On one hand, Tom Daschle appeared to be an excellent prospect to head up Barack Obama’s health care reform plans as Secretary of Health and Human Services.  The health care town meetings initiated by Daschle on behalf of the Obama administration were well organized, thoughtful, and provided the opportunity for people to share their experiences and ideas about changes in our health care system.   As the author of the book, Critical: What We Can Do About the Health Care Crisis, Tom Daschle also appears to be an informed, insightful, and well-spoken advocate of the need for health care reform.  In addition to clearly stating the problem of health care in the United States, Daschle’s book reasonably suggests the creation of a Federal Health Board as part of his concept of health care reform.  While all of these elements are promising signs of Tom Daschle’s ability to head reform efforts and set the tone of the discussion in a fact-based, rational, and inclusive manner, recent events in his confirmation process show that there is something to be desired about Tom Daschle.

In the last few days confirmation procedures have revealed that Daschle failed to pay taxes on some of his income and received payment for speaking engagements from some health care industry groups such as the Health Industry Distributors Association and America’s Health Insurance Plans.  In addition, Daschle served as an advisor for a law and lobbying firm that worked on behalf of powerful health care industry interests.  Even though Daschle was not officially a lobbyist, he did advise the health care industry clients on behalf of the firm according to Politico.com.

Given these recent revelations, it is reasonable for advocates of health reform to ask some hard questions about the two faces of Tom Daschle.  On one hand, he presents the image of a man who is knowledgeable and poised to serve the interests of the people.  On the other hand, recent disclosures by Daschle in the confirmation process also present us with the image of a man who earned some of his annual 5.3 million dollar income from services rendered to big corporate health care groups whose interests are unlikely to represent needs of the people.  While campaigning, Barack Obama asked the people who supported his presidency to hold him accountable to make change in Washington.  While no proposed cabinet member will be  perfect, it is time to ask some hard questions about Tom Daschle’s ability to serve in this role effectively.   If Washington is so riddled with politicians who have crossed the line and skirted lobbyist ethics, Obama needs to realize that such individuals will not ultimately supported by  the people who demanded reform and cast their vote for Obama in November.  Daschle is undoubtedly an intelligent capable man, but he is also a wealthy man who was paid for his services to health care industry groups by a lobbying firm.

As the economic crisis worsens, so too goes the health care crisis.  The  need for effective health care reform has only been heightened by recent job loss that leaves more Americans uninsured.  There are many educated, knowledgeable citizens who would be able to steer efforts for reform without the taint of past compensation by lobbyists or failure to pay taxes.  Those  individuals may not be connected, Washington insiders.  While there is arguably a benefit to appointing cabinet members who know the system, at some point we may be faced with the reality that change will only truly be realized by those who can operate outside the system.    Daschle has presented a vision for health care reform in his book and by his town hall efforts that make his financial disclosures regrettable.  Unfortunately for Tom Daschle, his income from sources in the industry make him a less trustworthy representative of what every day Americans need in terms of health care reform.

This could be a case of right ideas, wrong man for the job.

If you are working as a nurse and you are a mother, you have unique challenges: finding day care to cover a 12-hour shift, taking time to pump breastmilk for your baby while at work, dealing with the emotional stress of your job in a healthy way, and working holidays/weekends/nights. As nurses, we are fortunate to have many different options of when we work to help us plan and manage our children’s needs.

On the other hand, we lack a certain degree of flexibility. Calling in sick makes us feel guilty, and the nursing shortage leaves floors understaffed when nurses are unable to work. Our shifts start and end at precise times and the system affords little alteration to the schedule once it comes out. When things come up in our lives, we may rely more on our partners and extended family networks to get our children where they need to be. While each profession has unique challenges for working mothers, being in a profession that is predominantly women has a particular set of problems for implementing solutions to the work/life balance conundrum.

The nomination of Sarah Palin for the Vice-Presidency of the United States as John McCain’s running mate has been the subject of considerable water cooler and playground discussions among women in all professions. Since many nurses are also working mothers, I feel it is appropriate to look at these discussions and what those discussions tell us about the state of Feminism today.

Sarah Palin is the governor of Alaska, and a mother of five, including a four-month old with Trisomy 21. Her nomination has evoked conflicting sentiments for many women. On one hand, many women recognize that the nomination is another significant milestone for women in politics and that any criticism of her as a mother because of the demands of her career are signs of a serious problem with the central tenets of Feminism. Privately many women are asking themselves how Palin can take on the Vice-Presidency, a 4 month-old with special needs, a son going to Iraq, a pregnant teen, and two other children. Publicly, all women who believe in gender equality say her role as a mother does not alter her ability to be Vice-President and vice-versa. Women have also publicly noted that there is not such controversy about male politicians balancing work and home.

The public versus private dichotomy of feeling about Palin’s ability to fill both roles successfully is a reflection of the general feeling that women have in their own lives about being working mothers. For many, the ideals of Feminism that sold us on equality failed to account for the demands of motherhood.

Motherhood is a demanding career, and there have been several studies that indicate the working mothers still perform the majority of household and childrearing responsibilities even while working high-power jobs. The reality of women’s experience as working mothers is that they often feel they are not as successful as they would like to be in their careers or as mothers. I think much of the ambivalence about Palin is fueled by confusion.

Many women are genuinely unsure of exactly HOW Palin can perform two 24 hour a day, seven day a week jobs when one of them includes travel all over the world. They want to know what her secret is, because they have struggled to integrate work and mothering. With Palin’s voice about this issue absent in the campaign, women quietly feel that she must not be that successful at it.

Feminism sells us on the idea that we can do everything and be everything. Once we have children, we realize there are choices to be made about work, home, co-parenting and some things are sacrificed. While we all may make different sacrifices in this process, most women probably feel they sacrificed in their career, at home, or in both from time to time. I personally feel disillusioned with Feminism because I once believed I could do everything perfectly. Once I had my daughter I realized that being a mother was enough work that I felt I had to slow down in my career to get through babyhood.

Without question I felt meeting my daughter’s needs was my primary concern. While I still plan my career, I do feel that I placed it on hold to be the mother I wanted to be. When I see Sarah Palin seemingly manage motherhood and a career in politics without compromise, I feel a little like a failure for feeling that I couldn’t. If it is possible to be a mother of five and the Vice-President without making sacrifices that will negatively affect career or family, I want to know Palin’s secret. For now, I resent the campaign for selling the image of the mom who can do everything and never break a sweat, especially if the reality is that Palin sacrificed, worried, and felt a fear of utter failure just like so many other working mothers.

One of my first jobs out of nursing school was in Louisiana in a busy pediatric Emergency Room. We had very few resources and were very busy. For our whole 36-bed unit, we had two monitors and they were at least 42 inches square. They were so old, they did not print rhythm strips. One day I was standing at the bedside of a congenital heart patient and noticed two things: the patient was having PVC’s and periodic oxygen desaturation down to 50%. The monitor never alarmed. There was also no central monitoring station, so if you put a patient on the monitor you had to watch it all the time at the bedside to see what was going on.

We started realizing that they never alarmed. Given how short-staffed we were standing at the bedside watching heart rates and oxygen saturation levels on patients that were not so ill they needed constant care was not feasible. This, along with several other perceived patient safety issues prompted me to organize the nurses. We wrote a letter outlining our concerns for patient safety and requesting a meeting with hospital administrators to present possible solutions. All the nurses signed it, doctors also looked at it and voiced their support. We sent it to the top nursing administrator and copied the CEO, all the Vice presidents, and the president of the Board of Trustees.

Now this was New Orleans, and if you are not familiar with the “laissez le bon temps roulez” culture let me just say that in general, New Orleans is not known for being a culture of progressive change or process improvement. Needless to say, the nurses worked to create ideas for how to improve problems with staffing, suggested purchasing monitors and a central monitoring system, and looking at procedures for triage. We presented to the nursing administration and waited.

Shortly after the presentation, they tried to discipline me for poor clinical judgement for something that was completely bogus. Knowing they didn’t have a leg to stand on given my level of documentation, I asked them to put their concerns in writing so that I could respond appropriately, rather than calling me into meeting where they threatened and questioned my judgment. Needless to say, my documentation saved me and they never substantiated their claims or put anything in writing.

I felt that they were punishing me for organizing the staff, spearheading the letter and the presentation. I was so discouraged since I had tried so hard to make sure everything we did focused on illuminating the problem while providing positive suggestions for nurse-led improvement efforts. The intention of our work had always been about patient safety and I could not understand why they rejected me.

On the up side, 12 new monitors were purchased and the unit was wired for a central monitoring telemetry station. It took 8 months for that to be installed, and in that time, I was so depressed and discouraged that I left New Orleans (about 4 months before Hurricane Katrina).

5 years after those efforts, I ran into a nurse in Georgia from that pediatric E.D. in New Orleans. We talked about the hospital where we work now and how there are so many resources compared to where we worked previously. Where we work now seems posh and luxurious with great staffing ratios, all the best equipment, social work support, child life, etc. I told her that I had been so discouraged by how the treated me there after we did the presentation, but now that I had been away I felt as though we had done much good for the patients we served even without any resources.

She understood and said, “If you hadn’t done that, we never would have gotten any of that equipment, and we’d still be working with two monitors. They would still have nothing, at least we got what we got.” All these years, I felt like I had failed to make a difference there. Now, through her eyes I saw that I had made a difference. I may have paid a price for my actions, but I feel now that a purpose was served and change happened even though it took five years for me to see the result.

I was surprised when I returned to graduate school in nursing after 6 years at the bedside to find that my classmates were often fresh out of undergraduate nursing school with no work experience. Aside from feeling like an old lady, I wondered how they would define the nurse practitioner role without having worked as Registered Nurses. In addition, I felt that my experience shaped my desire to work as a nurse practitioner and gave me a strong background in basic assessment and treatment.

The biggest thing that I learned working as a nurse was just how much I didn’t know. And that was a good thing, because I learned that I needed to ask a lot of questions. I also learned that being aware of the limits of your knowledge made you a great nurse. Sometimes I still drive my coworkers crazy with questions about orders, medications, and treatments. But the truth is that there is so much that is not taught in school. Even if one works their whole life at the bedside, one will still not know everything. That is why you have to be able to think critically and ask questions to be an excellent nurse. It is not always what you know that makes you excellent, it is asking about the things you do not know.

Bedside nursing is hard work and many people who choose nursing as a career do not want to do bedside nursing. I understand that, but sometimes my fellow students seem to think they know everything they need to know. Sometimes a lack of respect for experience comes across. I think it is unintentional, but it sure ruffles my feathers. This is what was innocently said to me one day: “I think it will be harder for you to be a nurse practitioner because you will not be able to break out of your RN mindset. Since I never worked as an RN, I will not have that problem and will adapt better to the Nurse Practitioner role.”

We had some nurse executives speak to our class about leadership, ethics, and other current issues in nursing. One student expressed frustration that no one wanted to hire her as an advanced practice nurse because she did not have any nursing experience. She wanted to know why so many employers wanted experience when she felt her education gave her all the qualifications necessary to do the job.  This individual felt that as a nurse practitioner there was no difference in skill between herself and people who have worked previously as registered nurses.  The nurse leaders responded by saying they understood her frustration, but that in advanced nursing roles one needs credibility and that credibility comes from experience.

The ripple of ghastly exclamations practically reverberated through the class. While I empathize with my classmates’ frustrations, I do see the credibility issue present in nursing today. I think there should be opportunities for people who go straight through undergraduate to graduate programs. On the other hand, my experience working also indicates that many registered nurses are very aware of nurse practitioner experience levels. Many nurses say that they can see a big difference between the skills of nurse practitioners who have worked at the bedside and those who have not. I’ve heard nurses who feel that experience at the bedside makes nurse practitioners better also say that it doesn’t take many years of experience to make the difference. One or two years working as a nurse is usually enough for them to see increased competency in nurse practitioners. Whether all nurses agree with that in an idealistic sense, that reality of the credibility conundrum exists. Credibility from experience matters to many nurses and prospective employers. There are many new graduate nurse practitioners who will demonstrate advanced critical thinking skills despite less direct care experience. On the flip side, there are many experienced Registered Nurses who will struggle with the demands of advanced practice nursing. Even with this in mind there is a credibility issue that a lack of experience presents in many clinical settings.

This issue is magnified when new nurse practitioners with no nursing experience do not seem to understand the value of experience.  To express frustration with the challenge of finding a job is one thing, but to state that there is no difference between yourself and a new nurse practitioner with years of experience is another matter.  At times this failure to understand and respect that credibility from experience can be misconstrued as arrogance by other health care providers.

Even if you choose not to get experience before obtaining an advanced degree, I would encourage you to think about the importance of respecting experience. Recognizing that nurses with experience might know and understand things that you do not will go a long way towards those nurses wanting to work with you.  they will also give you respect for knowing the boundaries of your own experience and not equating education with experience.

Which Comes First, Health Care Cost Containment or Access:

Comparing the Health Plan Policies of John McCain and Barack Obama

Either John McCain or Barack Obama will become the next president of the United States in January 2009. According to a recent poll by the Kaiser Family Foundation, “one in four Americans cite paying for health care as a serious problem.” (Kaiser Family Foundation, 2008) Beyond the challenges of American individuals struggling to manage rising health care costs, insurance companies, hospitals, and employers continue to adapt their policies to attempt to decrease the economic burdens of health care. As these stakeholders have responded to rising costs by attempting to shift the cost burden to other stakeholders, the burden that is shifted back on the individual has contributed to increases in the number of uninsured Americans. The recent economic downturn and associated rise in the unemployment rate is associated with an increase in the number of uninsured individuals by a factor of 1.1 million new uninsured for every 1% rise in the unemployment rate. (Kaiser Family Foundation, 2008) The presidential candidates have both articulated health care plans and policies that address health care reform in terms of cost, quality, and access to varying degrees.

Barack Obama and John McCain’s foundational philosophies about health care reform are vastly different. Where Barack Obama aims to reform health care and create affordable, quality health insurance accessible to all Americans, John McCain’s approach is to reform health care by focusing on cost containment measures that will be market driven. While Obama does not articulate his plan as a plan for universal health care, the idea that health care is a human right appears to be the foundation of his plan. Obama’s rhetoric focuses on increasing access through increasing the role of the government in providing insurance along with investments in research, technology, and public health. McCain articulates a philosophy of change that emphasizes shifting control of the system to the individual consumer. In McCain’s health care reform paradigm, shifting control and cost burden to the individual consumer will optimize cost containment. According to McCain’s plan, the notion of moral hazard in our current health care system, where the consumer is shielded from the cost and therefore has no incentive to be cautious in their utilization of services, is a contributor to rising healthcare costs. In comparing the underlying principles without reference to the specifics, one must evaluate whether reform of health care is best accomplished by increasing access or containing costs first. Where Obama’s plan lacks clarity on cost containment, McCain’s plan does not significantly address the issue of access. In terms of the many details of their plans for increasing quality, the candidates are in agreement.

Access

The road to increasing access to insurance for all people is clearly defined in Barack Obama’s plan. Obama’s plan will create a national health plan that people who do not have access to insurance through their employer, cannot afford private insurance, or have not been eligible for coverage can purchase. Obama’s outline indicates that all premiums, co-pays, and deductibles will be “affordable.” According to the outline, those individuals who do not qualify for Medicaid or SCHIP but cannot afford the premiums of the national plan will be eligible for subsidies to offset individual costs. Other aspects of Obama’s plan that are designed to increase access include expansion of eligibility for Medicaid and SCHIP, mandatory coverage for children, creation of the National Health Insurance Exchange as a means of regulating the private insurance market, and inclusion of portability as a component of the national health plan.

While Obama’s plan does not mandate coverage for adults, it does appear that more Americans would have access to insurance through the creation of the national health insurance plan. One area that seems unclear is how well the subsidies would offset costs for families that would qualify. Obama does not dismantle the private insurance system, but would require employers to either provide insurance or contribute towards the costs of the national health insurance plan. The integration of public and private insurance under Obama’s plan makes it appealing, and less likely to evoke strong resistance on the part of big business than a true universal health care plan. In terms of access, Obama’s plan appears to be a true reform, but the implications of this plan for cost control in health care are problematic.

McCain contrasts sharply with Obama over the issue of increasing access to healthcare for Americans, though he has never articulated commitment to universal health care. McCain’s plan does state that they will make insurance more available to individual Americans by lowering costs and increasing portability. According to his outline, he will use tax credits to make insurance more affordable. He will eliminate the employer tax exemption on health care and provide families with direct tax credits they can use to pay for insurance. The idea here is that families will search for the lowest cost plans and this will drive competition in the industry. Employer-based plans are still an option, though. Bob Lazewski has analyzed McCain’s plan and notes, “With the average cost of employer-provided family health insurance at $12,000 a year, a $5,000 tax credit will often come up way short—especially for higher age people and those who don’t have the benefit of an employer contribution.” (Lazewski, 2008) In addition, if an employer pays a portion of the costs, families would now pay taxes on that benefit. In this sense, McCain’s tenet is that he will make health insurance more affordable, which will give more people access. The challenge here is that it is not clear who will benefit from this plan. It depends on how much one earns and the ability to find coverage. (Kaiser Family Foundation, 2008) In addition, there is no requirement of coverage. The McCain plan also emphasizes the use of Heath Savings Accounts, national plans that are portable, and a Guaranteed Access Plan for people who are otherwise ineligible for insurance. The mechanism of the GAP is not well-defined.

McCain’s plan may make health insurance more affordable for some, but the shift from the employer-based system to an individual purchaser system will undoubtedly be a bumpy road. The plan does not address how the uninsured poor will have more access to insurance, especially since the degree to which the costs will be driven down is unknown.

Cost

McCain’s plan is rooted in cost containment. In this sense, his plan does not require significant new expenditures that need to be funded by tax increases. His tax credit will essentially be funded by ending the tax exemption on health insurance benefits. Looking at how his plan impacts stakeholders, it appears as though his plan to drive down costs through competition would decrease costs for some stakeholders to some extent. By placing the burden on individuals, there would be some relief of cost burden for employers who may stop providing insurance and subsidize their employees’ individual purchases. At the same time, McCain’s plan does not articulate a clear mechanism to deal with the impact of the uninsured on hospitals and providers, who then pass the cost of providing care of the uninsured to private insurers. Unless there is flow of new capital into the system by way of more purchasers of insurance or some other means, the cost burden on the private insurers may increase, and then increase costs to individuals whose salaries do not rise at an equal rate. McCain does articulate other cost containment strategies such as: lowering drug prices through reimportation and increased generic availability, emphasizing preventive care and disease management strategies, greater use of information technology as a cost-saving measure, increased use of walk-in clinics in retail outlets, tort reform, and Medicaid and Medicare payment reform. In terms of cost containment, McCain’s plan does have a cost benefit in so far as the implementation of the plan will not produce significant new government expenditure; however, it does not clearly articulate who will have lower heath care costs and to what extent the costs will be lower. The extent to which low-income uninsured will benefit from tax credits depends on several specific details about tax credits that are not stated in McCain’s Plan. (Kaiser Network, 2001) McCain’s plan also does not demonstrate that the cost containment strategies he will implement will be equal or greater to the cost burden of 47 million uninsured on the system.

With respect to cost, Obama’s plan requires extensive government spending to be implemented, estimated at 50 to 65 billion dollars per year according to his campaign website. This cost will be passed on to individuals through the repealing of Bush’s tax cuts. In all fairness, those tax cuts have been noted to primarily benefit the wealthiest Americans. Essentially his plan will infuse cash into the system that will cover many uninsured and increase the number of insured. On the other hand, his other cost containment strategies are not well-defined and are similar to the McCain plan. Obama’s plan also emphasizes cost control through use of information technology and lower drug costs, though he does briefly discuss regulation of unjustified price increases by big business. Ultimately, if the cost of health care itself cannot be reduced through decreased utilization of the system and reduction of administrative costs, covering the uninsured will not be feasible in the long run with tax increases. The bottom line is that Obama’s plan will cover the uninsured which will help reduce the cost burden on hospitals, providers, private insurance companies, and the privately insured, but does not provide well-articulated strategies for controlling costs within the system.

Quality

There are few significant differences between Obama and McCain’s ideas about improving the quality of health care aside from the implications of access or as quality indicators. Both support initiative for preventive care, public health, research, increased use of information technology, and federally supported outcome measurement initiatives. Obama provides more specific examples of the types of quality initiatives he supports, but they are really not espousing vastly different quality improvement strategies other than the ways they relate reform of access and cost issues to issues of quality in health care.

Nurse Practitioners and the McCain and Obama Plans

McCain is the only candidate that gives some reference to utilization of nurse practitioners as a mechanism of improving access and quality when he discusses the use of walk-in and retail clinics, though he does not explicitly state that nurse practitioners constitute a component of the approach. The physician lobby is fairly powerful and both candidates are most likely aware that if they want support of their plans, they will need the blessing of the physician lobby. Even though increased use of nurse practitioners as providers has the potential to decrease costs for Medicare, Medicaid, and the insurance companies, McCain and Obama are not likely to state this in their plans.

Obama’s plan has potential to impact Nurse Practitioners favorably by virtue of increasing the flow of revenue into the system in the form of more insured patients. If nurse practitioners can position themselves as lower cost yet effective providers, they have the opportunity to create jobs for more nurse practitioners and have more money flowing into their pockets. Many nurse practitioners feel that the health of the population is adversely affected by the number of uninsured individuals.

Conclusion

While the lack of cost containment policies in Barack Obama’s plan is a concern, the expanded access that it will provide to uninsured Americans makes it a better plan than John McCain’s plan. I do not think the shift towards a consumer driven insurance market is going to aid the uninsured or be a real cost containment measure unless the shift is coupled to heavy regulation of the insurance industry. Given John McCain’s principles, it is unlikely that he would support increased regulation. Even though Obama’s plan is more costly, I support the repeal of the Bush tax cuts to pay for it and also believe that decreasing the numbers of uninsured will serve as a cost containment measure. Once access is expended, efforts to contain costs can be more focused and refined with the removal of the financial cost of caring for the uninsured. Without expanding access, I do not believe costs will be contained. While expanding access has a cost, it is a cost that also serves the health of the population, which is important. I also happen to support the idea that health care is a human right. Given the current state of the economy, I fear that McCain’s plan will only increase the numbers of uninsured as individuals struggling to make ends meet will be forced to use any tax credits to offset other necessary costs. If that were to happen, the cost burden could continue to be shifted back on the insured anyway. In do not believe the net cost effect on the average insured American differs that greatly between the two candidate health plans. While we may pay in the form of taxes for Obama’s plan, I believe McCain’s plan will probably cost us some employer-provided benefits that will not be made up by increased wages as well us cause increases in hospital costs to cover the uninsured. By failing to address the access issue for uninsured Americans, I believe hospitals and private insurance companies will continue to deflect the cost of care to the uninsured onto the privately insured. The costs associated with either plan are essentially equal in that I believe any health reform will cost me. But my belief that health care is a human right leads me to support Obama’s plan.

References

1. Bodenheimer, T. S. & Grumbach. (2005). Understanding health policy: A clinical approach. Stanford, CT: Appleton& Lange.

2. Kaiser Family Foundation (2008) New Analysis Shows Effect of Rising Unemployment on Health Coverage, Medicaid and SCHIP Spending and Enrollment. Retrieved on 7/13/08 from http://www.kff.org/medicaid/kcmu042808pkg.cfm

3. Kaiser Family Foundation (2008) Tax Subsidies for Health Insurance: An Issue Brief. Retrieved on 7/16/08 from http://www.kff.org/insurance/upload/7779.pdf

4. Kaiser Network. (2001) Presentation Transcript from 4/6/2001: A Briefing on Extending Health Coverage- Tax Credits, Public Program Expansion and Combination Approaches. Retrieved on 7/17/08 from http://www.kaisernetwork.org/health_cast/uploaded_files/kff040601.pdf

5. Lazewski, Bob. (2008) A Detailed Analysis of Senator John McCains’s Health Care Reform Plan. Retrived on 7/12/08 from http://healthpolicyandmarket.blogspot.com/search/label/McCain%20Health%20Plan%20Analysis

6. McCain, John. (2008) Straight talk on health Care System Reform. Retrieved on 7/10/08 from http://www.johnmccain.com/Informing/Issues/19BA2F1C-C03F-4AC2-8CD5-5CF2EDB527CF.htm

7. Obama, Barack. (2008) Plan for a healthy America. Retrieved on 7/10/08 from http://www.barackobama.com/issues/healthcare/

This essay originally written for my advanced practice nursing class on Health Policy and Finance July 23, 2008 at Emory University.

Most nurses are female. Given that women have babies it is reasonable to think that many nurses will have a baby or two at some point in their career. It would seem to make sense that the Nursing profession would be very supportive of women and the challenges of being a working mother, right?

Before I had my baby, I always supported the mothers I worked with by covering their patients while they pumped if they were breastfeeding or by letting them leave if they had a sick child or some other childcare issue. Since I had my first child, I have been supported by my colleagues in turn, but realized just how systematically unfriendly the nursing profession can be to working mothers.

When it came to pumping breastmilk while at work, I found that we were often so short staffed that pumping had to be delayed to the point that my milk supply and ability to provide milk for my baby was compromised. As supportive as my colleagues were, they had to assume care of lll my patients for 15 minutes every three hours so I could do this.

Furthermore, there was no physical place for me to pump. I had to search for an empty hospital room, occupy the bathroom, or hope some administrator with an office was not at work that day. When I did pump in a patient room, I prayed no one would ignore the sign on the door and come in.

When it came to juggling childcare, as a part-time employee it was not practical or economically feasible for me to have full time day care, as a result I needed a basically set schedule in order to be able to work and have child care. My manager told me that I needed to have complete availability and she was not able to accommodate my child care schedule. In the preceding 6 months I was one of the highest rated nurses in the department by this same manager. In addition, several working mother had vacated their positions because their child care needs limited their availability on certain days of the week. This was very difficult for all of us because we all loved our jobs and had been as flexible as humanly possible. At the same time, we were replaced by younger models with no children and a lot less experience.

I understand how difficult making a schedule can be when people have limitations, but the nursing shortage will only worsen if attempts to work with the needs of working parents are not included in our strategy for retaining nurses. I had even found a nurse who would job share with me so we could each work set days of the week, but that was not enough for the administrators. I attempted to have complete availability for a while, but I was spending so much time trying to juggle my schedule and have make sure I had childcare. In addition, my manager would release the schedule about a week before it started and coordinating child care at the last minute is near impossible. So I gave up my part-time job in favor of part-time PNP school and working PRN. I have a set schedule and child care but miss my job and they have a job vacancy it will take them months to fill.