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Eat, pray, love…yourself. ADA 2013 Shari Liesch APNP, CDE. Disclosures. Abbot Speaker Bureau. What we will look at. Health care providers care for others…do they look after their own needs Eat = physical needs, energy balance Pray = emotional needs

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Eat pray love yourself

Eat, pray, love…yourself

ADA 2013

Shari Liesch APNP, CDE


Disclosures

Disclosures

Abbot Speaker Bureau


What we will look at

What we will look at

  • Health care providers care for others…do they look after their own needs

    • Eat = physical needs, energy balance

    • Pray = emotional needs

    • Love = relationships (linked to well-being)

  • Goals:

    • evaluate physical, emotional role risks

    • explore how relationships (professional and personal) impact overall well being


Eat pray love yourself

EAT: the physical world


Health impact of your role

Health impact of your role

  • Think of a time that your role has impacted your health….

    • Illness

    • Injury

    • Rest/sleep

    • Demands, deadlines

    • Irritable clients

    • Administrative


Risks for health care providers

Risks for health care providers

  • Physical demands

  • Emotional demands

    • Acute & chronic needs of others

    • Death

    • The unexpected

  • Personal trials (what is happening in own life)

  • Lateral violence

  • Administrative changes

  • Governmental policy

  • How do we handle it all?


Workplace hazards

Workplace hazards

1. Biological: viral hepatitis, TB, HIV

2. Chemical: cytotoxic, anesthetic

3. Physical: radiation, needle stick, patient handling

4. Psychosocial: stress, shift work

Outcomes of exposure

Cancer, injuries, infectious diseases

2011 Nursing World: Health & safety top concerns:

Acute/chronic effects of stress & overwork (74%)

Musculoskeletal injury (62%)

Aiken et al 2002 ; Peipins, et al 1997


Odor noise stress

Odor, noise, stress

Work:

When controlled environmental factors: improved

  • Satisfaction

  • Retention

  • Stress

  • Outcome measurement of job stress: mood

    Full time & strains & sprains linked to turnover intent

  • Brewer et al 2011

Applebaum, Fowler, Fiedler 2010


Inpatient nurses

Inpatient nurses

  • Nursing shortage

  • Increased work load

  • Decreased support

  • Retention/turnover issues

  • Challenging work environment: are new grads ready for the demands

    • Polled nursing schools…

    • New grad comments…

    • Family bathes, trays passed by non nurses: Introduce Gloria...

    • IV, meds, monitoring

  • Job satisfaction matters

    • Time with patient & ability to care impacts satisfaction

    • Davey, et al 2009

Spence, et al 2009


Rate of illness for nurses

Rate of illness for nurses

  • Working age nurse: Younger nurse

    • TB death small

    • No excess death r/t HIV

    • CA: breast & colon CA slightly higher

    • Chronic lympho-leukemia slightly higher

  • Older nurse:

    • Chronic myeloid leukemia

    • Malignant neoplasm

    • Slight increased kidney cancer

    • Slight increase brain & CNS CA—compared to total

    • Nurse health study


Injuries in the line of duty

Injuries in the line of duty

Low back pain compared to personal/work characteristics

  • Korea: mean age 27

  • High prevalence of back pain in ICU nurses

  • Nurse w/2-4 years experience had greatest probability of back pain and treatment

    • 90.3 % had back pain/monthly

    • 18.3% received treatment

  • If perceived staffing as inadequate (64%) and working >6 night shifts/month (48%) = increase in back pain

  • Ja June & Cho 2010

Work injury influenced by psychosocial & physical exposures (Australia)

  • ^ stress  5% probability of injury

  • As # of health conditions increased, (3 & >6) chance of injury increased (5% & 15%)

  • Programs targeting modifiable factors (psychosocial & physical health) improved health & work productivity

    Vecchio et al, 2010


Mortality of nurses

Mortality of nurses

Mortality due to diabetes = white collar workers

  • Mortality due to heart disease: fewer compared to all

  • Working age nurse (vs retired): increased accidental poisoning: drugs/meds

  • Falls

  • Slight increased risk: suicide

  • No homicide or alcohol related increases

  • Baer et al 2010

Last nurse study: 2012

White rice activity


Interest of safety

Interest of safety…

  • Infection control, universal precautions

  • Protective needles

  • Remember finger cots?

  • Safety is improved

    • Masks

    • Gloves

    • Gowns

  • Attention to

    • Noise

    • Lighting

    • Shift limits

  • Protective gear matters

    • Hockey “cup” invented in 1874

    • Head helmet in 1974??


Risks of sleep deprivation

Risks of sleep deprivation

  • It’s cumulative

  • Linked to

    • Illness

    • Obesity

    • Heart disease/stroke

    • Hypertension

    • Diabetes

    • Cancer

    • Resilience problems

    • Grabbing “junk” food


Sleep deprivation cont

Sleep deprivation, cont…

  • Increased

    • Sleepiness: (subjective)

    • Mistakes

  • Decreased

    • Alertness (behavioral)

    • Safety

    • Productivity

    • Attention & working memory

    • Slowed thinking speed


Self determination theory basics

Self determination Theory Basics

  • Competence

    • Recognition

    • Ability

    • Strengths

    • Gifts

  • Autonomy:

    • Choices

    • Voice

    • Make decisions

    • Feel supported

    • Longevity,

    • Power, less hostility

  • Relatedness

    • Belonging

    • Connected to others that are supportive

    • Support

      • Professional

      • Personal

      • Teambuilding

Self determination Theory, Mental Fitness


Purpose of survey

Purpose of survey

  • Hypothesis: improved job satisfaction and overall perception of health positively impacts quality of life and perception of well being.

  • Examine job related autonomy, relatedness and competence in a group of health care providers (AADE members attending AADE12 invited to participate)

  • Assess if there is a correlation between overall quality of life and perceived autonomy, relatedness and competence.


Survey group composite

Survey group composite


Survey years in role profession

Survey: years in role & profession

k


Age practice location

Age & practice location


Summary

Summary

  • Relatedness increased if >33 hours per week:

    • <33 hrs. per week less relatedness (p=0.041)

  • Lower competence <11 years in role

    (p= 0.027)

  • Greater competence:

    • Age >47 (p = 0.015)

    • >25 years in profession (p= 0.015)

  • Increased autonomy :

    • >25 years in profession


The aging process

The aging process

  • Sense of smell & taste decline over time

  • Decreased muscle mass

    • After age 35 we lose ½ # muscle / year

    • = a shift in type of cells even if the scale doesn’t change

  • Energy: 3500 calories = # 1

    Sitting

    • Child 4-500 calories/hour

    • Adult 80 calories/hour

  • Muscle burns 35-50 calories/pound;

  • Fat burns 2 calories per pound


What is the plan

What is the plan?

  • How do we?

    • Combat aging

    • Deal with gravity

    • Stop muscle loss

    • Deal with work demands

      What about you and your work environment…

      How about activity?

      Do you have play time?


Eat pray love yourself

1. The leading cause of preventable death?

a. Smoking

b. Obesity

2. When sleep deprived, what type of food do persons grab the most?

a. fruits

b. veggies

c. cookie, candy, soda & donut like stuff

.


Heart association guidelines

Heart Association guidelines

  • If you have a minute, use it wisely.

  • Get active

    • 30-60 min. most days

    • More intense 45 min 2x/week

  • Monitor intake—journal

    • Eat breakfast

    • Fruit/veggie intake, fiber, portion sizes, reduce fat

    • Calcium, vitamin D, iron, etc.

  • Maintain a healthy weight

  • No/reduce smoking

  • Control health concerns:

    • Cholesterol

    • BP, weight, blood sugar

Zapka et al 2009


Eat energy balance

Eat = energy balance

  • Quality, quantity of energy intake

  • Food = socialization

  • Liquid calories?

  • Activity

    • miracle grow for the brain

    • stress management

    • Kaiser: healthy weight less likely to develop dementia

    • Amen clinics: dinosaur theory: smaller brain

  • What about your work team…..

    • Lemon bars need lemon


Eat pray love yourself

pray

  • Emotions and spirituality


Life journey

Life journey

  • Nursing

    • Maker of meaning

    • Member of technology

    • Each a mystery

    • People are messy

      Gallion & Stamp

      Link between patient safety & nurse safety

      Foley 2004

  • Self & growth

    • Public self

    • Private self

    • Personal self


Impact on our emotions

Impact on our emotions.

  • Think of a time when emotions were impacted

    • Elated

    • On fire

    • Dulled/numb

    • Hurting

  • Stress of diagnosis

  • Loss of the known

  • How was your life journey impacted?

  • The 5 minute call…

  • Happy

  • Proud

  • Surprise

  • Excited

  • Calm/relaxed

    • Frustrated

    • Anger

    • Irritated

  • Keeping the poker face when stressed…

  • Erickson & Grove 2011


    Emotions matter

    Emotions Matter

    • Does management of the emotion or the emotion itself cause burnout?

    • Burnout related to:

      • Older nurse: if low level of + emotions

      • <30 yr old: if experience agitation

    • Covering up true feelings lead to increased burnout than nurse who does not cover up true feelings

    • For practice:

    • Positive emotions may insulate us

    • Mentoring needs an emotional, supportive part

    • Erickson & Grove

    • Reviewed emotions & burnout

    • Knowing emotional demand is critical; how work stress translates to burnout & turnover

      • Influenced by organizational practices governing work place more than the challenge of care

      • How emotions are managed on the outside: surface acting Vs deep acting (how one feels on the inside)

        • Younger nurse experience more stress & burnout

        • Increased burnout if more surface acting & more masking of emotions


    Job satisfaction

    Job satisfaction

    • 2/3 say job satisfaction same or slightly less than in the past

    • Listed professional development & recognition as motivators

    • Administrators goal:

      • job satisfaction,

      • decreased turnover

      • less nurse shortage

    • Commitment of management in nursing:

    • Increased

      • quality care

      • professional development

      • patient safety

      • + clinical experience

      • retention

        Sammer & James 2011

    • All this helps weather health care’s economic storm

    Ma, Samuels & Alexander 2003


    Satisfaction cont

    Satisfaction, cont.

    • If more satisfied

    • Raise to challenge of organizational restructure, need

      • Access to information

      • Support

      • Opportunity

      • Resources to do the work

      • Certification and magnetism matters

      • Pursuit of higher education

    Structural & emotional empowerment matter

    Job satisfaction

    Increased retention

    Improved patient satisfaction

    • Personality traits do NOT matter

    Erickson & Grove 2011


    Nurse meta analysis

    Nurse meta-analysis

    • Job satisfaction

    • Job stress: leads to

      • work burnout

      • emotional exhaustion

      • work frustration

    • Autonomy—improved work environment, more control

      + relationship to job satisfaction

    • Weston 2010; Zangaro & Soeken 2007


    Survey accomplishment feelings

    Survey: accomplishment& feelings


    People at work care about me

    People at work care about me


    Oppressed group behavior

    Oppressed group behavior

    • Systemic problem

    • Disenfranchisement

    • Marginalization

    • Oppressed group created by powerlessness of nurse health care system

    McPhaul & Lipscomb 2004; Gates et al 2011; Jones & Argentino 2010


    Nurse to nurse hostility

    Nurse to nurse hostility

    • Emotionally challenged impacts

      • performance,

      • satisfaction,

      • retention,

      • health,

      • patient satisfaction

    • Does improved Emotional Intelligence (EI) impact group emotional competence

      • Constructive & appropriate behaviors : decrease anxiety & nurse to nurse hostility

    Feather 2009; Fuimano 2004; Zeidner, Matthews & Roberts 2004


    Emotional intelligence ei

    Emotional Intelligence (EI)

    Self aware: emotional feelings and reactions

    Emotion = energy

    Emotional resilience

    Motivation

    Interpersonal sensitivity

    • Conscious of energy behind the words and interactions

      Influence

      Intuitiveness

      Conscientiousness

      Body receives/understands information

      Wickipedia accessed 8/15/2011

    Mayer, Roberts & Barsade 2008


    Will enhancing ei matter

    Will enhancing EI matter?

    • Learned

    • Empowerment

    • Increase autonomy, locus of control,

    • Intrinsic & extrinsic motivators (individual)

    • Recognition

      • achievements

      • desire to care (intrinsic)

      • receive appreciation for care given (extrinsic)

    Hyrkas & Dende 2009


    Ei as a group

    EI as a group

    • Increased behaviors & habits that work vs. do not work for the group

    • Proactive skills speak up if out of line

    • 100% valued– experience desired teamwork

    • Build EI in the individual it builds

      • the group

      • team trust

      • effectiveness

      • networking

    Zeidner, Matthews & Roberts 2004; Feather 2009;


    What can we do

    What can we do?

    • Have space to experience own emotions

    • Empower each other: ^ trust, caring, safety, EI

    • Energize

    • Encourage, respect

    • Empathy: center to nursing role

      • Improves outcomes, increases satisfaction with care

      • It can be learned through in-service education

        Ward, et al (2012) assessed empathy in undergrad programs:

        • found decline in empathy over the school year

        • students with more clinical exposure had less empathy

        • historically younger nurse, with less experience more empathetic

      • Decline may be related to: time constraints, anxiety, lack of support, intimidating educational environment

        • expanded roles  increase in technical skills


    Empowerment

    Empowerment

    • Increase trust, care, safety

    • Increase EI & Group Emotional Quotient (GEQ)

      • Modify, redirect actions (based on assessment for the moment)

      • Increase constructive outcomes

      • Improved group member awareness, regulation, & interaction

      • Encourage behaviors that seek awareness (+)

      • Regulate emotions through personal growth increases group competence

    Fuimano 2004; Mayer, Roberts & Barsade 2008, Laschinger et al 2009


    Since 1960 s nurses eat their young

    Since 1960’s: Nurses eat their young

    • How are we doing?

    • Nursing 93-95% women

      • What about women?

      • Emotions

      • Hormones

      • Multi-task

      • Competitive

      • Internalize stress  health consequences

      • Stress eat

      • Lapse B/W knowledge and ownership of behavior

        • Women in survey CVD prevention: assessed knowledge, intake, if smoked, exercise

          Had knowledge, didn’t implement

    • Senior nurse down hill flow

      • Understanding the new nurse isn’t easy

    • Community vs. I approach

      • Proper orientation

      • Mentoring

      • Buddy system

      • Teambuilding

      • Conflict resolution skills

      • Commonwealth

      • Hold each other accountable

    Hippeli 2009; Mills & Mullins 2008; Zangaro & Soeken 2007


    Emotions

    Emotions

    • Belief in something greater than

      one-self

      • Offers renewal

      • Soul nurturing

    • Connect with nature

    • Where do you find balance in your life?

      • Floating down the Menominee River VS rafting class 4 rapids


    Other factors

    Other factors

    Stay or go?

    Personal factors

    • Marital status

    • Childcare needs

    • Greater chance at part time employment

      Higher education

      • Males: enroll in non nurse role

      • Advanced practice: decreased attrition

        Nooney, Unruh & Yore 2010

    • In business

      • Estrogen to profit ratio is well known

      • Women leaders mentor underlings

      • Nursing is flooded with “estrogen”, yet we struggle


    Resilience

    Resilience

    Handling the curves in life

    • Past experience

    • Current perspective (choices)

    • Rested vs. fatigued

    • Being vs. living

      Think of a time you were tossed an unexpected curve ball—how was this handled

      • Staffing changed unexpectedly


    Hope faith air

    Hope, faith, air

    • Hope = #1 predictor in goal achievement

    • Faith = belief in future

    • Air = deep breathing

      • Oxygen

      • Calming

    • RX: nature-play prescription

      • Acorns, water, sun, quiet

        Dr. Nan Strand and the amazing race


    What about music

    What about music?

    • Singing improves:

      • Immunity

      • Well being

      • Energy

      • Posture

      • Longevity

      • Decreases pain


    Of interest

    Of interest…

    • Muscles to smile = 22

    • Muscles to frown = 37-72

      • Smiling = anti gravity

      • Smiling = contagious

    • May 2 = world laugh day

    • Laugh for nothing: it’s heart friendly

    • Laugh at self—shift the perspective

    • No humor: emotional apathy  disease


    Hobbies and free time

    Hobbies and free time

    • Does how you spend your free time impact your emotions?

    • What impacts your well being?


    Summing up emotions

    Summing up emotions….

    • What keeps you grounded?

    • How do you keep your creativity alive?

    • What about work stress, how do you handle this?

    • How do you feed your inner child?

    • Is use of your hands important to you?


    Eat pray love yourself

    • Relationships: who is in your circle

    Love


    Who s in your circle

    Who’s in your circle

    Think of your relations

    Family

    Work

    Friends

    Neighbors

    Communities

    Who makes up the strands that help hold it all together for you?

    Wellcoaches, 2010


    Our survey on relationships

    Our survey on relationships

    MOOD Color Chart


    Love relationships

    Love = relationships

    • Life engagement

    • Connections:

      • Help with personal development

      • Help us achieve our potential

    • Life bands: link or connect us

      • Watch for negativity


    Does the age of your peers matter

    Does the age of your peers matter?

    • Veterans born: pre 1945 (>64)

    • Baby boomers: 1946-1964 (47-64)

    • Generation X: 1965-1980(30-64)

    • Generation Y: after 1981(26-30)

    • Millennium Era??


    What about generation gaps

    What about generation gaps?

    • Baby boomers

    • Value family

    • Job completion

    • Do as told

    • Commit to experience

    • Accomplishments matter

    • Roles overlap

    • Huge #; nursing is 2nd career

    • Focus on the big picture

    • Workaholics

    • Less appreciate rewards, feedback

    • Less balance

    • Veteran nurse

    • Hard work

    • Respect authority

    • Duty before play

    • Sacrifice

    • Follow rules

    • Work is obligation

    • Experience respected

    • No news is good news

    • Satisfied with job well done

    • Work & family kept separate


    Eat pray love yourself

    Generation X

    Generation Y

    Both

    Committed to the teamLongevity less embracedAuthority less valuedManager: people focused: motivator, communicator

    Less value on authority

    Personal touch matters

    Needs reinforcement

    Interested in work/life balance

    Value flexibility, fun, quality of life, & creativity

    Technology abounds: look at monitor; forget the patient

    Expect to be appreciated for their intellect

    Like recognition

    Mutual support

    Trust in system

    Embrace new

    Multi-task?


    How we see each other

    How we see each other

    • X & Y see baby boomers as self indulgent

    • Ruthless

    • Uncaring

    • Baby boomers see X, Y as slacker, want a free ride


    Relationships

    Relationships

    • Quality of relationships is reflected by the energy brought to the relationship

      • Increased purpose

      • Meaning to life

      • Respect & joy in each other

        I am lucky to have so many siblings…..

        I am lucky to have_____on my team


    Research shows

    Research shows…..

    Relationships:

    Key to survival

    Impact overall well-being

    In the DNA of well being: relationships are the strands that hold everything (us) together


    Eat pray love yourself

    Love

    • Adult life

      • 1st part: mind & heart (doing)

      • 2nd part: body & soul (being)

    • Increase mindfulness = attention to the moment

    • Story: shopping for furs in Chicago


    Love shows in your being

    Love shows in your being…

    • Heart energy is vital

    • Random acts of kindness: filling the bucket

      • Forgiveness

      • Friendship

      • Optimism

        At the beginning of the day, what do I look forward to?

        Look for reasons to say thank you…

        List 3 things grateful for daily…


    Love helpful in managing stress

    Love helpful in managing stress

    • Antidote for stress

      • Laughter

      • Joy

      • Humor

      • Future focus

      • Connectedness

      • Confidence

    • Stress impact

      • Foot on gas

      • Foot on brake

      • Foot on both


    Sharing a story

    Sharing a story

    • Sharing a relationship or personal challenge……….

      • Even short term***

    • How did you overcome?

    • How did it make you feel at the time? Later?

    • Was there someone or something that helped?

    • How were you impacted long term?


    Support

    Support

    • Obstacles

      • Life is busy

      • Convenience foods

        • Supersized?

        • Stress eating?

      • Impact on activity

      • Stress:

        • Deadlines

        • Perfectionist

        • Other contributor’s timeline

        • Health concerns

    • Increases longevity

      • Connections in your circle

      • Rejuvenate soul

      • Busy hands/mind

      • Increase humor

      • Friendships

      • Mind stimulating—never stop learning


    Eat pray love yourself

    Life balance

    • Stress

    • Time management strains

    • Dead lines

    • Sleep deprivation, shift work

    • Lifestyle choices (over-commitment, sedentary, dietary habits)

    • Stuff accumulation

    • The unexpected…

    • Cutbacks..

    • How well can you juggle?

    • Friendship/relationships

    • Helping profession

    • Like to spend time

    • Like to make a difference

    • Satisfaction in task completion

    • Happiness factors

    • Stress antidotes

    • Brain cell activation

    • Goal setting

    • positives

    • negatives


    Prioritize the positive

    Prioritize the positive

    • Gratefulness

      • Increased awareness

      • Satisfaction

      • Memories

      • + mindset,

      • appreciative

      • + emotions = life satisfaction, less depression


    Never stop playing

    Never stop playing

    • Brain socially connected

    • The potential to change, to learn, and to grow is in relationships

    • Have a sense of humor (must be mutually shared)

    • Are the persons in your circle nurturing for you?


    Making a difference

    Making a difference

    The Tipping Point

    By: Malcolm Gladwell

    Ideas are spread like epidemics

    Little things make a big difference

    3 rules of epidemics (agents of change)

    • Law of the few (80/20 rule)

      • Connectors =gift for bringing togetherness

      • Mavens = information specialist

      • Salesmen = persuaders, charismatic, negotiators

    • Stickiness factor

      • Retention of content & entertainment value

    • Context: sensitive to condition and circumstance at the time

    We are inundated with messages: back to word of mouth: personal connections matter


    Summary1

    Summary

    • Links to longevity

      • Hobby

      • Humor

      • Happiness

      • Positivity

      • Sleep

    • Think about:

      • Eat (energy balance),

      • Pray (emotions),

      • Love (life engagement through relationships)

        My first 30 years….Back to my friend Gloria


    Look at

    Look at

    • Be the tipping point

      • Maven

      • Salesperson

      • Connector

    • Use positivity to fuel your life journey

    • Create a future that empowers

    • Find/post an image to help maintain your goals

      • What can we do to be part of the tipping point that transforms health care in a positive way?


    Setting goals

    Setting goals

    • Pick 1 thing (personal or professional)

      • Where are you now

        (on a scale of 1 to 10)?

      • Where would you like to be?

      • What does your goal look like: visualize the dream…

      • What is the first step?

    • **If we are emotionally attached = increased likely to follow through & success


    Thank you

    Thank you!!

    Shari Liesch APNP, CDE

    CHW Fox Valley

    130 2nd Street

    Neenah, WI 54956

    [email protected]

    920 969 5302


    A butterfly s birthday

    A Butterfly’s Birthday

    • Daybreak calls.

    • She gently takes flight; wings alive and aglow.

    • Kissing each flower good morning,

    • Bidding them to rise—decorating her world;

    • Painting my world; with colors so magnificent.

    • She tickles each blossom, soon they are singing;

    • An enchanting choir fills the air. Our world is alive!

    • With all petals at attention, sweet sounds echo about.

    • Contented, she drifts down to her favorite rock,

    • Peaking over the peaceful ripples of the bay.

    • She rests, soaking up energy from the sun’s rays,

    • Until gentle breezes call her, to come and play.

    • Today as I rested on the sandy shore,

    • Peaceful breezes sang.

    • The butterfly sat down beside me. My heart swelled.

    • I tried to reach out to her,

    • But she flew away…eluding my touch.

    • I was saddened she left me so alone,

    • Yet, I thought I heard her whisper,

    • “Today I celebrate, come and play!”

    • By Shari Liesch RN, August 1996

    http://Nurspiration.proboards.com


    References

    References

    • Aiken L., Clarke S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288(16), 1987-1993.

    • Applebaum, D., Fowler, S., & Fiedler, N. (2010). The impact of environmental factors on nursing stress, job satisfaction, and turnover intention. JONA 40(7/8), 323-328.

    • Endicott, J. and Nee, J. (1997). Assessment letters for clinical studies. Psychopharmacology Bulletin 31(1), 13-16.

    • Endicott, J., Nee, J., Harrison, W., & Blumenthal, R. (1993). Quality of life enjoyment and satisfaction questionnaire: A new measure. Psychopharmacology Bulletin 29(2), 321-325.

    • Feather, R. (2008). Emotional intelligence in relation to nursing leadership: Does it matter? with lifetime history of mental illness. Psychiatry Research 152, 45-54. Journal of Nursing Management Issue, 376-382.


    References cont

    References, cont.

    • Gates, D., Gillespie, G., and Succop, P. (2011). Violence against nurses and its impact on stress and productivity. Nurse Economics 29(2), 59-67.

    • Gladwell, Malcolm. The tipping point.

    • Hippeli, F. (2009). Nursing: Does it still eat its young, of have we progressed beyond this? Nursing Forum 44(3), 186-188.

    • Jones, T. and Argentino, D. (2010). Nurse to nurse hostility, confrontational anxiety and

    • emotional intelligence: An integral, descriptive pilot study. Journal of Peri-Anesthesia Nurses 25(4), 233-241.

    • Kimball, B. (2004). Health care’s human crisis-Rx for an evolving profession. The Online Journal of Issues in Nursing 9(2), Manuscript 1. pages

    • Ma, C. C., Samuels, M., and Alexander, J. (2003). Factors that influence nurses’ job satisfaction. JONA 33(5), 293-299.

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