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Eat, pray, love…yourself

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1 Eat, pray, love…yourself
ADA 2013 Shari Liesch APNP, CDE

2 Disclosures Abbot Speaker Bureau

3 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

4 EAT: the physical world

5 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

6 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?

7 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

8 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

9 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 Polled nursing schools: post graduate surveys asked about how school prepared the student. None asked about lateral violence, nor how they are doing emotionally. New grad comments: working night shift, 0200 call to mom in GB RE did not feel qualified, unit full, no back up help. Overwhelmed with the acuity, inexperience, feeling of overload. Introduce Gloria. Friend, teacher, mother to Renee who I had the pleasure of caring for (CF). She was a nurse at same hospital. Taught me much about caring, being a mom, nurse. Now retired-ran into nurse still employed RE “You are lucky you are retired” and elaborated about the change in climate, family doing bathes, trays passed by dietetic staff (how do we get those secondary assessments). Nurse role more technical, monitoring, less time at the bedside. Nurse satisfaction greatly improved by “hands on” care---this part seems to be eroding away. Gloria reminded me of the waiver we had to sign that we were aware that handling “chemo” and body excrements are dangerous to our health. Recently treated at a smaller hospital. Noted “family, kind” interaction of all the staff. Job satisfaction matters Time with patient & ability to care impacts satisfaction Davey, et al 2009 Spence, et al 2009

10 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

11 Injuries in the line of duty
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 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

12 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 What does working age nurse mean? Last nurse study: 2012 White rice activity

13 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??

14 Risks of sleep deprivation
It’s cumulative Linked to Illness Obesity Heart disease/stroke Hypertension Diabetes Cancer Resilience problems Grabbing “junk” food

15 Sleep deprivation, cont…
Increased Sleepiness: (subjective) Mistakes Decreased Alertness (behavioral) Safety Productivity Attention & working memory Slowed thinking speed

16 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 No title? Self determination Theory, Mental Fitness

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

18 Survey group composite

19 Survey: years in role & profession
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20 Age & practice location

21 Summary Lower competence <11 years in role
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

22 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 calories/hour Adult 80 calories/hour Muscle burns calories/pound; Fat burns 2 calories per pound Is this writing going to be too small?

23 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?

24 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 .

25 Heart Association guidelines
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 If you have a minute, use it wisely. Zapka et al 2009

26 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

27 pray Emotions and spirituality

28 Life journey Nursing Self & growth Maker of meaning Public self
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

29 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… I spoke to the mom of a 5 month old. Complicated care, awaiting heart surgery, on tube feeding, Down’s syndrome, hypothyroidism, live far from specialists. Called lab results (continue same dose). Mom concerned about lack of wanting to nipple…. Reviewed lose what don’t use—especially when too much car time. The comment “It would have been easier to adopt a child with special needs than feel so responsible…. The pieces of this life, conversation stayed with me. How do you handle all the emotions of the lives you touch every day…. Erickson & Grove 2011

30 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

31 Job satisfaction All this helps weather health care’s economic storm
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 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 Ma, Samuels & Alexander 2003

32 Satisfaction, cont. Structural & emotional empowerment matter
Job satisfaction Increased retention Improved patient satisfaction Personality traits do NOT matter 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 No title? Wording is different on this slide. Erickson & Grove 2011

33 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

34 Survey: accomplishment & feelings

35 People at work care about me

36 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

37 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

38 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

39 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

40 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;

41 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

42 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

43 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

44 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

45 Other factors Stay or go? Personal factors In business 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 No title?

46 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

47 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

48 What about music? Singing improves: Immunity Well being Energy Posture
Longevity Decreases pain

49 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

50 Hobbies and free time Does how you spend your free time impact your emotions? What impacts your well being?

51 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?

52 Relationships: who is in your circle
Love

53 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? Do you want to use bullet points like you have on all the rest? Hold what all together? Who’s in your circle Wellcoaches, 2010

54 Our survey on relationships
MOOD Color Chart

55 Love = relationships Life engagement Connections:
Help with personal development Help us achieve our potential Life bands: link or connect us Watch for negativity

56 Does the age of your peers matter?
Veterans born: pre (>64) Baby boomers: (47-64) Generation X: (30-64) Generation Y: after (26-30) Millennium Era??

57 What about generation gaps?
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 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

58 Generation Y Generation X
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? Both Committed to the team Longevity less embraced Authority less valued Manager: people focused: motivator, communicator Do you want to make the 2 generation slides the samebottom?

59 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

60 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

61 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

62 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

63 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…

64 Love helpful in managing stress
Stress impact Foot on gas Foot on brake Foot on both Antidote for stress Laughter Joy Humor Future focus Connectedness Confidence

65 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? In my early 40s my mother developed lung cancer after 50+ years of smoking. She had a right lower lobectomy. Went home on O2, had therapies., etc. Thursday 3 weeks after discharge she had her first outing to the annual chili supper. That Friday I brought her fish, Saturday did laundry and visited, Sunday brought ribs. She was in good spirits and getting better. On Monday I was to pick her up for her post op appt. with the lung surgeon. When I arrived, her physical therapist was there waiting for me. She had called the doctor as mom wasn’t feeling well. We were to bring her in for the appt. When I approached the bedside feelings were non-specific, but she thought she would be ok. I totally went into daughter mode as she told me to go to city hall and get the wheel chair from Sue to help get her to the car. I left the room, but decided I should call to make sure the chair was ready. I couldn’t find the phone book, so returned to her bedside asking where the phone book was…but stopped, as she had that look. I reached down and cradled her as I guided her head to the pillow. At that time I was CPR trained for over 20 years, and never used it, not once. I called to the therapist, called 911—started CPR. was grateful, for the 6 minutes it took for the ambulance to arrive to not be alone. When the AED was applied, we knew what the outcome would be. During this very difficult moment in my life, this very short term relationship had a lasting, forever impact. I am so glad I was not alone.

66 Support Increases longevity Connections in your circle Rejuvenate soul
Busy hands/mind Increase humor Friendships Mind stimulating— never stop learning Obstacles Life is busy Convenience foods Supersized? Stress eating? Impact on activity Stress: Deadlines Perfectionist Other contributor’s timeline Health concerns

67 Life balance positives negatives 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

68 Prioritize the positive
Gratefulness Increased awareness Satisfaction Memories + mindset, appreciative + emotions = life satisfaction, less depression

69 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?

70 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

71 Summary Links to longevity Think about: 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 I introduced you to Gloria a nurse I worked with. She had a daughter Renee that I had the joy of caring for and being part of her life through my role as a RN. Over the years, we shared many joys and trials. Renee’s lung function got progressively worse. Her family brought her to USC for a living donor lung transplant. This is where they take the right lower lobe out of 2 separate donors, and transplant them to Renee. Think of how complicated the surgery would be, reconnecting all the vasculature, etc. When Renee survived the surgery, I channeled my joy into a poem called The Butterfly Lady—where her web was released, and she could breathe once again. The poem was even published in the hospital paper. Renee’s lungs allowed new life, for a while. Eventually the lungs failed. As the helecopter transported her to Madison, then back to USC for another transplant, I once again channeled my thoughts and fears into poetry and My Broken Butterfly was written. This is what I read at the funeral, as there were complications with the second surgery. Fast forward 15 years. On the day of the funeral Renee’s sister did a home pregnancy test that was positive. Rebecca is now a freshman in HS, and in forensics. Although she never met Renee, Renee is in her heart through stories, photos, etc. It is 2012 and I get a call from Gloria, as Rebecca will be reading the 2 poems for forensics competition. She reminds me that Frosh usually do not place. Imagine the excitement when I got the call that she took first and was going to state!! And 3 weeks later when the call came in that she “aced” it at state, as a freshman this is rare. Imagine the joy we all felt. As I prepared this talk I thought how wonderful that my joy and grief continue to life in the poems, and how lucky I have been to have relationships like the one with Gloria, the nurse, mother, mentor, friend to guide and care for me as a nurse, mother, mentor, friend. I truly feel blessed and amazed. Rebecca is a very talented orator, but in my heart I believe Renee’s angelic presence may have helped a little.

72 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?

73 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

74 Thank you!! Shari Liesch APNP, CDE CHW Fox Valley 130 2nd Street
Neenah, WI Thank you!!

75 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

76 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), Applebaum, D., Fowler, S., & Fiedler, N. (2010). The impact of environmental factors on nursing stress, job satisfaction, and turnover intention. JONA 40(7/8), Endicott, J. and Nee, J. (1997). Assessment letters for clinical studies. Psychopharmacology Bulletin 31(1), Endicott, J., Nee, J., Harrison, W., & Blumenthal, R. (1993). Quality of life enjoyment and satisfaction questionnaire: A new measure. Psychopharmacology Bulletin 29(2), Feather, R. (2008). Emotional intelligence in relation to nursing leadership: Does it matter? with lifetime history of mental illness. Psychiatry Research 152, Journal of Nursing Management Issue,

77 References, cont. Gates, D., Gillespie, G., and Succop, P. (2011). Violence against nurses and its impact on stress and productivity. Nurse Economics 29(2), 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), 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), 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), Manojlovich, M. and Spence Laschinger, H. (2002). The relationship of empowerment and selected personality characteristics to nursing job satisfaction. JONA 32(11), Mills, J. and Mullins, A. (2008). The California nurse mentor project: Every nurse deserves a mentor. Nursing Economics 26(5),

78 references Nooney, J., Unruh, L., and Yore, M. (2010). Should I stay or should I go? Career change and labor force separation among registered nurses in the US. Social Science & Medicine 70, Peipins, L., Burnett, C., Alterman, T., & Lalich, N. (1997). Mortality patterns among female nurses: A 27 state study, through American Journal of Public Health 87(9), Schechter, D., Endicott, J., and Nee, J. (2007). Quality of life of “normal” controls: Association selfdetermination.org. (2010). Perceived autonomy support: The climate questionnaires: The work climate questionnaire (WCQ). Retrieved February 18, 2010, from Venhaus Stein, J. and Reeder, F. (2009). Laughing at myself: beginning nursing students’ insight for a professional career. Nursing Forum 44(4),

79 references Watts, M. (2010). Certification and clinical ladder as the impetus for professional development. Critical Care Nurse Quarterly 33(1), Zangaro, G. and Soeken, K. (2007). A meta- analysis of studies of nurses’ job satisfaction. Research in Nursing & Health 30,


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