“Killing Americans softly, the act of repealing affordable healthcare”

“Killing Americans softly, the act of repealing affordable healthcare”

Before the Affordable Care Act (ACA) many people, including the author, were denied health insurance because of pre-existing conditions such as, but not limited to: obesity, cancer, or pregnancy. Since the ACA was signed into law in 2010, approximately 30 million people gained access to health insurance. Overall, the ACA has achieved its purpose of providing affordable health insurance to individuals regardless of health status. Even with the success of the ACA some politicians actively seek to “repeal and replace” this law. Numerous statutes to replace Obamacare were introduced in Congress after the inception of the ACA.  The following are proposed bills currently in Congress, one of which may serve as a potential replacement to the ACA.

Secretary Tom Price introduced the Empowering Patients First Act (HR. 105) during the 112th Congress in response to escalating pressure for Obamacare repeal. In brief, the Empowering Patient First Act aims to provide tax credits to purchase family and individual policies. As individuals grow older and sicker these tax credits will increase. Consequently, the individual mandate and tax penalty for not maintaining insurance coverage would be abolished. Also, funding for Medicaid expansion will cease to exist. This bill would eliminate the federal insurance exchange; meaning no subsides to assist low-income persons with individual cost of insurance premiums. States would be responsible for developing and maintaining websites to only provide information regarding health insurance plans and prices. These state – controlled websites cannot directly enroll people in private plans and Medicaid. Finally, the Empowering Patients First Act enables insurance companies to determine length of previous coverage when establishing cost of insurance premiums.

“The Empowering Patients First Act”


The Patient Freedom Act of 2017 (S. 191), was sponsored by Senator Bill Cassidy (R – LA) during the 115th congress. As another ACA substitute bill, this act allows states to decide how intrastate health insurance is regulated, thus minimizing government involvement. The individual mandate, employer mandate, and federal essential health benefits mandate would all be repealed. For individuals who choose to opt-out of basic health insurance coverage a Roth health service account would be created to help fund medical expenses. According to this statute, each state would set its own rules for deciding on whether it would participate.

Unfortunately, there are several unknowns regarding the Patient Freedom Act of 2017. One such variable is cost of high – deductible plans. The amount of the deductible is also unknown. There is little discussion of what health services would be covered at little or no cost. Furthermore this act states, “some versions” of prescription drugs and childhood immunizations would be covered.

“The Patient Freedom Act of 2017”


 The Obamacare replacement act (S. 222), introduced by Senator Rand Paul (R-KY), seeks to repeal all ACA mandates such as individual and employer mandates, community rating restriction, rate review, essential health benefits requirement, and medical – loss ratio. This plan provides a two year period for people with pre – existing conditions to obtain insurance coverage. Once this term ends the pre-ACA practice of denying health insurance to individuals with pre- existing illnesses will resume. Additionally, the Obamacare replacement act increases states flexibility to conduct Medicaid waivers. Under the ACA, if states would like to modify their Medicaid coverage rules, before those changes are initiated, the state must request a waiver from the Department of Health and Human Services. Senator Paul’s bill allows the states to have more control over instituting changes to Medicaid without government involvement.

“The Obamacare Replacement Act”


By numerous accounts, the ACA is accomplishing its ultimate goal: lowering the number of uninsured and making certain that Americans have comprehensive, affordable health insurance. According to the Centers of Disease Control and Prevention (CDC) and census data, for the first three months of 2016 the uninsured rate was 8.6% down from 9.2% in 2015, and from 15.7% before the ACA was signed into law. For states that have set up their own insurance marketplaces and expanded Medicaid, the number of uninsured has dropped from 45 million in 2013 to 29 million in 2015. These statistics should continue to decrease with more individuals signing up for insurance coverage through the ACA. Conversely, approximately 130,000 Americans died between 2005 and 2010 because of their lack of health insurance according to a 2012 healthcare consumer study. The uninsured are less likely to have a primary care physician and often go without screening and preventive care. Without routine screening and preventative care diseases such as HIV and cancer are detected at a later stage leading to higher rate of death.

 The previously mentioned replacement acts for Obamacare collectively discuss eliminating ACA mandates. The fierce opposition towards the individual mandate stems from a widely held belief that health insurance should be a choice not forced upon individuals and businesses. Fortunately, the individual mandate allows insurance premiums to remain relatively affordable. This mandate forces healthy people into the insurance market thus decreasing risk to underwriters and overall cost. Eliminating the individual mandate may send health insurance markets into a tailspin increasing cost consequently leaving millions without insurance due to exorbitant expense. Another destabilizing factor of keeping health insurance affordable is the practice of allowing healthcare plans to be purchased across state lines.  

 Building a national insurance system is nearly impossible because developing a national provider network is difficult. Establishing contracts with doctors and hospitals is expensive and time consuming for insurance companies. There are numerous, varying regulations within a state’s health insurance department.  Insurance tends to be less expensive in states where more people are young and healthy. Cost may rise if individuals from other states were to buy insurance in the cheaper state. Concurrently, Humana announced that it has plans to leave eleven state marketplaces in 2017 due to loss of revenue. Humana reports nearly $1 billion dollars in losses since the beginning of the ACA. Aetna is considering following in Humana’s footsteps, leaving the marketplace also citing cost. Aetna reduced its presence in the market from 15 to four states, after losing $450 million on sales of ACA plans in 2016.

 As everyone understands, providing affordable healthcare to all is a complex matter. The hallmarks of the ACA finance the plan and provide stability. Abolishing the mandates and allowing health insurance to be purchased across state lines severely increases volatility of the health insurance market. Large insurance companies such as Humana and Aetna leaving the healthcare exchange creates another level of instability to the marketplace. Yes, the ACA is problematic and modification should occur but hopefully when the dust settles, the American people will have a healthcare plan that is stronger not weaker than the original.      




Tactful vs. Tactless: A primer of appropriate behavior when leading

Tactful vs. Tactless: A primer of appropriate behavior when leading

“Tact is the art of making a point without making an enemy” — Sir Isaac Newton

Tact is the capacity to relay facts in a manner that is sympathetic of a person’s emotions and reactions. Tact enables people to say the right thing to preserve a relationship. Tact encompasses many things, including discernment, thoughtfulness, and compassion. When leaders communicate tactfully respect is gained professionally and personally. Individuals who encounter a leader who is devoid of tact conceivably lose respect for the leader and their vision. The following examples are real life scenarios of people in leadership positions lacking tact when interacting with a colleague.

Tactless:  During a meeting the importance of compact licensure regarding a particular state was discussed by a committee chair.  While speaking, the committee chair mistakenly named a state not participating within the Nurse Licensure Compact (NLC). After the nurse was finished with her example the presiding chair states, “That was a bad example, Alabama is not a compact state, however Mississippi is a compact state and you can skip over states to work…..” Additionally, the presiding chair’s diatribe was complete with posturing and finger pointing.

Tactful:  A prudent response would be, “That was a great example, however the state you mentioned is not a compact state but your example could work with South Carolina which is a border state that participates within the NLC.”

Tactless:   A student nurse practitioner was presenting a case to her preceptor who was known to have a horrible temper. While the student was presenting the case, the preceptor started to interrogate her regarding trivial matters having absolutely nothing to do with the patient’s diagnosis. As a consequence, the student became increasingly nervous and started stuttering. Then her preceptor states the following, “You’re too slow.”, “Get your act together.”, “You should know these things before you report off to me.”. Finally, adding insult to injury the preceptor says, “Continue down this path you will not be a good nurse practitioner and certainly not one I would hire.”

Tactful:   Displaying a calm, assuring manner while the student presented their case would’ve been the most sensible approach.

Tactless: After a failed partnership, a mutual acquaintance approaches the person who left the alliance to tell her, “You have missed your opportunity. That was your time to shine. We don’t know when your time will reappear again, it may be 5, 10, or 15 years. We don’t know.”

Tactful:  A statement such as, “Although I may feel it’s unfortunate you chose not to work with this person, I wish you continued success regarding your endeavors”; would’ve proven sufficient.

 A few key ideas leaders should remember:

1)      There is a difference between being assertive and aggression.

A leader who is assertive displays confidence when voicing their opinion. An assertive leader is always tactful in their interactions with others.  Tactics of aggression such as posturing and finger pointing are unprofessional. When colleagues are faced with an aggressive leader some retreat or others may fight back. Retreating and retaliation creates a hostile environment of which nothing meaningful to promote the group’s vision is completed.

2)      Leaders should never extinguish the dreams of others. 

Leaders fertilize the dreams of associates through mentorship. A measure of a great leader is the number of leaders that are produced from their guidance. Leaders should strive to grow their own crop of leaders.  Alternatively, telling someone they would not be a good nurse practitioner is destiny assassination. This type of malicious behavior demonstrates the true personality of an individual who considers himself a leader. Often a person who says these despicable things is insecure regarding their leadership abilities.

3)      Listen to understand not to solely respond.

Commonly, people listen only to immediately retort. It seems as though when tensions are high both parties neglect to understand the other’s point of view. This misperception has the potential to ruin personal and business relationships alike. It may be difficult for some but it is essential leaders attempt to understand the other person’s position. This higher level of comprehension is what builds character among leaders.

4)      Watch your body language

Body language has an important effect of perception to the listener. A smile indicates a pleasant demeanor. Good body posture suggest confidence. Finger pointing and posturing indicates insecurity and aggression. Leaders should aim to exhibit positive body language when interacting with colleagues.

5)      Think before you speak

Whether the comment was meaningful or occurred during a fit of rage, once the remark is said it can never be taken back. The person may state, “I didn’t mean to say that.”; however the majority forgives but never forgets. When a leader is led by emotion rather than rational logic a seed of failure is planted within the group. This seed breeds negativity, discourse, and dissention. These variables are detrimental to an organization and its purpose.

For many, tact is a learned behavior. The person may be unaware of how their words or actions are perceived by others. Implementing tact within one’s moral compass takes time and self – reflection.  A self – assessment is necessary for the leader to gauge how injurious their comments were towards others. This voluntary action of inward reflection could possibly serve as a catalyst of change for the person. Through this metamorphosis of thought a substandard boss develops into a prominent leader.



“Shield of White”: A culture of silence among nurses

“Shield of White”:  A culture of silence among nurses

Imagine… a young professional nurse excited about her first appointment to a national committee. In the midst of her happiness she discloses the good news to her colleagues. However, much to her chagrin, one associate defiantly insulted her in front of ten colleagues regarding her choice of accepting the offer to join the committee. After the associate’s tirade was over the remaining colleagues said nothing in defense of the young professional nurse. They kept silent and the subject was changed.

Remaining silent or excusing the reprehensible behavior in an attempt to minimize the effects of lateral violence has become commonplace. I refer to this phenomenon as the “Shield of White” comparable to the “Thin Blue Line” of law enforcement. The culture of silence among nurses must end. Silence equals acceptance. Listed below are a few reasons why nurses remain quiet when confronted with workplace bullying.

Fear of retaliation

Fundamentally, retaliation is not about getting revenge or “getting back” at anyone. Instead retaliation centers on making people afraid to complain or to assert their rights. For example, an individual responds to a group email and the status quo does not like this person’s response; therefore the status quo begins to exclude this individual from leadership opportunities within the group. Organizations or hospitals are unlikely to prosper when people are made to be afraid. A few consequences of retaliation are: (1) neglecting to ask the “tough” questions (2) underreporting of unlawful/unethical occurrences (3) an unwillingness to challenge authority. Most healthcare institutions consider retaliation unlawful and prohibited. In July 2012, a jury made an award of 1.2 million dollars in a retaliation case against a rehabilitation facility in Saginaw, Michigan.

Fear of rejection

Humans demonstrate an essential need of belonging to a group. This need can stifle a one’s ability to advocate for others.  Fear of becoming isolated from promotions or social events may inhibit a person’s willingness to speak – out against injustice.  Also, some are afraid of being ignored or criticized within their professional and social circles. Unfortunately, when people speak unfavorably about misconduct, colleagues may employ devious methods of rejection such as deleting the bullied person’s email address from a governing body listserv before their term is over in a thinly veiled attempt to restrict access.


Conceptually known as “nothing is going to change anyways” or “why bother” mentality. This attitude is exposed among individuals who feel the misconduct is not happening to them so they do not care. People who are ambivalent regarding bullying are indecisive in temperament. Typically these people may share the same views as the bullied individual privately; however publicly they agree with the majority to avoid confrontation and as a show of solidarity to the perpetrator. These individuals understand acts of lateral violence are wrong but feel powerless to change years of bad behavior from peers that has been validated and in certain circumstances enabled by others.

We cannot afford to stand idly by as our colleagues are enduring abuse at the hands of their peers. As Mohandas Gandhi once said, “You must be the change you want to see in the world. One must be willing to advocate for their beleaguered colleagues in order to initiate the difficult conversations of which will prompt change. If each nurse spoke their truth, we would heal ourselves and become agents of change for a wounded profession.

A New Normal: Graduate Nursing Students Paying for Clinical Rotations

A New Normal: Graduate Nursing Students Paying for Clinical Rotations

Aspiring Advance Practice Nurses (APNs) enter their prospective graduate programs each semester with the good faith of excelling at their course work and practicum. Unfortunately, that notion may be tarnished by the misfortune of not finding a clinical site. In some instances, unwarranted cancelations by a preceptor occur each time leaving the pupil to hastily find another preceptor. Consequently, if the student is unable to obtain a new preceptor their graduation is postponed for months or sometimes years.

With advent of online advanced nursing education the demand for preceptors has skyrocketed. Many students spend months calling around for a preceptor to no avail. Plenty of primary care clinics are, booked full of students, a year or two in advance. To offset the demand some practices and health care practitioners have begun charging students for time spent precepting in their clinics. Thus, herein lies “an elephant in the room”, is it ethical for clinics to require payment for nursing practicums? Sadly, there is no straightforward answer to this question; yet among students there are two schools of thought.

One school of thought: “It’s unethical to pay for a clinical rotation. Why would I pay for something that a person should do out of the goodness of their heart.”

Central to any health profession is service. This act of unselfish kindness and generosity bears meaning to one’s career and, above all, sustain and dignify the future of others. In this instance, a pupil in need of mentoring isn’t too lowly for the time and attention necessitating growth. Unselfish service is marked by giving freely without expecting anything in return, as explained within an excerpt from the Hippocratic Oath, “To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract…..”

Second school of thought: “You’re paying for your education just as you would in a classroom environment.”

Some clinics are charging a minimum of $200 per week for a practicum experience. Which translates into $1600 – $2000 for an eight to ten week session. However, not all clinical sites are created equally. Some preceptors allow the pupils to independently see patients and afterwards they confer to execute a treatment plan for the individuals. Alternatively, other preceptors adopt a “hands off” approach and throw the student “out to the wolves” with little to no experience. How can schools of nursing solve this burgeoning problem?  

Graduate nursing clinical rotations should be regulated by an accreditation body such as the Commission on Collegiate Nursing Education (CCNE). Program effectiveness, assessment and achievement of program outcomes are addressed within CCNE’s Standards for Accreditation.  Presumptive regulation of graduate nursing clinical sites should be addressed under section IV – B, “program completion rates demonstrate program effectiveness”. How effective is the nursing program if students are not graduating due to sparse clinical sites? The school of nursing should be held accountable to help their students find practicum placement. If a large percentage of pupils are unable to complete the program of study due to insufficient assistance with securing a preceptor, a mandate should be placed upon the school of nursing to provide a written explanation and analysis along with a plan of action for improvement before re-accreditation is approved for the graduate nursing program.




“Agent of Change: A Push for Legislation to Protect the Healthcare Provider”

“Agent of Change: A Push for Legislation to Protect the Healthcare Provider”

Lateral violence is defined as a set of destructive behaviors occurring between colleagues intended to humiliate, offend or cause distress. It has been noted, the Mother of Modern Nursing, Florence Nightingale’s caustic manner towards nurses of lower social class during the Crimean War planted the seeds for lateral violence to take root in present – day nursing culture. Nightingale’s sarcastic nature throughout her 1859 book “Notes in Nursing” set the tone for the prevailing incivility between nurses.

Many healthcare organizations have attempted to abolish this problem of lateral violence with various strategies such as education or organizational leadership. However, based upon the sheer volume of articles published in reference to lateral violence, these methods are not solving this dilemma. Complicating matters, most United States legislators consider lateral violence an organizational problem instead of an issue which should be addressed legislatively. The U.S. is the last of the developed nations to initiate mandates outlawing lateral violence within the workplace. Internationally, seven countries have instituted anti workplace bullying statues.

The Australian state of Victoria enacted Brodie’s law in June 2011. Brodie’s law became the world’s first anti – bullying law to criminalize bullying. This law was named for Ms. Panlock, a 19 year old waitress who was tormented by three older coworkers. During her employment, Ms. Panlock was called, “fat, stupid, ugly, and a whore.” Also, Brodie’s tormenters physically restrained her in order to pour beer, oil, and fish sauce on her. Consequently, the abuse was intolerable for Ms. Panlock, she committed suicide in September 2006. ‘Brodie’s law makes it unlawful to make “threats to the victim”, to use or perform or direct towards the victim, “abusing or offending” words or acts. Also punishable is acting “in any other way that could be reasonably be expected to cause physical or mental harm…” Mental harm is defined as psychological harm or suicidal thoughts’ (Victoria State Government, 2016).

Within the healthcare spectrum, suicide due to lateral violence is a sobering reality. The continual stress of being bullied has caused some nurses to commit suicide. As result of vicious name-calling when transferred to a new unit, Mrs. Gettins, a 50 year old English nurse committed suicide by hanging in 2010. The Workplace Institute conducted a survey in 2012 of which indicated that 29% of bullying victims contemplated suicide, and 16% had a plan in place for carrying it out. Armed with these disturbing facts the author poses an important question, “Should the perpetrator be convicted of murder if their acts of bullying drive a person to commit suicide?” This an important question to address. The answer is yes.  Unfortunately, stateside, anti – bullying statues contain vague or minimal language in reference to specific ramifications of bullying. Degree of punishment is usually left up to the institution.  One way healthcare providers can address this is the act of petitioning local legislators to expand existing anti – bullying laws to accommodate healthcare providers. In my home state of Georgia, there are six anti – bullying laws. However, all of these laws are centered on education not healthcare. To give practitioners much needed legal protection against workplace bullying simply requires a language change to include healthcare providers. Also, the proposed expansion of existing anti – bullying statues must incorporate clear, concise language detailing consequences of lateral violence.

 Another method of addressing this dilemma is organizing a grassroots campaign. The aim is to create awareness regarding the importance of instituting state and federal laws to protect healthcare providers from the negative effects of an unhealthy work environment. The Healthy Workplace Campaign was created by Dr. Gary Namie in 2001 to lobby for anti – bullying statues across the United States. To date, the Healthy Workplace Campaign has introduced the Healthy Workplace Bill in 29 states. Currently, none of the 29 states have passed this bill into law.


Victoria State Government. (February, 2016). Criminal Law. Retrieved April 20th, 2016, from http://www.justice.vic.gov.au/home/justice+system/laws+and+regulation/criminal+law/





“No Bullying Zone”: Cultivating a Fair and Just Nursing Culture

“No Bullying Zone”: Cultivating a Fair and Just Nursing Culture

Lateral violence is pervasive throughout all levels of nursing. Workplace bullying and lateral violence are interchangeable terms to describe nurse to nurse bullying. The American Nurses Association (ANA) defines lateral violence as, “acts that occur between colleagues.” Similarly, the ANA describes bullying as, “acts perpetrated by one in a higher level of authority and occur over time.” There are many reports of how lateral violence effects the individual from an emotional and psychological standpoint. The occurrence of increased staff turnover resulting from workplace bullying lessens the productivity of a healthcare organization. Armed with this information, we as healthcare providers should recognize events of lateral violence must end in order to promote a professional nursing atmosphere of mutual respect and professional growth.  

One may ask, how we can cultivate a fair and just nursing culture within the walls of our institution. Unfortunately, there are no clear – cut solutions. However, there are several methods that have helped individuals and organizations alike to promote healing after an incident and/or prevent subsequent occurrences of lateral violence. Conflict resolution techniques may help the bullying perpetrator to recognize their behavior. Role playing and open communication are conflict resolution techniques most often used in the professional setting.

When two individuals are communicating openly they have created an open dialogue for mutual exchanges of ideas and perceptions. Open communication may be unsuccessful if trust is not apparent from both parties. Role-playing takes place between two or more people, who act out roles to explore a particular scenario. The bullying perpetrator and victim may act out an alleged incident of lateral violence. The hope is the perpetrator would gain a sense of clarity and empathy by placing themselves in the role of victim.  While using conflict resolution techniques to solve a problem remember to keep an open mind and discuss solutions respectfully when conflict arises. It is ok to disagree; yet it is important to maintain a spirit of cordial relations amongst colleagues who have offended you. Retaining a positive attitude after a devastating encounter with an associate will improve your self – esteem and is the first step to cultivating a fair and just nursing culture.