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Courtesy Counts in Nursing

By Genevieve M. Clavreul, RN, Ph.D.

Working Nurse Magazine

Being busy is never an excuse for being rude

Nurses are constantly reminded that we are held to higher standards than people in other professions, both at work and in our personal lives. We are judged by how our patients and coworkers perceive us as well as how they perceive our nursing skills. People expect us to be not only competent, but also compassionate and caring.

Unfortunately, nurses often overlook the role that basic courtesy plays in our profession. When stress levels rise, good manners are often the first things to go out the window. We’ve all been there at one time or another when tired or overwhelmed. The consequences of that rudeness can be much more serious than you think.


When it comes to the workplace, politeness might seem like a very trivial issue, particularly in a profession as demanding as ours. Not so, says Pier M. Forni, Ph.D., a professor at Johns Hopkins University and the author of several books on civility and ethics. “Incivility is very costly,” he told David Zax of in 2008. “Incivility is both caused by stress and causes stress, and stress is not only a producer of human misery, but is also very costly in dollars.”

Discourtesy costs businesses and organizations a lot of money in the form of reduced productivity and higher turnover rates. Rude behavior in the workplace can make workers avoid each other when they should be collaborating, “tune out” when doing important tasks or even quit. Considering how many talented nurses become burned out, the latter is no small concern.

For healthcare workers, the stress caused by incivility is also bad news for patient safety. The Joint Commission’s 2012 report “Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation” notes that workplace civility is “[c]losely associated with, and perhaps a necessary precursor to, improving safety culture.”

Then there is the problem of lateral violence. Research has repeatedly demonstrated the terrible impact workplace bullying has on nurses and such bullying is all too common. Some researchers have estimated that as many as 85 percent of nurses suffer lateral violence at one time or another and up to 93 percent of nurses have witnessed it. Discourtesy isn’t the same thing as bullying, of course, but an environment in which coworkers are frequently rude to one another and to patients is one in which lateral violence can thrive. So, civility and manners do count and the lack thereof can and does have an impact on our workplace and in turn on our patients.


Common courtesy promotes a more positive work environment and allows for better relationships with the people you know and the ones you meet on a day-to-day basis. Good manners convey respect for those with whom you interact and encourage them to respond in kind. A more congenial workplace also makes it harder for lateral violence to take root.

Negativity feeds on negativity, but it is also possible to shift the atmosphere in a more positive direction. Sometimes, all it takes is a few people making the choice to be polite and pleasant.

I often share with people my experience of changing the negative milieu at a local county hospital — not as a nursing director or a nurse, but as a patient undergoing treatment. While the physicians at this hospital had the expertise to provide the treatment I needed, the downside of going there was the very high volume of patients: almost 100 a day. During my first few visits, it was apparent that while the nurses and auxiliary staff were good at their jobs, many treated the patients more like cattle than people.


Patients were given little guidance on how to navigate the complex procedures for making appointments or about how to get labs and X-rays done prior to being seen by the doctor. Worse, the nurses seemed to be doing almost nothing to help. I realized that the reason the nursing staff wasn’t trying to making the patients’ lives easier was that no one had made any effort to make the nurses’ lives easier.

Seeing that, I decided to perform simple acts of courtesy like making eye contact, addressing nurses by name and offering a cheerful “hello” to the nurse in the intake line. When I noticed one of the nurses go out of her way to help a patient, I made a point of complimenting the nurse for her act of kindness, remarking that such acts are a fundamental part of our nursing function. I also brought in treats like homemade cookies for the nursing staff.

This reinforcement had a gradual but observable impact in how the nurses treated me. Over time, I also saw the nursing staff demonstrate a bit more kindness and consideration to other patients and even to one another. These were all small things, but they made the clinic a more pleasant place to be and in which to work.


It’s easy for nurses to blame our lack of courtesy on having one too many patients, not enough ancillary help, being short-staffed and so forth. However, good manners and civility shouldn’t suffer just because we’re too busy.

I have a friend who’s now a plastic surgeon in France. She has a very outgoing personality and greets everyone who crosses her path with a warm “hello” or “good morning” regardless of where she is. As a result, people almost always respond positively to her. Even the curmudgeonly chief of service would find himself smiling (if for only a moment) whenever she entered the room.

Being polite to others is not a one-sided affair. People have a hard time ignoring someone who offers a kind word or other simple courtesies. Taking the time to make these small gestures will go a long way towards achieving positive outcomes in most if not all of our encounters.

Nurses face many challenges in our daily work, but civility and the practice of good manners shouldn’t be given short thrift in the name of efficiency. Courtesy never goes out of style even if people sometimes forget to practice their manners. Let’s make this one of the many areas in which nurses lead the way.


10 Ways Nurses Can Be More Courteous

1. Be respectful. Respect is reciprocal. If you want respect from others, you must be prepared to show respect to them as well.

2. Appearances count. Make a point of coming to work in clean, pressed scrubs (or the uniform of the day) and make sure you wear your identification so it can be seen by coworkers and patients.

3. Politeness wins the day. Always say “please,” “thank you” and “you’re welcome” when interacting with your coworkers, patients and their families. It’s easy to forget in the hustle and bustle of the floor, but is always remembered by the people on the receiving end.

4. Voices carry. Whether interacting with coworkers, patients or patients’ families and friends, remember not to raise your voice, use foul language or slang or talk down to others.

5. Promptness is a virtue. There are times when you’ll be late due to some unforeseen circumstance beyond your control, but chronic tardiness is disrespectful and places an additional burden on your coworkers, which breeds resentment and hostility.

6. Gossip is never harmless. Talking or gossiping about a person who isn’t present is disrespectful and generally ends badly for all involved. It harms the person who’s the subject of the gossip and reflects badly on the one doing the gossiping.

7. Don’t ignore people in your presence. The clinical floor isn’t kindergarten. It’s rude to ignore or refuse to acknowledge people when they approach. A polite “hello,” a wave of the hand or a smile will go a long way.

8. Pay attention when someone else is speaking. Show interest, maintain eye contact and listen to what the other person is saying. It’s easy to get distracted when others are speaking, but making the effort to pay attention and show an interest in their thoughts and ideas helps to build a civil work environment.

9. Keep the common areas neat. When in the nurse’s lounge, staff lunch room or other common areas, be sure to clean and put away your dirty dishes. Don’t be a food thief and make sure you keep the refrigerator, microwave and other appliances neat and clean.

10. Use the correct name. Mangling someone’s name or calling someone by a unwanted nickname doesn’t engender positive feelings. If you’re not sure how someone wants to be addressed, ask them. If you’re not sure how to pronounce a name, ask the person to spell it for you (even if that means spelling it phonetically to help you remember the correct pronunciation!).

This list is by no means exhaustive, but these 10 basic tips will prove helpful in most situations.

With more and more dire reports coming out about California’s growing nursing shortage, you would assume that our state desperately needs nurses. Nearly every day, my email inbox is besieged with messages advertising temporary and permanent nursing positions and a cursory search on one of the national nursing job boards returns more than 1,000 job openings.

However, if you read the forums on those same job boards, you’ll find post after post from nurses — mostly new graduates — complaining that they’re unable to find a job in their chosen profession. To hear them tell it, there are too many nurses vying for too few jobs.

So, what’s going on? Is there a nursing shortage or is there really a nursing glut? The answer is yes and yes. Confused? Read on.

Failing Grade
According to the U.S. Nurse Workforce Report Card and Shortage Forecast, published in the American Journal of Medical Quality in 2012, over the next two decades, the demand for nurses will greatly outpace the supply.

Even states that currently have good nurse-patient ratios, like Massachusetts, are expected to slip to mediocre by 2030, so you can guess what that means for our fair state, which is already near the bottom of the heap.

California’s nurse-to-population ratio has ranked a dismal 48th in the nation for the past 10 years. In 2013, California had an estimated 657 RNs for every 100,000 population, well below the national average of 874 RNs per 100,000. The Nurse Workforce Report Card gave California’s RN supply a “D” grade and projects that by 2030, we will be more than 193,000 nurses short of our nursing needs. (So much for the wishful thinking 10 years ago that legally mandated nurse-patient ratios would somehow resolve our nursing shortage!)

By now, we’ve all heard the reasons for the predicted nursing shortage: an aging population that will need more care, more people having access to care due to the ACA and an aging workforce that’s not being replaced fast enough. It paints a worrisome picture.

Unprepared For Nursing School
Between 2001 and 2010, the number of people enrolling in nursing school here in California increased dramatically, leading to predictions that the state’s total nursing workforce would grow by about 60 percent between now and 2030. Currently, the reality looks much less rosy. According to a recent report prepared for the BRN by the Philip R. Lee Institute for Health Policy Studies and School of Nursing at UCSF, nursing school graduation rates for the past few years have been lower than expected and growth has been slow. Only 195 more nurses graduated in the 2012–2013 academic year than in 2011–2012, an increase of only 1.8 percent. The report predicts that graduations for the 2015–2016 school year will actually drop below the 2010–2011 level.

The number of licenses granted to foreign-educated and out-of-state nurses is also down. While fewer California RNs are leaving the state for greener pastures, fewer nurses are moving to California. As a result, the report forecasts that even in a best-case scenario, California’s RN supply will grow only about 10 percent by 2030 — not nearly enough.

The UCSF report recommends “growing our RN programs a bit more,” but that may be easier said than done. In California, many students are ill-prepared to enter a nursing program due to a lack of prerequisites like microbiology, statistics or psychology. Having to play catch-up will delay admission.

Students who do enter nursing programs may face a shortage of instructors. Quality nursing faculty is already in short supply and that shortfall is also getting worse.

New Grad “Catch-22”
If all that is true, why are so many newly minted RNs (both ADN-prepared and those with BSNs) having a hard time finding work? And why do many chief nursing officers in California believe there are more than enough RNs to meet current requirements?

First, keep in mind that the various estimates and projections of nursing shortages are for the state as a whole. California is a big state and even if you live in a county that’s been designated as a registered nurse shortage area (like Los Angeles County), that doesn’t mean you can just stroll over to your neighborhood hospital and get a job tomorrow.

Healthcare provider shortages are usually most severe in poor or rural areas where new grads may not think — or want — to look for jobs. Hospitals in more prosperous areas often have plenty of nurses and lots of applicants and can therefore be pickier about education and experience.

One of the most common demands is acute care experience, something in which far too many new grads are sorely lacking. Getting enough experience to satisfy a hospital recruiter may require some creative solutions on the part of new grads.

Back in the “good old days,” a new nurse could gather a plethora of real-world experience by working as a travel nurse, but today, most travel nurse services require at least two years of hospital experience prior to placement.

Adding to the frustration of the new grad looking for work is the fact that many current RNs are still putting off retirement. The UCSF report confirms that employment rates are higher among older RNs, many of whom continue to practice because they can’t afford to retire. That means new grads are competing for jobs with older nurses who have far more clinical experience.

The Spectrum of Staff Experience
While some parts of California do have a nursing glut right now, hospital nursing directors and chief nursing officers need to recognize that in many cases, the current honeymoon won’t last. Eventually, older nurses will leave the nursing workforce, either because the economy has improved enough to rebuild their retirement nest eggs or for health reasons.

The vacuum left by those departures will need to be filled — in all likelihood, by the same new grads being turned away now. Even without an overall RN shortage, such “backfilling” is critical to maintaining a healthy and vibrant nursing workforce.

During my tenure as a director of nursing, I worked hard to ensure that our hospital’s nursing team was as diverse as possible. A critical component of that diversity was having a wide spectrum of experience, from new nurses to seasoned veterans.

In that way, our experienced nurses could mentor the new grads, who would in turn bring a level of enthusiasm and cutting-edge knowledge that benefited their more experienced colleagues. It was a win-win situation.

What’s the outlook for new grads? There are nursing jobs to be had, but in the short term, finding one without acute care experience will continue to be a challenge. That leaves the new grad with a choice: If you don’t want to wait around for your more experienced colleagues to retire, you’ll need to either find ways to build your clinical experience or be willing to look for jobs in areas off the beaten path.

Few will deny that California’s nursing population needs to grow or that there are real obstacles to that growth that need to be addressed, such as the shortage of nursing faculty. However, it’s important to recognize that nursing shortages (or surpluses) are not cut and dried. The future of nursing in California is in our hands.

A Tale of Rabies

The only hope was a radical experimental protocol

By Genevieve M. Clavreul, RN, Ph.D.

We called him Peanut: a small, fragile boy who was admitted to our pediatric intensive care unit (PICU) at Columbus Medical Center in Columbus, Ga., in the late ‘70s with an infection we would later diagnosis as rabies.

Although rabies is no longer as common as it used to be in the U.S. — an aggressive public health campaign has reduced the number of confirmed cases from almost 6,000 a year in 1979 to fewer than three in 2010 — it is still a lethal disease that can test caregivers to their limits. When Peanut came to us three decades ago, it was an almost certain death sentence if not treated in time.

No one was ever quite sure how a little boy in one of Georgia’s larger cities had come to be bitten by a rabid animal. The most common carriers of rabies in western Georgia were raccoons, skunks, foxes and bats — not your typical urban fauna. Peanut’s parents had brought him to the emergency room with no idea of the nature of his illness and his symptoms had puzzled the ER physicians. When he was transferred to our PICU, the doctors were still unsure what was wrong.

Caring for Peanut presented some unique challenges. He was just a toddler and his age and condition limited his ability to communicate with the staff. We used a combination of sign language, pantomime and pictograms to quiz him on how he felt, where he had pain and so forth. His parents did their best to help, but they were as flummoxed by his condition as we were.

Rabies is a viral infection with three clinical stages. Peanut was admitted during the prodromal phase, which may include several days of flu-like symptoms. During the second stage, known as the excitation or “furious” phase, the patient may present with the symptoms commonly associated with rabies, such as dilated or rolling eyes, tachycardia, hyperventilation and hydrophobia. If the patient survives this phase, the disease moves into its third and final stage with the progressive onset of paralysis, stupor, coma and death.

Days passed as Peanut’s physician ordered test after test to whittle down the list of suspects. Then, Peanut presented with two of the unmistakable signs of rabies: a “locked jaw” and excessive salivating. The evening when I came on shift and saw the latter symptom made me and my team dread the impending diagnosis. Reviewing the likely outcomes left us on the brink of despair. Survival from rabies at that stage was so rare that it was not even included in the list of outcomes.

Our PICU team was by no means unaccustomed to death, but nothing in Peanut’s original symptoms had prepared us or his family for such a grim prognosis. How were we going to inform Peanut’s parents that their son’s most likely outcome was death?

Later that day, our unit’s doctors and nurses held a meeting to discuss Peanut’s case. Since his condition was so advanced, neither rabies vaccine nor antiserum was an option. Instead, we decided to place him in an induced paralytic state, use supportive therapy to get him through the worst of the symptoms and hope for the best. (This was decades before the development of the Milwaukee protocol.)

After many telephone calls and much research on different paralytic drugs, our pediatric chief of staff settled on Pavulon, the brand name for Pancuronium bromide, a non-depolarizing curare-mimetic muscle relaxant. There was just one hurdle: Pavulon was not approved for pediatric patients and this off-label use required the approval of both the manufacturer and the FDA. Fortunately, after much finagling and promises to carefully document everything, our team got the necessary authorizations and set about developing a protocol for Peanut.

Since this was uncharted territory, we kept the protocol as simple as possible. We titrated the muscle relaxant until we discovered the minimum amount of Pavulon needed to paralyze Peanut. Doing so left him completely aware but unable to move, which was the only way to keep him from fighting the vent. (In those days, we had no inline suction and lacked the sophisticated equipment now available to anchor and stabilize an endotracheal tube.)

Our chief of staff then wrote a standing order to administer that same amount of Pavulon whenever Peanut exhibited any signs of movement. To help us monitor Peanut’s sedation level, we came up with an ingenious system of strings and mobiles that would move with his slightest motion. I can’t remember whose idea this was or where it originated, but it was wonderfully simple and very effective.

After many weeks, we were able to wean our patient off both the Pavulon and the vent. During this period, poor little Peanut could barely move his stiffened muscles, but every time he reached out for something or took a step, however stiffly or woodenly, we saw it as one more sign of a hard-won recovery from a devastating disease.

Peanut’s case was highly inspirational to those of us in the PICU, showing us that if we came together as a team, we could move mountains. He also taught me an important lesson: No matter what condition or state of mind patients may be in, they can still tell you a great deal about how the nurses interact with their patients.

As Peanut emerged from his induced paralysis, I noticed that there was one nurse on our team around whom he was visibly apprehensive. Later, when he was again able to move, he would run screaming from her into the arms of his parents or any other nurse who happened to be nearby.

At first, I couldn’t understand why Peanut would so be afraid of that particular nurse, who hadn’t subjected him to any procedure that hadn’t also been performed by every other nurse in our unit. It wasn’t until much later that I discovered Peanut had good reason to fear that nurse, who had a cruel streak that would eventually lead to her dismissal from our unit. She didn’t have the temperament for the PICU and Peanut was the first to catch on. I wish I had listened sooner.

Eventually, Peanut was stable enough to be released and return home. I lost track of this spunky little patient as my life and career handed me other challenges. I’d like to think that he was one of the lucky few to survive his encounter with rabies, although the odds were against it.

As of 2008, there were only three known unvaccinated rabies survivors in the United States. Peanut might have been one of those three; I certainly hope so. I do know that I and the PICU staff at Columbus did everything in our power to make that outcome possible.