DiversityNursing Blog

Nursing Specializations

Posted by Pat Magrath

Tue, Aug 23, 2016 @ 10:39 AM

870423026.jpgIf you are a Nursing student wondering what Specialty is right for you, please read on. Perhaps you’re an Experienced Nurse thinking about changing your area of focus. If so, this article is for you too. We hope you find it helpful!

The nursing profession has evolved considerably over the last century, including the introduction of specializations for nurses, with specific knowledge and experience to practice in certain fields. There are now many possible areas that a nurse may choose to specialize in, and these continue to grow.

Some of these are covered in more detail below, although there are more beyond this list.

Advanced Practice Registered Nursing

Advanced practice registered nurses have acquired more advanced skills and knowledge through a master’s degree program, in addition to the undergraduate degree to become a registered nurse.

This extended training distinguishes them from other nurses and they often go on to work as a clinical nurse specialist (CNS), nurse practitioner (NP), nurse anesthetist (CNA), or certified nurse-midwife.



Ambulatory Care Nursing

Ambulatory care nurses provide health services to patients directly in an environment outside of a hospital, wherever it is required. They are responsible for following treatment plans for acute conditions, monitoring signs, communicating with the patient and their family, and promoting overall patient health.



Cardiac Nursing

Cardiac nurses care for patients with cardiovascular disease or health problems related to the heart and have specialized knowledge in this area. They are responsible for monitoring signs, treating symptoms, addressing clinical needs, and providing relevant support and education to the patient and their family.



Case Management Nurse

Case management nurse care for patients who require ongoing support and work to develop and implement a treatment plan that aims to stabilize health and minimize hospitalization.



Critical Care Nursing

Critical care nurses work with patients who are critically ill or injured and require close monitoring and care. They are responsible for looking after patients with potentially fatal conditions and following the treatment care plan for the best outcomes.



Dialysis Nursing

Dialysis nurses care for patients who require dialysis as part of their treatment plan, such as those with kidney disease. They are responsible for monitoring signs and progress, administering medications, and providing support and advice to patients throughout the process. They may work in a hospital, clinic, or provide in-home care.

Genetics Nursing

Genetic nurses care for patients with a genetic disease and have in-depth knowledge about the role of genetic in the pathology of these conditions. They are responsible for conducting family risk assessments, analyzing genetic data, researching genetic diseases, and providing support to affected individuals and families.

Geriatric Nursing

Geriatric nurses care for elderly patients and have a thorough understanding of the health and treatment of conditions that commonly affect the elderly. Geriatric nurses often specialize further, to care for elderly patients with a specific health condition.

Mental Health Nursing

Mental health nurses, also known as psychiatric nurses, care for patients with mental health, psychiatric, or behavioral disorders. They help to provide support to these patients and their families while they recover.

Neonatal Nursing

Neonatal nurses care for young infants in the first few weeks of their life and have specialized knowledge about how to take care of infants and the conditions that may affect them.

Oncology Nursing

Oncology nurses care for patients who have cancer. They help in the treatment and monitoring of the disease, in addition to providing support and education to patients and their families.

Pediatric Nursing

Pediatric nurses care for young children and their families. They have specialized knowledge about the function of young bodies and the health conditions that may affect them and assist in the diagnosis, treatment, and monitoring of these patients.

Other Specializations

There are many possible fields that a nurse may choose to specialize in, including:

  • Gastroenterology nursing
  • Holistic nursing
  • Medical-surgical nursing
  • Midwifery nursing
  • Neuroscience nursing
  • Obstetrical nursing
  • Occupational health nursing
  • Orthopedic nursing
  • Ostomy nursing


Have questions about changing your area of focus or maybe you have a general question, just ask one of our Nurse Leaders. 
Click Here To Ask Question

Topics: nursing specialty

The Human Side of Cancer Treatment

Posted by Erica Bettencourt

Mon, Aug 22, 2016 @ 02:42 PM

HM_0817_sm.jpgYou must take the time to read this article! If ever there was a tribute to Nurses, this is it! This story is written by an oncology patient who pays wonderful tribute to many Nurses, but also a particular Nurse who took care of her and helped her get through her surgeries and treatments. I think most patients feel this way about the Nurses that take care of them. They don’t always show their appreciation, but this patient took the time to write about her experience. I hope this will make your day.

RELATIONSHIPS WITH NURSES can stick with patients for the rest of their lives. From nurses, I learned the power of accompaniment. One held my hand as I uncontrollably teared up before port surgery. Another nurse on the oncology floor, when she found out that my husband and I had been married two weeks before I had checked into the hospital, made me a pillow adorned with our wedding pictures. Another shaved my head for me when my hair started falling out at an unsightly pace. A patient-care technician—what used to be called a nursing assistant—held me while I threw up in the bathroom after a two-hour MRI.

Though I don’t like to remember these things, I feel deep gratitude for the nurses who were there with me during painful and sorrowful days. In Siddhartha Mukherjee’s The Emperor of All Maladies: A Biography of Cancer, he quotes journalist and breast-cancer patient advocate Rose Kushner. “Few doctors in this country seem to be involved with the non-life-threatening side effects of cancer therapy,” Kushner notes. “In the United States, baldness, nausea and vomiting, diarrhea, clogged veins, financial problems, broken marriages, disturbed children, loss of libido, loss of self-esteem, and body image are nurses’ turf.”

Although I respected my oncologists for the important role they played in my cancer treatment, I found the wide and varied “turf” that exceptional nurses cover astounding.

A year ago last May, I was checked into Boston’s Beth Israel Deaconess Medical Center (BIDMC) as a 29-year-old non-Hodgkin lymphoma cancer patient just out of spinal surgery and unsure if I’d be able to walk again. A few days post-surgery, two nurses held me next to my hospital bed to see if I could stand. Although I was frightened, I particularly remember Neely Beaulac, R.N., joking with me in her thick Boston accent while I slowly tried to march in place with feet that moved like cinderblocks. Somehow, I broke into a small smile and laughed as Neely cheered me on.

Nearly a year later, I walk the 1.1 miles to the BIDMC from my apartment, stroll into the ’80s-style lobby, and wait in a herd of visitors to ride the elevators to the upper floors. I had planned to meet Neely after her shift. I wanted to interview her about working as an oncology nurse. But when one of her patients had an allergic reaction to a transfusion, she asked if we could meet at the outpatient clinic instead in order to be nearby in case her patient needed her.

While in the elevator, I remember my own allergic reaction to a transfusion, which made my eyes puff up to the size of bouncy balls. Given the complexity of cancer treatment and the series of patient issues that arise moment to moment, the end of an oncology nurse’s shift can be fluid.

“Sorry to make you come here!” Neely says with an incandescent smile. I greet the other staff I know, and the two of us head to a break room to sit and talk. She puts a small bottle of water in front of me, as she has so many times before.

Neely is in her mid-thirties with clear blue eyes and dark hair. She’s attractive in that cool-girl way that makes you want to know her jokes. When she’s doing her job, she can be efficient and quick but also chatty. She makes her nursing tasks look easy yet precise. She’s the kind of nurse who makes a note of when your IV bag is going to run out so you’re not repeatedly awoken by a beeping apparatus. She’s at home barging into a room to restore order. The blue shirt of her scrubs matches her eyes and is adorned with a flowered nametag and a pin a patient gave her, a take on the Superman insignia.

Neely was born for nursing. She tells me her mother would describe her as bossy, organized, particular, “and just that little bit defiant.” Even as a child, she always liked “to be a little helper.” If she thinks she can help by providing information, she wastes no time telling a patient the truth of the matter. She doesn’t sugarcoat.

Once when a consult team visited my room to inform me of a drug called Lupron, used to protect ovaries during chemo, they called it a quick shot in the arm. Neely’s eyebrows furrowed. As soon as the doctors left, she told me, “It’s not a quick shot in the arm, it’s actually a pretty large shot in the tush.”

But for all her native bossiness and helpful bluntness, she says nursing has changed her: “I’m definitely still organized, but I’m not as uptight, not as intense.” She has become better at listening rather than convincing. When frustrated and overwhelmed patients say they want to stop cancer treatment, not an infrequent occurrence, Neely now tries to hear them out, helping patients feel they have more control and aren’t being bossed around.

“I’ve come to realize that a lot of times people don’t want to just go home and be left alone and die,” she says. “They want treatment. But they just want to hear they can leave if they want to.”

ACCORDING TO THE Bureau of Labor Statistics’ Occupational Outlook Handbook, important qualities for nurses are attention to detail, critical thinking, communication, compassion, emotional stability, organizational skills, and physical stamina. Nurses spend their days multi-tasking and managing all kinds of people throughout the day, from patients to parents to spouses and doctors. Although they take on many roles throughout a shift, an eye for detail is essential. Oncology nurses administer chemotherapy and other cancer drugs, making sure that “the correct dose and drug are administered by the correct route to the right patient,” as the nursing reference book Cancer Medicine puts it. Too much of the poison can be fatal.

Oncology nurses also take on other more complicated and personal roles. When I was a patient last year, feeling miserable and immobile in a hospital bed, saltine crumbs were scattered all over the bedtable. I had not asked my husband to clean it, because I was tired of asking him to do things, and I figured crumbs were the least of my worries. Neely then came into my room, and before leaving, wiped down my table. It wasn’t part of her job; she just did it. I felt comforted by someone willing to blur the lines between professional nursing responsibilities and basic human-to-human caregiving, as if going out of her way is not out of her way at all.

“I never want anyone to feel like they’re imposing on me or to say sorry I’m keeping you,” she says. “You’re keeping me?” she pretends to ask a patient while talking to me. “I’m going home…I know you’d rather be anywhere but here.”

Not only do nurses do small things to give you dignity, like picking up crumbs or wiping your mouth, they also clean up filthy messes to restore livable conditions for their patients. One night early in my treatment, my husband and I had friends visiting. As I began falling asleep and my husband was saying goodbye to the friends in the hallway, I had a late onset of nausea from the chemo drugs. Before anyone knew what was happening, I was throwing up my dinner without being able to get off my hard neck brace. In what seemed like seconds, nurses rushed in to clean me off, change my sheets, and generally get the room back in order as if the disgrace had never happened.

Those nurses’ NASCAR crew-like handling of my soiled room helped me move past such a gross and miserable situation more quickly. While receiving cancer treatment and undergoing several surgeries, I encountered numerous take-charge, warm, nursing souls who literally ran toward problems rather than away from them.

And oncology nurses don’t just keep things orderly; the great ones boss people around in both clandestine and overt terms to get the best outcomes for their patients. When I was Neely’s patient, she would gently boss around my husband. “Don’t forget to pack her underwear!” she would remind him, when I had to stay in the hospital longer than expected and he’d rush home to bring me more T-shirts and yoga pants. “Husbands always forget underwear. I don’t know why that is,” she tells me during our recent interview.

Good nurses chase down doctors, assert their opinions based on their sometimes superior knowledge of a situation, and appease family members and other caregivers. Once my discharge was postponed for 48 hours by the attending doctor who barely seemed to have read my file and was rarely available. I felt I could not spend one more day in the hospital with its scratchy sheets, bad food, being woken up every few hours for vital signs, no chance of getting outside into the light of day, institutional showers, and daily injections. It was a nurse who listened to my husband’s rising anger throughout the day as he saw how my mental state was deteriorating. The nurse didn’t have the power to discharge me, but sought out answers from the doctor time after time, despite having a list of patients in equal or worse predicaments.

Oncology nurses are masters at balancing the tensions between patients and doctors, family and treatment team, all the while remaining upbeat and encouraging. Of her tireless questioning of doctors, Neely shrugs and laughs. “What’s the worst they’re going to say? No? And I’ll ask again, ask someone different. And sometimes you never get the answer you want, but at least you feel like you tried.”

BEFORE SHE KNEW so much about the packing tendencies of husbands or the best ways to get patients discharged, Neely wanted to be a teacher. In fact, she went to college for teaching. She had considered nursing, but felt teaching sounded “less stressful and more fun.” During her junior year of college, her cousin had a car accident, and she went to San Diego for the summer to help him around the house and take him to medical appointments. She was inspired by the nurses that cared for him and could see the tangible and emotional difference they made. “That intrigued me,” she says.

Six months before graduating with a degree in teaching, while gaining experience in schools, Neely decided working in a school system wasn’t for her. “I love spending time with children,” she says now, but the built-in tension between teachers and parents and the regiment of teaching to tests didn’t appeal to her. “It wasn’t as fun as I thought,” she admits, even though her parents told her to stick with it.

Just six months after graduation, she had her way and got into nursing school at a two-year program at Labouré College in Dorchester, Massachusetts. After a semester of science courses, she could then start working in hospitals as a floating patient-care technician (PCT). First she gained experience as a PCT in Beth Israel Deaconess Hospital’s Needham outpatient center, and then at BIDMC’s main campus in Boston in an oncology inpatient unit, where I met her and where she has been for more than ten years.

Neely says she’s had no doubts about her profession since graduating from nursing school and has found oncology nursing especially intimate. Instead of patients coming in to be “fixed” and then put on their way, in oncology units, patients often stay for days or weeks, or come back repeatedly for treatment or follow-up in an outpatient clinic. Nurses know everyone’s name and usually the names of many family members or friends. “You want to put a lot into it,” she says, “because you know [your work] really affects people.” Getting to know someone as a person instead of “just a body,” in her words, does make a difference. I can testify.

Each day she’s on the inpatient unit, Neely tries to give patients a goal to improve or maintain their mental state. “Every patient needs a goal for the day, whether that’s to get out of bed, or to go home, or to visit with family,” she says. When she starts her inpatient shifts, she tries to check in with each patient to set a goal and ask, “OK, we have 12 hours, we need to get this done, how do you want to do it?” And on the inpatient floor, she’s up front about how few choices there are for patients. “It’s not rainbows and sunshine. Let’s be real,” she says.

On some days, I remember my goal was to have a bowel movement or to get from the bed to the chair. “Hopefully by the end, you’re getting out of your chair and doing a few laps [in the hallway] before you go home,” Neely tells me in our interview.

Another of her daily exercises is to put herself in the shoes of others: “I feel like if this were me, what would I do? If this were my husband, my father, what would I do? That’s what it comes down to.”

SEVERAL STUDIES HAVE SHOWN that workplace stress for an oncology nurse can lead to compassion fatigue and burnout that’s caused by just this kind of effort to help others. One 2010 study on oncology nurses, done by Washington University Medical Center in St. Louis, measured compassion fatigue through surveys that captured data on secondary traumatic stress, burnout, and compassion satisfaction. For the study’s 153 oncology inpatient staff participants, 132 of which were registered nurses, nearly 40 percent were at a high risk for compassion fatigue, while 44 percent of inpatient staff were at high risk for burnout.

But another 2008 study conducted by Beth Perry, a professor at Athabasca University in Canada, found that “exemplary oncology nurses were able to avoid compassion fatigue by creating moments of connection and making those moments matter.” Sometimes small moments are all that’s left.

Neely says that one of the hardest parts of her job “is when you’re giving someone treatment and it’s not benefitting them. When you know you’re prolonging these horrible side effects.” She tells her patients in that situation, “I’ll give you chemo until your last day if that’s what you want, but I just want you to know you’re not gonna get better. So if there’s anything else you wanted to do, get it done. Don’t have me poison you to the very end.”

I ask Neely about how she manages working through life and death situations daily. She admits that other nurses she works with are better at erecting emotional barriers. When one of her patients has a bad outcome, “It still rocks me every time.…I can’t separate myself,” she says. “I’m home praying for these people, I say my prayers every night.”

But even in hopeless times, she still feels she can help. “If you know someone is not going to do well—and ultimately die—because that’s what everyone is afraid of with cancer, the Big C, just give them dignity. If there’s something they want to do, get it done. You want your dog to come in? You want to leave and go wherever? Just help them get that done.” She admits that if she were in that situation, she would most likely want to go home with her husband and dog to die.

Neely’s husband, Jamie, survived testicular cancer before they met, which gives her additional personal insights, but also makes her feel she shouldn’t discuss emotionally difficult parts of her day with him—it would hit too close to home. On the other hand, their joint experiences with the effects of cancer help crystallize their priorities. “There’s a lot that just doesn’t rock us,” she says. “To me, unless someone’s dying, dead, or suffering from extreme illness, I’m like, how stressed out can you be?”

She knows that life can change in a minute. Neely texted me the day after I met with her to say our discussion had made her reflect more deeply on her nursing career. One thing that kept coming to her mind was something that happened to her in college. While on a jog, a car hit her.

“I don’t remember much from that day,” she wrote in the text, “But I do remember I had this nurse who was with me every moment and kept telling me everything is going to be OK.…He was so comforting, and when I decided to go into nursing, he always stuck with me. I always want to give people the comfort that he offered me that day.”

As for me, I’m grateful that I can sit up, reach my computer to type this, and be able to thank Neely for the part she played, alongside many others, in getting me to where I am today. When I do thank her during our interview, she looks me in the eye and insists, “You did it!” Of course she would. 

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Topics: Oncology Nursing

Why Is Diversity In Nursing So Important?

Posted by Erica Bettencourt

Fri, Aug 19, 2016 @ 01:51 PM

Diversity in the Nursing field is essential because it provides opportunities to administer quality care to patients. Diversity in Nursing includes all of the following: gender, veteran status, race, disability, age, religion, ethnic heritage, socioeconomic status, sexual orientation, education status, national origin, and physical characteristics. Communication with patients can be improved and patient care enhanced when healthcare providers bridge the divide between the culture of medicine and the beliefs and practices that make up a patient's' value system.
When the Nursing workforce reflects its patient demographic, communication improves thus making the patient feel more comfortable. A person who has little in common with you cannot adequately advocate for your benefit. Otherwise, you might as well have a history teacher in charge of advanced algebra. 

If you have Nurses who understand their patient’s culture, environment, food, customs, religious views, etc, they can provide their patients with ultimate care. Every healthcare experience provides an opportunity to have a positive effect on a patient’s health. Healthcare providers can maximize this potential by learning more about patients' cultures. In doing so, they are practicing cultural competency or cultural awareness and sensitivity.

According to www.acog.org, Cultural competency, or cultural awareness and sensitivity, is defined as, "the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences, self-awareness, knowledge of a patient's culture, and adaptation of skills."
Our demographics are changing and our healthcare providers would be wise to hire Nurses from a variety of backgrounds that reflect their changing patient population. Usually health systems that value representation are more valuable to its patients. For centuries, the United States has incorporated diverse immigrant and cultural groups and continues to attract people from around the globe. Currently minorities outnumber whites in some communities in the United States. 

Many cultural groups, including gay and lesbian individuals; individuals with disabilities; individuals with faiths unfamiliar to a practitioner; lower socioeconomic groups; ethnic minorities, such as African Americans and Hispanics; and immigrant groups receive no medical care or are grossly underserved for multiple reasons. Lack of diversity and inclusion of healthcare providers is one of the reasons these groups receive inadequate medical care.
Diversity and inclusion is the combination of different cultures, ideas, and perspectives that brings forth greater collaboration, creativity, and innovation, which leads to better patient care and satisfaction. This is the direction in which healthcare needs to go in order to better the health of our current and future demographics.
Related Article: Bringing diversity to the nursing workforce

Is Diversity and Inclusion prominent in your workplace? Find Out!
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Topics: diversity in nursing

OBGYN Shortage Is Extremely Dangerous For Expecting Mothers

Posted by Pat Magrath

Thu, Aug 18, 2016 @ 11:55 AM

obgyn.jpgAs our population continues to grow, there are increasing demands on our healthcare system to handle the growth in the number of babies born every year in the US. Do we have enough physicians and midwives to handle the demand for medical services? The answer is No, we don’t. If you’re in a major city, the chances of receiving good maternal healthcare increases, but for those in rural areas, it’s becoming very difficult.
This article explains the situation in our country and offers some potential ways to increase access and delivery of good maternal healthcare. What do you think about the suggestions offered? Do you have any ideas to share on this subject?

Faced with a shortage of obstetricians and gynecologists and nurse midwives, several states are considering proposals that advocates say would improve healthcare for women.

But with the female population of the United States and number of babies born here projected to increase sharply over the next decade and beyond, scholars and medical organizations say more dramatic changes are needed to ensure that the medical needs of American women are met.

One possibility: easing restrictions on nurse midwives, who attend to labor and delivery and also provide routine primary and gynecological care for women of all ages. Other steps under consideration include offering financial incentives to encourage more medical professionals to specialize in maternal health care and to encourage them to locate in regions with extreme shortages, particularly in rural areas.

“It’s very simple,” said William Rayburn, a professor of obstetrics and gynecology at the University of New Mexico who has written on maternal health issues. “Our population is continuing to grow faster than we are producing ob-gyns.”

Nearly half the counties in the U.S. don’t have a single obstetrician/gynecologist and 56 percent are without a nurse midwife, according to the American College of Nurse-Midwives (ACNM).

“There are women in California who have to drive hours in order to see an ob-gyn,” said California Assemblywoman Autumn Burke, a Democrat.

The workforce shortage can have dangerous consequences, and may help explain why a relatively high percentage of American women die as a result of pregnancy, said Eugene Declercq, a professor of community health sciences at Boston University who has studied the ob-gyn workforce.

Burke is author of a bill in the California Legislature that would remove the requirement that nurse midwives practice under the supervision of doctors, a change that supporters say would boost maternal health services in underserved areas. There is a similar effort in North Carolina, and many other states have adopted those reforms over the last decade.

As restrictions have been lifted, the numbers of nurse midwives has risen. The number of nurse midwives has grown by 30 percent since 2012, according to the Bureau of Labor Statistics. But their overall numbers remain low, with about 11,200 in the whole country. There are about 20,000 ob-gyns.

Meanwhile, the American Congress of Obstetricians and Gynecologists (ACOG) is pushing measures in the U.S. Congress that would provide financial incentives to encourage medical school graduates to go into the field.

But even that may not be enough. By ACOG’s estimate, the U.S. will have between 6,000 and 8,800 fewer ob-gyns than needed by the year 2020 and a shortage of possibly 22,000 by the year 2050.

Demographic Shifts

The number of women in the United States is expected to climb by nearly 18 percent between 2010 and 2030, and, with it, the number of births. The Centers for Disease Control and Prevention recorded 3.9 million births in 2014 and projects that number will rise steadily in the years to come, reaching about 4.2 million births a year by the year 2030.

The number of medical school graduates going into obstetrics and gynecology residency programs has remained steady since 1980, with about 1,205 residents entering the specialty each year, according to Thomas Gellhaus, ACOG’s president.

Most ob-gyns over age 55 are men. But women are almost equal in number in the 45-54 age group and outnumber men at the younger end of the profession. In 2013, more than four out of five first-year ob-gyns were women.

That’s important, Gellhaus said, because female ob-gyns retire about 10 years earlier than their male counterparts and often prefer part-time schedules.

At the same time, Gellhaus and others familiar with workforce issues say, both women and men entering the field are less inclined to make themselves available around-the-clock in the way older practitioners did.

“The traditional model was that ob-gyns made this extraordinary commitment,” said Boston University’s Declercq. “I’ll be there for you, pre-natal, delivery and post-delivery. Women patients loved it, but today’s obs are looking for a better balance in their lives and don’t want to make that kind of sacrifice in their lives and their families’ lives.”

Those shifting attitudes have given rise to the growing use of “laborists” — ob-gyns or nurse midwives who do nothing but attend labor and deliveries in the hospital. That model leaves ob-gyns with time to concentrate on other maternal health issues. More than 250 hospitals now have a laborist on staff.

Another factor is the growing number of doctors entering obstetrics and gynecology who are choosing subspecialties such as gynecologic oncology, reproductive endocrinology and infertility, and female pelvic medicine and reconstructive surgery, further reducing the number available for routine maternal preventive care and normal deliveries. According to ACNM, 7 percent of ob-gyns residents entered a subspecialty in 2000. By 2012, the percentage had grown to 19.5 percent.

To help address the shortage, ACOG and other physicians’ groups are supporting congressional proposals to increase the number of medical residencies by 15,000 positions over a five-year period, with half of those designated for medical specialties in short supply, including ob-gyns.

The federal government spends about $15 billion a year on medical residency education, most of it by way of Medicare, the health plan for the elderly, and Medicaid, the state-federal partnership health plan for lower income Americans. It now funds about 30,000 residency positions a year.

Another proposal backed by ACOG would have the federal government designate obstetrical shortage areas in the country as it currently does with primary care, mental health and dental services. That would make ob-gyns and nurse midwives eligible for financial help with their education debts from the National Health Service Corps.

At least one state, Wisconsin, has begun an initiative to address the shortage. Starting next year, the University of Wisconsin School of Medicine will designate one resident in obstetrics and gynecology who will do at least a quarter of his or her training in rural areas with too few maternal health providers.

“The goal is to give them experience in these underserved areas because residents who train in certain settings are likely to locate their practices in similar settings,” said Ellen Hartenbach, an ob-gyn professor and residency program director at the Wisconsin medical school.

The program is the first to train ob-gyns in underserved areas, she said, and it has already attracted interest from medical schools elsewhere in the country.

Bigger Role for Midwives?

Nurse midwives see themselves as part of the solution to the shortage of maternal health services, but they face some legislative hurdles if they are going to play a greater role.

Nurse midwives are registered nurses who also complete an accredited graduate school course of study in midwifery. Licensed (or its equivalent) in all 50 states, nurse midwives are trained in all areas of maternal health, usually can prescribe and administer medications, and they deliver babies, almost exclusively in hospitals or birthing centers. (Another class of midwives, called “certified professional midwives,” perform home births in the U.S., but they are licensed or statutorily authorized in only 29 states.)

In half the states, nurse midwives are permitted to practice independently.

But 25 states require them to practice under the supervision of a doctor or in collaborative arrangements with doctors. But the ACNM and its state affiliates have complained for years that many doctors are unwilling to take on midwives, denying women access to these maternal health care providers.

While ACOG opposes the restrictions on nurse midwives, other physician organizations, including the American Medical Association and many of its state affiliates, have continued to insist that doctor supervision of nurse midwives is essential to patient health.

In North Carolina, where 31 of 100 counties do not have an ob-gyn, nurse midwives must have signed supervisory agreements with a doctor in order to practice. Nurse midwives are fighting a legislative battle to remove the restrictions.

Suzanne Wertman, president of the state chapter of the ACNM, said few doctors are willing to enter into such arrangements because they regard the nurse midwives as competition or can’t afford the steep increases in their medical malpractice premiums such agreements would require.

John Thorp, Jr. a professor of obstetrics and gynecology at the University of North Carolina agreed that malpractice concerns discourage doctors from entering into those supervisory agreements with nurse midwives.

The ACNM says state Medicaid programs should pay nurse midwives at the same rate they pay doctors for performing the same services, and states should require hospitals to offer nurse midwives the same clinical and staff privileges, including hospital admitting privileges that they extend to physicians.

There is precedent for nurse midwives to play a larger role. In the U.S., physicians deliver 90 percent of the babies. But in other countries, midwives attend the majority of births. In England, for example, over half of deliveries are performed by midwiveswhile ob-gyns concentrate on patients with higher risk pregnancies.

“That model has proven to work,” Declercq said, “and it just makes sense.”

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Topics: ob gyn, nurse shortage, nurse midwife

Can a Nurse Practitioner Do That? [INFOGRAPHIC]

Posted by Erica Bettencourt

Tue, Aug 16, 2016 @ 03:00 PM

blog_hero_CanNP_DoThat-02-e1470408521503.jpgThink you need to hire a physician to fill an opening at your hospital, practice, or organization? Not necessarily: A nurse practitioner (NP) may be able to get the job done, says Tay Kopanos, DNP, NP, the Vice President of State Government Affairs for the American Association of Nurse Practitioners. As an added bonus, it typically takes less time to find a locum tenens NP to fill an open position.

So, could bringing on an NP work for you? Use our infographic to find out www.bartonassociates.com:


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Topics: nurse practitioner, NP

Paraplegics moving again years after injuries

Posted by Erica Bettencourt

Mon, Aug 15, 2016 @ 04:37 PM

Paraplegics-jpg.jpgBrain training with virtual reality systems and robotic exoskeletons are helping paraplegic patients regain some sensations and possibly mobility. Brain-machine interface is changing diagnoses from complete to partial paralysis.

Researchers have just witnessed something that they say has never before been seen in the field of medicine: Patients who have been severely paralyzed for more than a decade have regained some sensation and neurological control in key muscles.

In other words, they can move again, at least a bit. 

Paraplegic people with spinal cord injuries spent a year training on brain-machine interfaces, such as virtual reality systems and robotic exoskeletons, which allowed them to use their own brain activity to simulate control of their legs, according to a small study published in the journal Scientific Reports on Thursday

The findings suggest that long-term training on such interfaces that utilize the virtual world could help paraplegic patients regain some sensations and possibly mobility in the real world, said Dr. Miguel Nicolelis, a neuroscientist at Duke University who led the study as part of the Walk Again Project in São Paulo, Brazil.

About 282,000 people are living with spinal cord injuries in the United States (PDF). Most of the injuries are a result of traffic accidents, falls or violence, according to the World Health Organization.

"Since I went to medical school, I heard that there was no hope to recover patients with spinal cord injury," Nicolelis said.

"So, I was shocked. I was really shocked, so much that it took us several months to report this because we wanted to confirm every detail," he said of the study findings. "Brain-machine interface, we designed this in the late '90s as a potential technology to assist patients to move, as an assistive technology. We never thought that we would induce neurological recovery in these patients."

The study involved eight paraplegic patients who had been completely paralyzed for at least three years due to spinal cord injuries. They were asked to spend at least two hours a week training on brain-machine interfaces over the course of a year.

How did the brain-machine interfaces work? The patients were fitted with caps lined with electrodes that recorded their brain activity. That brain activity triggered movements or behaviors in virtual reality systems and robotic exoskeletons, such as making the virtual avatar of a patient walk. Then, the interface sent signals back to the brain, such as the sensation of movement, Nicolelis said.

"So you're getting an exoskeleton, and your brain activity is triggering the device to move, and you're getting feedback from the device. You're feeling the ground; you're feeling the legs walking," he said. "If the brain of a paralyzed person is engaged and imagining movements and controlling a device directly and then the brain gets feedback from this device and the body of the patient is moving too, the brain is reinforced. The brain says, 'OK, I'm imagining that I'm moving, and something moved.' "

The researchers conducted clinical evaluations on each patient on the first day of the study and then repeated those evaluations after four, seven, 10 and 12 months.

"After we did this for several months, we tested the patients outside of the [brain-machine interface] device, and to our shock, people who were not supposed to move ever again in their lives were spontaneously moving their legs and feeling sensations," Nicolelis said.
Indeed, the researchers discovered that all of the patients experienced significant improvements in their recoveries. Four improved so much in their sensation and muscle control that their diagnoses were changed from complete to partial paralysis. 

Additionally, many of the subjects reported improvements in their everyday lives. Two became more independent in the bathroom, able to more effectively move from their wheelchairs to the toilet. Another patient reported an improvement in moving from the wheelchair to the car, according to the researchers.

In a separate proof-of-concept study, published last year in the Journal of Neuroengineering and Rehabilitation, scientists in California demonstrated that a brain-computer interface system could be used to allow a paraplegic patient to take steps using nothing but a brain-controlled muscle stimulator.
"The study by Nicolelis and colleagues employs very similar methodologies with the addition of tactile feedback," said Zoran Nenadic, an associate professor of bioengineering at the University of California, Irvine, who led the proof-of-concept research and was not involved in the new study.

"The [new] study presents encouraging findings which demonstrate that a combination of a non-invasive brain-computer interface for restoration of walking and tactile feedback can lead to improvements in both motor and sensory functions in a small group of individuals with paraplegia, or the inability to walk," he said. "This approach could potentially lead to the development of novel physiotherapies for those with complete or incomplete loss of leg function due to spinal cord injury."

The researchers also hope that brain-machine interface devices could be offered as therapy options for paraplegic patients around the world. Seven of the patients in the new study have continued their rehabilitation with brain-machine interface technologies, and the researchers are continuing to document each patient's progress.

"What this suggests is that, in the future, you could go to a rehab center for an hour a day and either do a virtual reality session or get inside of a robotic device and walk back and forth for an hour under the control of your brain," Nicolelis said. "When you get out after this training is done, after months, you basically feel that now you can move your leg. You now have reacquired several functions that you have lost because of these spinal cord injuries."
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Topics: medical technology, paralysis, paraplegic

What the new mandatory bundled payments for cardiac care could mean for the industry

Posted by Pat Magrath

Thu, Aug 11, 2016 @ 11:51 AM

bundlecardiac.jpgWe here at DiversityNursing.com are looking for a variety of topics that we hope you’ll find interesting. Is this article about new bundled payments models something that is helpful and informative for you? Please let us know your thoughts.

On July 25, the Centers for Medicare and Medicaid Services (CMS) proposed a new bundled payment model for heart attacks and bypass surgeries; it will be launched in 98 markets that have yet to be determined. The proposed model is scheduled to go into effect over a five year period, beginning in July of 2017.

“The extension of mandatory bundled payments to cardiac care provides further confirmation that CMS means to reshape healthcare delivery away from fee-for-service and towards value-based care,” says Michel Abrams, co-founder and managing partner of Numerof & Associates. “Practically speaking, it means that the profitability of two high utilization treatments in cardiology has likely peaked, and for many hospitals, these important revenue centers have leaner days ahead.”

The CMS proposal also extends the current Comprehensive Care for Joint Replacement (CJR) model to include other surgical treatments for hip and femur fractures beyond hip replacement. It also includes:

  • A new model to increase cardiac rehabilitation utilization; and
  • A proposed pathway for physicians with significant participation in bundled payment models to qualify for payment incentives under the proposed Quality Payment Program.

How the proposal will affect continuity of care

Abrams says the fee-for-service model has, over time, encouraged healthcare delivery organizations to allocate fewer resources to activities that weren’t explicitly paid for, such as care coordination. “This has been one of the drivers of the high costs and mediocre results that characterize our current system of care,” Abrams says. “Making acute care providers accountable for the costs and outcomes of the total care experience is a logical path to reversing the current situation.”

“Bundles encourage care redesign by incentivizing gainsharing and risk taking among previously disparate provider groups,” says Christopher Donovan, partner at Foley & Lardner LLP. “This will produce better outcomes over the long term through IT investments and clinical practices that focus on care management and continuity/prevention.”

Do bundled payments keep costs down?

To make its case for mandatory bundled payments, CMS points to a number of pilot programs it claims have shown they can help providers work more closely together to provide better care at lower costs. These programs include:

  • The Medicare Acute Care Episode (ACE) demonstration project tested bundled payments for cardiovascular and orthopedic care;
  • The Medicare Participating Heart Bypass Center Demonstration project tested bundled payments for bypass surgery; and
  • The Bundled Payments for Care Improvement Initiative included cardiac and orthopedic bundles.

“Data from these pilots and other state and private research initiatives all suggest that bundled payments encourage better care coordination and lower delivery costs,” says Abrams.

But according to Denise Burke, a partner in the Memphis office of Waller Lansden Dortch & Davis, LLP, official CMS studies show that bundled payments have had only limited success so far. For example, Burke says the CMS ACE pilot project, which included 28 cardiac and nine orthopedic procedures, reported a savings of only $319 per patient. “Preliminary results from the voluntary programs, however, show promise,” she says. 

Why make bundled payments mandatory?

CMS has set a goal of having 50% of traditional Medicare payments flowing through alternative payment models by 2018. According to Abrams, results of a recent company survey, which assessed U.S. hospital progress toward adopting value-based care models, “confirmed that hospitals, given the option of staying with the historical fee-for service model, won’t meaningfully change their approach to care delivery on their own.”

“CMS is in a unique position to reshape the industry, and it must do so if it is to connect payments with improved outcomes and avoid the sea of red ink that waits at the end of the current trend in healthcare cost inflation,” Abrams says.

What could be bundled next?

Jerrod Ullah, RN, BSN VP Product Management at ViiMed, says based on conversations with practitioners and experts, he believes the industry can expect to see similar models on the horizon for oncology and maternity care. “Each of these areas involves a significant amount of care coordination throughout the treatment process, and patients could see big benefits through a bundled payment approach,” he says.

According to Abrams, the industry can expect to see the subsequent expansion of bundled payments for chronic conditions within already established service lines. “For example, congestive heart failure is a likely candidate for expansion once the cardiology project is underway,” he says.

The proposed rule was published in the Federal Register on August 2. Comments will be accepted for 60 days after publication.

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Topics: bundle payments, cardiac care

More And More Women Are Now Dying In Childbirth, But Only In America

Posted by Pat Magrath

Wed, Aug 10, 2016 @ 11:03 AM

t1larg.child.birth.gi.jpgIn this day and age, you probably think women don’t die in childbirth, and if they do, it must be an extremely rare occasion or in 3rdworld countries – right? No, it’s happening right here in the US. Find out why and what you can do to help these numbers go down.

More women are dying in childbirth in the US than in any other developed country. And experts say the problem is likely to keep getting worse.

You can see how alarming the issue is in this chart. In other countries, maternal death rates have fallen sharply since 1990. In South Korea, the rate of women dying in childbirth fell from 20.7 deaths per 100,000 live births in 1990 to 12 today. In Germany, it dropped from 18 to 6.5.

But in the United States, the opposite is happening. The rate of women dying in childbirth is going up.

This wasn’t supposed to happen. During the 20th century, the maternal death rate in the Pregnant-Photo-1-594x460.jpgUnited States dropped from 607.9 deaths per 100,000 births in 1915 to 7.2 in 1987. But over the past 30 years, the maternal mortality rate trend reversed and steadily marched upward.

Pregnancy-related deaths are still rare events in the US; only about 700 women die out of 4 million live births annually. But the US is one of the few rich countries in the world where maternal mortality is steadily rising. The maternal mortality rate has more than doubled since 1987, the first year the Centers for Disease Control and Prevention began collecting data through its pregnancy mortality surveillance system.

And experts are just now understanding why this is happening — why the United States looks so different from other countries, and why so many more new mothers are dying. They think maternal deaths are rising because of the rising toll of chronic diseases.

Thirty years ago, women died in the delivery room because of hemorrhages and pregnancy-induced blood pressure spikes. Now they are much more likely to die because of preexisting chronic conditions like heart disease or diabetes.

"We’ve seen a big bump in cardiovascular disease and chronic disease contributing to maternal deaths," said Dr. William Callaghan, chief of maternal and infant health at the CDC. "Underlying heart disease is common, diabetes is common. We now have a group of women bringing with them into pregnancy their entire health history."

Cardiovascular diseases are now the second leading cause of pregnancy-related deaths in the US

Thirty years ago, almost a third of all pregnancy-related deaths were because of hemorrhages — or women bleeding to death.

But today that number has dropped by nearly a third. Hemorrhages now account for 11.4 percent of pregnancy-related deaths. Deaths related to embolisms and pregnancy-related hypertension disorders have also steadily declined. And deaths due to anesthesia complications have almost entirely disappeared.

Instead, more women are dying from pregnancy complications related to preexisting chronic diseases — in particular, cardiovascular diseases.

Cardiovascular conditions are now the second leading cause of pregnancy-related deaths, falling right behind non-cardiovascular diseases. And when combined with cardiomyopathy (diseases related to weakened heart muscle tissue) cardiovascular disorders make up more than a quarter of all pregnancy-related deaths.

Thirty years ago, cardiovascular diseases accounted for less than 10 percent of all pregnancy-related deaths, but as of 1998 to 2005, CDC researchers noted their increased prevalence as a leading cause of death.

Part of the uptick in cardiovascular-related deaths is because more pregnant women in the US have chronic health conditions such as hypertension, diabetes, and obesity, all of which put them at a much greater risk for pregnancy complications.

"It’s a larger problem than just dealing with women during pregnancy, it’s the health of our society," said Callaghan. "Imagine a [pregnant] woman comes in with BMI of 40, and she’s 24 years old — that didn’t happen in the past year, it happened in the past 24 years."

The number of pregnancy deaths caused by infections has, meanwhile, held relatively steady — not a building problem, but an indication of how the American health care system struggles to protect patients from risks once they enter the hospital.

Age doesn’t explain why maternal deaths are increasing

More than a quarter of all pregnancy-related deaths in the US involved women 35 and older. This is a substantial improvement from previous years, when the percentage topped 50 percent.

The risk of dying from pregnancy complications increases with age for women of all races and ethnicities. But experts don’t think older women having children in the US explains the upward trend of the maternal death rate.

"Pregnancy is riskier the older you get and the risk increases exponentially past the age of 35," said Nicholas Kassebaum, assistant professor at the Institute for Health Metrics and Evaluation. "But the number of women who have delayed pregnancy in the US has not gone up more than in other high-income places."

Black women still experience the greatest risk of dying from pregnancy complications

One stark — and somewhat inexplicable — trend in pregnancy-related deaths is that black women are significantly more likely to die than their peers.

Studies have shown that black women are less likely to begin prenatal care in the first trimester and are more likely to have preexisting chronic conditions such as hypertension,diabetes, or obesity than white women. But this still doesn’t account for the enormity of the disparity that currently exists.

Black women are two to three times more likely to die from pregnancy complications than white women. What’s more, researchers found this to be true regardless of age, education, or similarities in living conditions.

And the disparity is growing worse. The maternal death rate for black women rose from 34 percent in 2007 to 42.8 percent in 2011. During the same time period, the maternal death rate for white women only increased by 0.7 percentage points.

Sadly, this finding is not all that surprising. Black people, and in particular black women, are significantly more likely to die from a health condition than their white peers. But according to Dr. Callaghan, the differences in the maternal death rates for white and black women are currently the most severe disparity in US health care.

"It’s the thing that wakes us up in the middle of the night as we try to understand it," said Callaghan. "It’s access issues, differences in care based on geography, differences in health status — it’s all these things … and we’re not going to find the one thing that causes it."

Lots of maternal deaths are preventable. But we don’t have the right public infrastructure in place.

We know that maternal mortality is a big problem in the United States. But one of the most vexing issues researchers face is the absence of reliable data. Some states have maternal death review boards to collect data. But other states don’t. And what the boards do can vary tremendously from state to state, leaving public health researchers with an incomplete view of the problem.

And it's especially important to study pregnancy-related deaths because the best research we have suggests as many as one in three were preventable. So public health officials are now working on a national initiative to review every single pregnancy-related death in America — and the movement is building momentum.

In 2012, the CDC partnered with the Association of Maternal & Child Health Programs (AMCHP), a public health advocacy group, to help create state-level review boards to assess maternal deaths in every single state.

When they started, there were only 18 states with active review boards, but by 2016 at least 39 states had review boards either active or in the works.

How it works is simple: A board of medical experts in each state meets and reviews information on every single maternal death in that state, looking at potential issues ranging from prenatal care to the role preexisting health conditions played.

The idea is that by determining the causes of each maternal death, trends will emerge, which in turn will help doctors and health care providers identify how to best prevent maternal deaths.

In my interview with Dr. Callaghan, he credited the drop in pregnancy-related deaths caused by hemorrhage and pregnancy-induced hypertension to improved medical interventions. Doctors began to use oxytocin to stimulate uterine contractions in the case of hemorrhage and more regular prenatal blood pressure checks to assess risk of hypertension. They learned from what went wrong in previous cases, and worked to prevent those situations.

So Callaghan is hopeful the same success can be replicated for treating and managing more troubling complications, such as cardiovascular diseases, by studying the causes of maternal deaths on a case-by-case basis.

The CDC and AMCHP are analyzing the data collected by the individual review boards. The current plan is to establish an active review board in all 50 states, and produce a national report so that lessons can be more readily shared between states and health care providers.

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Topics: maternal death rate

These Factors Influence Retention of Newly Licensed Nurses In Hospitals

Posted by Erica Bettencourt

Thu, Aug 04, 2016 @ 03:10 PM

Nurse_Retention.jpgIf your hospital is experiencing high turnover among your newly licensed Nurses, this article may give you an idea of why they’re leaving and areas where you can improve your work environment.

Some factors influencing low unit-level turnover: first professional degree was a baccalaureate or higher, greater variety and autonomy, and better perceived RN-MD relations

“About 80% of newly licensed nurses find their first work in hospitals,” says New York University Rory Meyers College of Nursing (NYU Meyers) Professor Christine T. Kovner, PhD, RN, FAAN. “Turnovers are one of the costliest expenditures in our profession. In fact, costs are estimated at $62,000 to $67,000 per departure, amounting to $1.4 to 2.1 billion in expenses for new nurses who leave their first jobs within three years of starting.”

Prior research on newly licensed nurses tended to focus on organizational turnover, where a nurse leaves the hospital or organization. However, there is scant literature on internal or unit-level turnover, which occurs when a nurse leaves their current assignment to take up new roles or positions within the organization or hospital.

Recently, Dr. Kovner led a team of researchers at NYU Meyers and the School of Nursing at SUNY Buffalo in conducting a study to fill in the gaps. Published in the International Journal of Nursing Studies, the study of a nationally representative sample of new nurses working in hospitals, sought to better inform unit-level retention strategies by pinpointing factors associated with job retention among newly licensed nurses.

“The internal turnover rate for the one year between the two waves of the survey was nearly 30%,” said Dr. Kovner. “This turnover is in addition to those leaving the organization. This figure is substantially larger than previously reported in other studies, which estimated a 13% one-year internal turnover rate among new nurses.”

The researchers looked to bolster the existing evidence on internal turnover to determine precursors to remaining on the same title and unit-type from the first to the second year of employment.

The nurses (n=1,569) were classified into four categories based their unit and title retention. 1090 nurses (69.5%) remained in the same title and unit-type at wave two, while 129 (8.2%) saw a change in title, but not in unit-type. A similarly small group of 185 (11.8%) had no change in title, but changed unit-types, while 165 (10.5%) had a change in their title and unit-type.

In addition to collecting the new nurses’ demographical data, Dr. Kovner and her team assessed their perceptions of their work environment in both surveys.

“In doing this we were able to examine the changes in work environment perceptions over time between nurses who remained in the same unit and title to those who changed unit and/or title,” said Dr. Kovner.

Upon analysis, the researchers found five factors most strongly associated with retention: holding more than one job for pay (negative), first professional degree was a baccalaureate or higher, negative affectivity, greater variety and autonomy, and better perceived RN-MD relations, all positively related.

“Our results point to the variables on which managers can focus to improve unit-level retention of new nurses,” said Kovner.

Related Article: Fellowship Program Improves New Nurse Retention, Nets Savings

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Funding. Funding for this research was provided by the Robert Wood Johnson Foundation.

Topics: retention rate, retention

CDC issues a travel advisory to Florida, which has 10 new cases of Zika

Posted by Pat Magrath

Tue, Aug 02, 2016 @ 12:32 PM


In case you haven’t heard the latest news about the Zika virus in south Florida, please read this article for the most recent information. We hope you find it helpful.

For the first time, the Zika virus has prompted public health officials to warn pregnant women to avoid traveling to a part of the continental United States. The travel advisory comes in response to a growing outbreak of the mosquito-borne disease in South Florida.

The state on Monday said there are 10 more people who have been infected with the Zika virus who likely contracted it from local mosquitoes, bringing the total number of such cases in the state to 14. All of the cases have surfaced in a densely populated community north of downtown Miami.

Because the virus can have devastating consequences for a fetus, the Centers for Disease Control and Prevention urged pregnant women to avoid traveling to the area, and for pregnant women who live and work there to make every effort to avoid mosquito bites and to get tested for possible exposure during each prenatal visit. It also advised women to use protection during sex, because the virus can be transmitted sexually.

Furthermore, the CDC is advising that all pregnant women should be asked about travel to Zika-infested areas during routine prenatal visits. Any pregnant women who have traveled to Zika areas -- including this area of Florida on or after June 15 -- are advised to talk with their healthcare providers and get tested for Zika.

For couples trying to have a baby, women and men who traveled to this area should wait at least eight weeks before conceiving a pregnancy. Men with symptoms of Zika virus disease should wait at least six months after symptoms begin to attempt conception.

CDC Director Tom Frieden said the agency issued the travel warning because of the additional Zika infections that were identified in the last 48 hours, and because of new information that indicates mosquito control efforts are not working as well as officials would have liked.

Frieden said it's possible the insects have developed resistance to some of the insecticides being used, or that the mosquitoes are able to continue laying eggs in "cryptic breeding places," or that it may simply be that it's very difficult to do mosquito control in this particular area.

He said more infections are likely, because four out of five people with Zika don't have symptoms.

Although the CDC issued a similar travel warning for Puerto Rico in January because of widespread transmission on the island, this is the first time the agency has issued such a travel advisory for the continental U.S., Frieden said.

The CDC already has two of its experts on the ground in Florida, and six more will be there by Tuesday as part of a rapid-response team. The experts include specialists in birth defects, mosquito control and community engagement.

In a statement, Gov. Rick Scott (R) said state health department officials believe that active transmission is occurring in one several-block area that was announced on Friday. This remains the only area of the state where the health department has confirmed ongoing local transmissions of Zika. Among the 10 new cases announced Monday, six people are asymptomatic and were identified from the door-to-door community survey that the health department is conducting.

The Zika area is a dense, diverse section about one-mile-square that includes the neighborhood of Wynwood. It has now become the first area in the continental United States with confirmed local spread of the Zika virus. State and federal officials have warned for months that such a transmission was inevitable.

Wynwood is one of Miami’s trendiest neighborhoods and draws visitors from around the world to gawk at the array of murals and exquisite graffiti on the walls of warehouses. Once known primarily as a Puerto Rican enclave, and sometimes called Little San Juan, Wynwood has gone through multiple transitions in recent decades and a recent spurt of gentrification. In the 1980s it became a magnet for artists looking for affordable studio space. It's now internationally renowned for its outdoor art as bars, cafes and art galleries spread throughout the neighborhood.

Tourists were still visiting the neighborhood this weekend, largely unconcerned about the Zika outbreak, according to local news reports.

At the present time, there is no need for the travel advisory to be broader than this specific Zika-affected area, Frieden said. Unlike other mosquito-borne diseases that can be spread by humans and animals, there are no other animal reservoirs for the Zika virus other than infected humans. The virus spreads most easily in crowded settings where people don't have access to air condition or window screens, and where there are large numbers of Aedes aegyptimosquitoes.

In addition, the mosquito can only travel about about 150 yards during its lifetime, he said.

"There wouldn't be a technical or scientific basis to give a broader recommendation," Frieden said.

"Nothing we've seen so far indicates widespread transmission," he said. "But it's certainly possible we could be seeing sustained transmission in small areas."

About 40 million people from the United States travel every year to the nearly 50 Zika-affected countries that are mainly in Latin America and the Caribbean, and could get infected unknowingly through a mosquito bite.  "Everyone coming back should use repellent for three weeks in case a mosquito bites them and they get infected," Frieden said.

Because the Aedes aegypti mosquito is also present in parts of 30 states, pregnant women in all of those places should protect themselves against mosquito bites, he said.

“The frustration is that this wasn’t unexpected,” and Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine. “It’s not like we were caught by surprise. We knew this train has been heading our way.”

Hotez said the outbreak in Florida is beginning to make clear why lawmakers on Capitol Hill should have to appropriated funding for states and counties to prepare for the Zika threat. The Obama administration requested nearly $2 billion to prepare for the virus in February, but the House and Senate left for their summer recess last month without approving any new funding.

“Congress didn’t do their homework,” Hotez said, noting that the congressional recess corresponds nearly exactly with the peak of the season when mosquitoes traditionally spread the most viruses such as Zika. “They left. So I don’t have kind words to say about Congress right now.”

Republicans and Democrats in Congress have been deadlocked for months over a $1.1 billion spending bill that would help fight the spread of Zika and there is no sign that outbreak in Florida will spur either side to action.

Democrats in the Senate have blocked the funding package drafted by congressional Republicans over politically motivated language, including provisions that would deny Zika-related funds from being sent Planned Parenthood and loosen environmental regulations on pesticides. Democrats also want the funding to be increased to nearly $2 billion without corresponding cuts elsewhere in the budget.

Last week, Senate Minority Leader Harry Reid (D-Nev.) called on Senate Majority Leader Mitch McConnell (R-Ky.) call a special session of Congress. “We need to act now," Reid said.

Senate Republicans responded by blaming Democrats for blocking the House-passed spending bill. McConnell and Florida Sen. Marco Rubio (R-Fla.) have both said President Obama should use money left over from fighting the Ebola virus to combat Zika. On Monday, Rubio  also pushed for Congress to come back to Washington early to vote on a long-term Zika spending bill.

"A week ago, before the cases were announced, I had asked President Obama to take $300 million that’s disposable, that he has under his control," Rubio said at an event in Clearwater. "I’m prepared to go back in a moment’s notice and vote on this and get it done quickly given the state of affairs now."

The lack of funding has hindered the ability of many localities to conduct surveillance that could identify new cases of Zika, Hotez said. In many parts of the Gulf Coast, underfunded districts simply have no capacity to monitor for the disease or to actively fight the mosquitoes that spread it.

“[Miami] is just the one outbreak we know about,” he said. “I think it’s equally possible that multiple outbreaks are simultaneously occurring up and down the Gulf Coast and Florida.”

Like other communities, Hotez said, South Florida has the major elements needed to lay the groundwork for a Zika outbreak – the Aedes aegypti mosquito that primarily carries it, a population never before exposed to the virus and densely populated areas.

“We should expect to see multiple outbreaks of varying sizes occur in South Florida and the Gulf Coast during the traditional peak of arbovirus season,” he said. “Everything we’ve known about this epidemic in the Western Hemisphere indicates this is a virus that, when it gains a foothold in a population, can aggressively spread.”

Scott said health officials have been testing individuals in three locations in Miami-Dade and Broward counties for possible local transmissions through mosquito bites. Two locations have been ruled out for possible local spread. His statement did not provide additional details on location.

Since the health department began its investigation July 7, more than 200 people in Miami-Dade and Broward counties — who live or work near the likely mosquito-borne transmissions — have been tested for the virus. These people have provided blood and urine specimens.

Of the 14 individuals identified, two are women and 12 are men. The governor's statement did not say whether either woman was pregnant.

Although no mosquitoes have yet tested positive for the virus, Frieden explained that confirming infections in mosquitoes is much harder than confirming them in people — which is why there can be local transmission even in the absence of positive insect tests.

Most of the 14 infections were identified within a much smaller geographical section in the center of the Zika area, Frieden said. He described it as 150-yard area surrounding two workplaces.

Mosquito control is difficult in this area because it has a mix of industrial and residential buildings.

Testing for Zika is challenging because four out of five people don't show symptoms.  The virus is primarily spread through the bite of an infected Aedes aegypti mosquito, but it can also be transmitted through sex. That means someone who has been bitten by an infected mosquito could unknowingly spread the virus to a sex partner. And an infected person can pass the virus back to another mosquito, which can then infect another person through a bite.

June 15 is the earliest known date that one of the 14 people in Florida could have been infected, the CDC said.

Scott said Florida would rely on the approach it has taken in tackling similar mosquito-borne viruses, such as dengue and chikungunya, which are spread by the same mosquito species.

He encouraged residents and visitors to drain standing water and use bug spray. But the governor added:  "Florida remains safe and open for business. This year, we have already welcomed a record 30 million tourists and we look forward to welcoming more visitors to Florida this summer.”

The exact location of where the health department believes there are active transmissions of the Zika virus is within the boundaries of the following area: NW Fifth Avenue to the west, U.S. 1 to the east, NW/NE 38th Street to the north and NW/NE 20th Street to the south. This area is about one square mile, and a map below details the area.


Gayle Love, a spokeswoman for Miami-Dade County Solid Waste Management, said officials have been going door-to-door in the affected area, eliminating sources of standing water and spraying for mosquitoes, both from trucks and by hand. Workers also have intensified their efforts just beyond the community where the transmission occurred, in an effort to halt further spread of the virus, she said. Officials also have rotated pesticides in an effort to combat resistance among mosquitoes to the treatments.

The local cases of Zika have gotten the attention of local residents. Love said that on Friday, the day public health officials disclosed the first locally transmitted cases, her department received 224 calls requesting mosquito abatement -- far more than any other day in recent months. "People are concerned," she said.

Still, she said it is imperative that people do their part to cover or drain any water containers around their homes and wear repellent -- messages local authorities have been trying to hammer home for months. "There’s a tremendous level of personal responsibility associated with this," she said.

One of the biggest hurdles in controlling the spread of Zika is that most people don't get sick. And in pregnancies, problems may not be apparent until six or seven or eight months later, Frieden said.

Zika can cause microcephaly, a condition where babies are born with abnormally small heads and often underdeveloped brains. But even babies who look normal at birth can have a variety of other severe neurological problems, and no one knows the scope of those problems yet.

"It is a scary situation but it's not immediately apparent to people," Frieden said.

The Aedes aegypti mosquito can breed in the smallest spots in and around homes. Its larvae don’t necessarily need water to survive, and eggs can lie dormant for a year or more, only to hatch once submerged in water. The sticky eggs glue themselves to containers as common and varied as the insides of old tires and the edges of birdbaths.

Aedes aegypti mosquitoes are aggressive daytime biters, especially around dawn and dusk. They can hide under beds, in closets or in other shady places. They are “sip feeders,” meaning they feed often and on multiple hosts — a practice that makes it possible to spread disease quickly. They also are adept, experts say, at launching sneak attacks, in which they approach people from behind and bite them on the ankles and elbows to avoid being detected and slapped.

Joel Achenbach and Kelsey Snell contributed to this report.

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