’s basic human needs and power theories.
I would like to identify challenges that healthcare across the United States has faced over the past 20 years and what they have learned or processes they have defined and implemented to address the concerns of their nursing staff related to job satisfaction, and the impact unions have presented.
The objective in conducting this research is to explore job satisfaction with nurses, and identifying the issues and concerns that are barriers to achieving what is needed for them to feel satisfied. Additionally, I would like to explore how nurses feel about union membership and whether they feel it helps them in the work environment. The study will further explore post unionization, and if union membership improves job satisfaction among nurses.
As a final goal, the objective of this research is to hear the nurses perspective directly. Nurses feel healthcare leaders need to do more to improve their job satisfaction. The information gained in this research project will be used to develop a nurse satisfaction plan at my hospital.
Is This a Good Fit? (Simpson & van Luinen, 2009)
The book explores organizational models and culture. It categorizes people and groups based on hierarchy and personality and desires of the group’s members and how they communicate. The author has a doctoral degree, work experience in organizations and is unbiased in the explanation of organizational culture and how groups come together.
In “Is This a Good Fit, the opening by Simpson & van Luinen (2009) begins with:
Whether you are a manager or staff in the C-Suite or HR or OD or IT, you have probably thought about the issue of ‘fit.’ A good fit is a match between the organization and its staff member’s processes, andcsystems. A bad fit does not find that math and results in interpersonal conflict, ineffective teams, inadequate or inappropriate systems, and lost productivity and revenue (p 4).
This reference describes the culture of an organization and the co-existence of the employees and explores the connection between organizational culture and communication styles; The book is relevant to this research project since it explores the types of people in organization types of communication, and how personalities fit with organizational goals. It also analyses employee’s behaviors, personal needs, within an organization’s structure. The research can be strengthened by exploring why unhappy employees stay with an organization for reasons other than money.
Laboring for union nurses: with (CNA) first win outside California, competition is heating up to organize registered nurses. Some say that’s good for providers (Evans, 2005).
This source investigates whether unions are detrimental to the nursing profession. It also surmises that financial gains are at the core of why unions seek to represent this group. Written objectively by Melanie Evans, a nurse in 2005, the introduction gives a straightforward view of the reader by stating, “Registered nurses, already pursued by competing hospitals and aggressive recruiters, now face an increasingly crowded field of unions vying for their time, money and loyalty” (p. 6).
The methodology included interviews. The results were not predicted, and it is relevant to the research as the results explain how the nursing occupation is affected by the rivalry between unions and the approaches employed by California Nurses Association (CNA). The article discusses the competition for nurses by the larger organized unions and how the tug-of-war is hurting camaraderie in the profession. The article makes the assumption that cash fuels the interest of the unions in this group. This article furthers the understanding that the competition that exists for this group of professionals may be doing more harm than good. Also brought to the forefront are the financial gains to the union that prevails in obtaining the right to represent this group.
Professional Nurses in Unions Working Together Pays Off (Lucas Breda, 1997)
The article by Lucas Breda (1997) explores the relationship between nurse, healthcare organizations, as well as unions. It also discusses the power nurses hold as a group. As stated in the article (Luca Breda, 1997):
Unionization by professional nurses in the United States has increased steadily over the last three decades. Formerly considered to be the domain of male-dominated, blue-collar categories of work, labor unions now allow nurses a mechanism to attain professional as well as personal and economic goals. (p. 99)
The author is a registered nurse, which may help her understand the issues but may also influence her ability to be objective. Due to this author’s own experience and knowledge in the field, this author supports that Lucas Breda was objective in her assessment of the information.
In the introduction to the article Lucas Breda (1997) states:
A nurse is sometimes caught between the choice to be considered a professional or unprofessional. In the United States, some nurses find themselves estranged from belligerency and politicking because they are perceived as unprofessional due to speaking out and being involved in union activities. This posture abates a nurse’s ability to establish alliances, increases their power foundations, and to act as an agent for both nurses and patients. This article studies how nurses collectively worked alongside a labor union to achieve professional advantages. (p. 99)
This researcher conducted her own study and is relevant to the topic because it explores the relationship between nurses and unions. The author collected data on unionized Registered Nurses by observation, face-to-face interviews, and employee meetings. Additionally, the researcher observed a session of negotiations being held by hospital management and the union bargaining team, which included staff nurses.
The research established that the unionized RN’s successfully changed the nature of power inside the hospital where they were viewed as a force of positive change and advocates for a better quality of care. They accomplished change by picketing outside the hospital for safer working conditions, improved staffing, and better care. The RNs commanded more power and dignity for themselves, along with improved working conditions, and higher professional standards which included the freedom to make self-directed choices and control over their practice.
The condition of union RNs as workers in a female-dominated line of work can be studied as follows: (1) Union membership offered RNs not only the protection of a collective bargaining agreement, but also a vehicle to bond for common causes and to develop professionally. (2) Due to hospital administration’s inflexibility, RNs believed they had no recourse other than remaining resilient and cohesive in the union (p. 107).
In conclusion, unionization by nurses at Shawmut Hospital was an empowering and emancipating for RNs because it allowed them to jointly organize as a sociopolitical and governing force within the hospital culture. “Before unionization, there was hegemony (ideological predominance) of patriarchal authoritarianism; afterward, there was counter-hegemony of egalitarianism based on the feminist values of connectedness, caring, and community” (Lucas Breda, 1997, p. 108). This article may aid the in the understanding of why nurses feel membership in a union is in their better interest.
Hospital RN Job Satisfaction and Nurse Unions (Seago, Spetz, Ash, Herrera, & Keane, 2011)
This reference used a mixed methodology approach to obtain the data with the goal to survey whether unionization was associated with RN’s job satisfaction in the United States. Influences that forecast job satisfaction for RNs remains a concern for healthcare leadership as job satisfaction remains an important issue to retain this group. In addition, the notion of having unions for RNs has also gained prominence on the national stage. The relationship between RN’s job satisfaction and having a union has not really been explored. Two studies indicate that while retention was higher, hospitals with unions experienced greater RN job dissatisfaction. The study tested recent national data related to the relationship between the union that represents the nurses and job satisfaction. The data showed union-represented nurses are more likely to express dissatisfaction and are more vocal due to being less fearful of losing their jobs. As stated by the authors (Seago et al., 2011) “If managers can harness this ability of the nurses to be articulate and outspoken, working with unions and union nurses can be productive and satisfying”, (p. 109).
The authors were from a diverse background and produced an objective look at this topic. As stated in the article’s introduction (Seago et al., 2011):
In 2004 and 2008 more than 10,000 direct care RN’s were sampled for the survey less than 20% of them were unionized. The study conveyed 74-78% that nurses were either satisfied or very satisfied with their jobs. This data is consistent with improvements in satisfaction reported in California (p.109).
During the same period, the hospital experienced spike in the numbers of male nurses and minority nurses it employed. The increase was most noticeable with Asians and Hispanic nursing professionals. Additionally, the average income ranged from $56,400-$60,400 during this same time period (p. 109).
Public data used was from the National Sample Surveys of Registered Nurses (NSSRN), which is conducted approximately every 4 years and samples roughly 30,000 RNs. The survey has an impressive 80% response rate. The analysis studies several aspects of the nursing workforce. Samples were drawn from each state’s list of active licenses. The researchers indicate two areas where the data was oversampled they were states with smaller RN populations this was done to provide more accurate workforce estimates at the state level, and with minority, data to ensure adequate representation in the survey. The 2004 sample for the survey yielded a response rate of 70.5% (p. 110).
For explanation: Oversampling is “the practice of selecting respondents so that some groups make up a larger share of the survey sample than they do in the population. Oversampling small groups can be difficult and costly, but it allows polls to shed light on groups that would otherwise be too small to report on” (www.pewresearch.org).
Respondents in the survey were asked to share if they were still working as a nurse as of March 2004. The study was forwarded to 55,151 RNs and the response rate was 62.4% in 2008 with similar questions about employment as in 2004. The researchers limited the analysis to RNs who provided direct patient care in an acute setting (Seago et al., 2011).
A remarkable finding in both surveys was the decline of union status. An explanation for this change could indicate associations rather than causal relationships. Organization of nurses by unions may not cause lower levels of job satisfaction, but job dissatisfaction may be the cause nurses join unions (Segal et al., 2011). The assumption that low job satisfaction drives union membership might explain the adverse relationship in 2004 and the immaterial relationship in 2008.
It has also been proposed (Arch & Graetz, 1989; Freeman & Medoff, 1984) that unionized nurses are more inclined to voice dissatisfaction, but are not functionally more dissatisfied than nonunion RNs in terms of retention. It is possible that union nurses feel free to express their dissatisfaction, whether they are less satisfied or not. The difference between 2004 and 2008 may also have been due to a decline in the economy. Even union nurses may have felt less secure about voicing job dissatisfaction in the unstable job environment that existed in 2008 ( Seago et al., p. 112).
The satisfaction rate of hospital-employed RNs reporting “satisfied” or “very satisfied” increased from 74.2% to 78.1% between 2004 and 2008. It is interesting to note that national and California data had similar percentages related to increasing job satisfaction among nurses. Between 2004 and 2008, the national hospital employed an RN workforce which experienced an increase in representation of male and minorities , especially among Asians and Hispanics. Average income also rose, from $56,400 in 2004 to $60,400 in 2008.
Hospital Association of Southern California (HASC):
2016 Quarter One Survey Report – Effective January 1-March 31, 2016
This California workforce survey is produced on a quarterly basis. For this report, I included data on the length of RN service before termination was used. In the first quarter, 80 hospitals reported the average length of employment for 1086 nurses as those employed 1 year or less 28% or 300 participants, RN’s employed 1-2 years 23% or 245, RN’s employed 3-5 years 20% or 212 (HASC, 2016). This data is appropriate to this research project because it provides an overall view of the average time an RN stays with an organization.
The information is objective as it based on actual numbers and not opinions. As a former healthcare recruiter, this data is accurate based on professional experience and trending organizational separation data the highest nursing turnover occurs between 0-16 months. The majority of these terminations are “voluntary-other employment.” This data is documented by hospital human resources department to track turnover that occurs for other job opportunities
The Effect of a Nursing Labor Management Partnership on Nurse Turnover and Satisfaction
(Porter; Kolcaba, McNulty & Fitzpatrick, 2010)
The objective of the article was to examine the effect a nursing labor-management partnership (NLMP) has on job satisfaction and turnover. A key component to retaining nurses is job satisfaction. The lack of satisfaction with the job has been linked to the nursing shortage that has been experienced over the last 10 years. The NLMP involved union and non-unionized nursing staff and management. Together they worked cohesively improve patient care issues.
The study was conducted in a large U.S. hospital that had more than 1,000 inpatient beds and 2,200 registered nurses. Of those nurses, 2,107 were represented by a union. The study examined turnover and job satisfaction before the year 2005 and after 2008 using the partnership model where labor and management worked collaboratively to impact retention and job satisfaction. The results revealed a significant decrease in nurse turnover and a substantial increase in nurse satisfaction.
This study established an example of what can happen when groups put aside their personal feelings to work together to improve patient outcomes. Additional information to further the study could track this partnership over time to see if it continues to prosper or declines after a period of time.
Registered Nurse Job Satisfaction and Collective Bargaining Unit Membership Status (Pittman, 2007).
The objective was to explore the difference in job satisfaction between nurses who were part of a union and those who were not. The shortage of nurses influences declines in quality patient care, heavy workloads, and recurring overtime. These factors impact job satisfaction and can cause nurses to leave an organization. Unions utilize collective bargaining agreements to control patient assignments, which decrease over time while increasing salaries and job security. The survey data showed positive support for membership in unions it did not indicate that nurses overwhelmingly feel the union increased their job satisfaction. It is pertinent to understanding the retention and recruitment of nurses.
There is currently a nationwide nursing shortage due to an aging workforce and limited educational opportunities causing job vacancies in hospitals across the United States. This lack of adequate staffing has several implications for patients including high risk to safe patient care due to an increased patient assignments and limited resources. Nurse burnout is a factor in decreased job satisfaction and may influence the decision of some nurses who decide to leave the profession.
My literature review consists of seven peer-reviewed sources. One source is a book, a workforce survey, and the remaining five are professional journal articles. The journal articles are similar in that they all concentrate on the nursing profession and the power this group has in the industry. While the content of the article is objective, I believe they are also biased to some degree because some of the authors are registered nurses.
The sources for the literature review differ in that one by Pittman (2007) deliberates nurse’s curiosity in union membership and what may motivate that curiosity or the power the nurses believe are achieved as members of the union; while another article explores the interest in nurses and the fight between the various labor unions to represent the group. There are also financial implications for those unions that win the nurse’s unit versus those that lose. There was a mixed methodology used to obtain the information among the various sources including survey’s and interviews. Remarkably, the article (Porter et al., 2010) that focuses on RN’s job satisfaction and union membership yielded interesting results. While union membership and salaries went up during the years of 2004 and 2008, job satisfaction was not significantly impacted. This data is surprising because a natural assumption may be that higher salaries are associated with higher job satisfaction. This causes a gap because while money may be significant, it may not be a key component in driving job satisfaction.
The study results showed that during 2004-2008 RN’s salaries rose; they did not leave the organizations they worked for, but job satisfaction did not increase. The data implies that personal satisfaction also plays a part in job satisfaction. For example, a married nurse was found to be more satisfied than a nurse who was not. The data also showed that older nurses were more likely to be unionized than younger nurses. The article used a mixed methodology to gather data. In contrast to this article, a leading industry survey was reviewed. This California survey provided statistical data related to workforce trends.
The book (Simpson & van Luinen, 2009) is similar to the articles in that it explores the people in an organization’s culture and communication styles, but it does not focus on a particular profession just employees in general. It seeks to explain what happens if an organization hires individuals that are not a match for its needs and the groups that are formed as a consequence. The area of the compatibility between the organization and its employees related to requirements, processes, and systems are used as a foundation. These areas are reflective of social and basic needs theories. The book examines interpersonal conflict, ineffective teams and lost productivity. Group and organizational conflict is also a similarity for all four sources. This is also an area where the sources are similar, organizational culture and environment, and most importantly workload has a direct impact on nurses joining unions. The data showed unionized nurses were more likely to voice their opinions versus those that were not members.
This relates to the basic human needs and power theories because of the nurses need to be shown appreciation and supported in the work they perform. The subject also refers to the power theory that nurses as a group are sought after by unions and healthcare organizations. They have the ability to impact the operations as well as the finances of the healthcare industry. Their job satisfaction is a concern that warrants action as the industries dependence on the profession is unquestionable. As an example, the nurse’s identity and sense of value is tied to the source of the conflict which they believe to be unfair wages, inadequate staffing, and the lack of recognition for the work they perform. The effectiveness of analyzing the power theory is further intensified by the gender issue that exists between the younger and older nurses as more males enter the profession, and the disparity of power that exists within the group. This is a topic for a future research project.
As a Healthcare Executive, I find the information in the literature reviews to be accurate and unbiased as the information documented in the literature reviews are well known in the industry. I have worked in both union and non-union hospitals; my first-hand observation is that unionized nurses are more vocal than nurses that have no union affiliation and that nurses that are not members of a union tend to be more satisfied overall with their jobs.
For my research, I used a mixed qualitative methodology that included the use of an online survey and face-to-face interviews (see Appendix). I invited 11 Registered Nurses who are currently employed in the field to participate in a 10-question survey. All of the invitees responded to the invitation. Of the 11 invitees, nine (9) responses were received via an online survey, and two (2) participated in face-to-face interviews.
The intention was to examine individually and then collectively the nurse’s view of the union to trend whether the relationship satisfies their need for recognition. Based on the foregoing the questions were designed to explore the nurse’s affiliation with unions and how satisfied they are with the relationship. From a power aspect, the question seeks to uncover if they feel they have been helped by the union and would stay in their jobs without the union.
The survey data obtained in this research shows there is support for membership in unions by nurses. However, the numbers did not indicate that nurses overwhelmingly feel that union affiliation increased their job satisfaction. When asked if union membership increased job satisfaction the 11 participants responded as follows: 0 = Yes; 4= somewhat; 3= not all, and 4= declined to answer the question. Six of the 11 participants responded they were happy with their current wage, while 4 were not happy, and 1 declined to answer. On the subject of strikes; 4 stated they approved of strikes; while 2 disapproved; 3 were indifferent, and 2 declined to answer.
These results support that money is not a major factor in nurse’s willingness to strike or not to strike. Of the 11 survey participants, 0 felt union membership helped them; 6 felt union membership somewhat helped; 2 responded: “not at all”; and 4 chose not to answer. Interestingly 6 stated they would stay in their jobs if there was no union, 2 said they would not; and 3 declined to answer.
The individual of the years of experience breakdown is as follows:
2 – 30 years
2- 18 years
1- 14 years
1- 8 years
2- 6 years
1- 7 years
2- 2 years
The average length of service for those polled was between 1-5 years. 66.67% of respondents stated they and been offered other employment while 33.33% said they had not. There was only one participant who had a 30-year work history with the same employer. The participant pool was small because my hospital is currently dealing with contract issues, and I was concerned about giving the wrong impression by asking staff to participate in my survey. I feared it might be taken out of context and used by the union as a negative. That said, I relied on nurses with whom I or someone I know have a personal relationship. The 11 respondents had a total of one hundred thirty-five (135) years of experience as RN’s.
It is important to note despite the small sample size the results received with literature reviews, current activity, and my personal experience as a human resources leader in the healthcare field.
This research is a platform for further studies related to nurse to nurse conflict and nurse bullying.
The social dynamic between nurses, healthcare leaders, and unions is prevalent. The nurses feel they should be provided more recognition and in their opinion provided a higher wage for all work they perform. This is reflective of the “Basic Human Needs” theory because of the nurse’s feeling they are superior over other healthcare workers. As an example, the nurse’s identity is tied to the source of the conflict, which is they are not well treated or valued. They also do not care if it is at the risk of other workers. A first year RN earns an average of $34.00 an hour. The average wage for a 15-year and 20-year RN are in excess of $60.00 an hour. These hourly rates do not include various differentials for the weekend, night shifts, float bonuses and other extras. In my hospital, a new grad nurse has the potential to earn approximately $100,000.00 in the first year.
Members of the nursing unions attend town-hall public forums, joint labor management meetings, and are willing to participate in strikes to express their concerns and disagreements. The action of this group is backed by their unions and is reflective of both structural and individual personal power. On structural and personal power, in The Dynamics of Conflict, Bernard Mayer (2012) states:
Structural or systemic power is lodged in the situation, the outside resources people bring to a conflict, the legal and political realities within which the conflict occurs, the formal authority disputants have, and the material choices that exist. Personal power has to do with individual characteristics such as determination, knowledge, charisma, wit, courage, energy, and communication skills. (p. 72)
They are vocal about what they deserve and the lengths they are willing to go to achieve their goals even if it means a strike. They have the power to command healthcare leaders to listen and unions to back them up.
Despite this power, they are still an unhappy group. From recent staff meetings that I have attended it is the need for recognition and conflict with the nursing ranks that are most responsible for their job dissatisfaction. This is not to say other issues related to patient volume and adequate staffing are not mitigating circumstances in the lack of job satisfaction for nurses. Whether we like it or not they are needed and the issues they bring forth need to be addressed.
Overall, nurses will band together to get the job done, and the quality of patient care is affected in a positive manner.
Evans, M. (2005). Laboring for union nurses: With CNA’s first win outside California, competition is heating up to organize Registered Nurses. Some say that’s good for providers. Modern Healthcare, 35(21), 6-7.
Hospital Association of Southern California (2016). 2016 healthcare workforce survey report 1st quarter. Retrieved http://www.hasc.org/
Lucas Breda, K. (1997). Professional nurses in unions working together pays off. Journal of Professional Nursing, 13(2), 99-109.
Mayer, B. (2012). The dynamics of conflict. San Francisco, CA: Jossey-Bass. Retrieved from ebrary link: http://0-site.ebrary.com.torofind.csudh.edu
Mercer, A. (2016). Oversampling is used to study small groups, not bias poll results. Retrieved from http://www.pewresearch.org/fact-tank/2016/10/25/oversampling-is-used-to-study-small-groups-not-bias-poll-results/
Pittman, J. (2007). Registered Nurse job satisfaction and collective bargaining unit membership status. JONA: The Journal of Nursing Administration, 37(10), 471-476.
Porter, A., Kolcaba, R., McNulty, J., & Fitzpatrick, J. (2010). The effect of a nursing labor management partnership on nurse turnover and satisfaction. JONA: The Journal of Nursing Administration, 40(5), 205-210.
Seago, J. A., Spetz, J., Ash, M., Herrera, C., & Keane, D. (2011). Hospital RN job satisfaction and nurse unions. JONA: The Journal of Nursing Administration, 41(3), 109-114.
Simpson, M., & van Luinen, E. (2009). Is this a good fit? The connection between organizational culture and communications style. Los Angeles, CA: PSM Publishing
- How long have you been an RN?
- How long have your been with your current hospital?
- Have you been offered another job within that time? Yes /__/ No /__/
- Are you in a union? Yes /__/ No /__/
- How do you feel about your membership in the union?
- Very pleased
- Somewhat pleased
- Not pleased
- Do you feel the union helps you?
- A lot
- Not at all
- Does your union membership:
- Increase your job satisfaction
- Not at all
- Would you remain in your current position if there were no union? Yes /__/ No /__/
- How do you feel about strikes?
- No answer
- Don’t know
- Are you happy with your current wage?
- Very pleased
- Somewhat pleased
- Not pleased
I would like to thank the participants for trusting me enough to give their honest opinions. I thank my Chief Nursing Officer for making me think outside the box and assisting me in understanding this complex topic. I would also like to thank Professor(s) Deborah Thomas, Maria Simpson, and Margaret Manning; I must express my sincere gratitude for your guidance and help with developing my thoughts in the creation of this research paper, for being supportive, and always willing to TEACH.