DiversityNursing Blog

By BENJAMIN MUELLER

In a case weighing the government’s ability to require vaccination against the individual right to refuse it, a federal judge has upheld a New York City policy that bars unimmunized children from public school when another student has a vaccine-preventable disease.

Citing a 109-year-old Supreme Court ruling that gives states broad power in public health matters, Judge William F. Kuntz II of Federal District Court in Brooklyn ruled against three families who claimed that their right to free exercise of religion was violated when their children were kept from school, sometimes for a month at a time, because of the city’s immunization policies.

The Supreme Court, Judge Kuntz wrote in his ruling, has “strongly suggested that religious objectors are not constitutionally exempt from vaccinations.”

The lawyer for the plaintiffs, Patricia Finn, said she plans to appeal the decision, announced this month. On Thursday, Ms. Finn asked the district court to rehear the case.

Amid concerns by public health officials that some diseases are experiencing a resurgence in areas with low vaccination rates, the decision reinforces efforts by the city to balance a strict vaccine mandate with limited exemptions for objectors. Pockets of vaccination refusal persist in the city, despite high levels of vaccination overall.

State law requires children to receive vaccinations before attending school, unless a parent can show religious reservations or a doctor can attest that vaccines will harm the child. Under state law, parents claiming religious exemptions do not have to prove their faith opposes vaccines, but they must provide a written explanation of a “genuine and sincere” religious objection, which school officials can accept or reject.

Some states also let parents claim a philosophical exemption, though New York does not. Some parents refuse to have their children vaccinated because of a belief that vaccines can cause autism, though no link has ever been proved.

Two of the families in the lawsuit who had received religious exemptions challenged the city’s policy on barring their children, saying it amounted to a violation of their First Amendment right to religious freedom and their 14th Amendment right to equal protection under the law, among other claims. Their children had been kept from school when other students had chickenpox, their suit said.

The third plaintiff, Dina Check, sued on somewhat different grounds, saying that the city had improperly denied her 7-year-old daughter a religious exemption. She said the city rejected her religious exemption after it had denied her a medical exemption, sowing doubts among administrators about the authenticity of her religious opposition. But Ms. Check said the request for a medical exemption had been mistakenly submitted by a school nurse without her consent.

After the school barred her daughter, Ms. Check home-schooled her and then moved her to a private school that accepted her daughter without the vaccinations. State vaccination requirements cover public and private schools, but in New York City, private schools have more autonomy in handling exemptions.

“Disease is pestilence,” Ms. Check said, “and pestilence is from the devil. The devil is germs and disease, which is cancer and any of those things that can take you down. But if you trust in the Lord, these things cannot come near you.”

In turning down all three families, Judge Kuntz cited a 1905 Supreme Court ruling that upheld a $5 fine for a Massachusetts man who disobeyed an order to be vaccinated during a smallpox outbreak, a case that helped establish the government’s right to require immunizations as a matter of public health.

Ms. Finn, the families’ lawyer, said that case should not be relevant. “There’s no way that court anticipated that children would be subjected” to the vaccines they must get today, she said.

In New York, the statewide mean religious exemption rate rose over the last decade, from .23 percent in 2000 to .45 percent in 2011, a 2013 study in the medical journal Pediatrics said.

New York City schools granted 3,535 religious exemptions in 2012-13, according to data from the state’s Health Department. Though city schools, public and private, have an overall immunization rate around 97 percent, according to the department, 37 private schools were below 70 percent. Health experts believe that above a certain immunization rate, outbreaks are limited because a disease cannot spread to enough people during its incubation period to sustain itself, a phenomenon known as “herd immunity.” For measles, which is highly contagious, that rate is believed to be 95 percent, according to Daniel Salmon, deputy director at the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health.

Though widespread vaccinations have practically eliminated diseases like measles and mumps from the United States, flare-ups have occurred. The 477 measles cases reported this year represent the worst year-to-date count since 1994, according to the Centers for Disease Control and Prevention.

Among the 25 people who contracted measles in New York City between February and April this year, two were school-age children unvaccinated because of parental refusal. When one of the children, who was being home-schooled, contracted the measles, city health officials barred that child’s sibling, who had a religious exemption, from attending school. The sibling eventually contracted measles as well. Health officials credited the decision to keep the second child out of school with stopping the spread of disease in that community.

Ohio, which granted more than three times as many religious and philosophical exemptions to kindergarten students last year as it did in 2000, is struggling to contain a measles outbreak that has recently spread to 339 Amish people who were largely unvaccinated, the state health department said.

Mr. Salmon said it can be difficult for states to balance an obligation to mandate vaccination with some leniency for families who have strong objections. Rules that force parents to articulate their beliefs and require public officials to educate them about the risks of exemption are states’ best defense against the spread of disease, he said.

Still, especially because parents who refuse vaccination tend to cluster geographically, it takes only a few unvaccinated children to start an outbreak, he said. At that point, even vaccinated children are at risk.

“Diseases have a way of finding our vulnerabilities,” Mr. Salmon said, “the kinks in our armor.”

We want to know what you think. Agree or disagree?

Source: nytimes.com

By Nurse.com News

Home visits by nurses and paraprofessionals to children of low-income women had some positive benefits on cognitive and behavioral measures for the children, according to results of a clinical trial.

Home visits by nurses to low-income families have been promoted as one strategy to improve health and development outcomes for first-born children from those families, according to background information in the study, which was published Dec. 2 as an online-first article in JAMA Pediatrics.

David L. Olds, PhD, of the University of Colorado Denver, and colleagues followed up on a randomized trial in Denver that included 735 low-income women, most of them unmarried, and their first-born children as part of the Nurse-Family Partnership, a program that has been conducted in other cities. 

The goals of the NFP are to improve pregnancy outcomes by helping women improve their health-related behavior, improve their children’s subsequent health and development by helping parents provide competent care, and enhance a mother’s personal development by promoting the planning of future pregnancies. The Denver trial was meant to test the program model when it is delivered by paraprofessionals, who were required to have a high school education and no college preparation in the helping professions and who also shared many of the same social characteristics as the families they visited.

Women in the study were divided into three treatment groups: The first group of 255 women received free developmental screening and referral for their child, the second group of 245 women received the screening plus a paraprofessional home visit during pregnancy and the child’s first two years of life, and the third group of 235 women were provided the screening plus a nurse home visit during pregnancy and the child’s first two years of life.

The researchers found that children born to mothers with low psychological resources but visited by paraprofessionals showed fewer errors in visual attention or task switching at age 9. Children visited by nurses were less likely to be classified as having total emotional or behavioral problems at age 6, internalizing problems at age 9 and dysfunctional attention at age 9. 

Nurse-visited children born to low-resource mothers also had better receptive language and sustained attention averaged over time, the researchers reported.

Unlike in a similar trial that previously was conducted in Memphis, children visited by nurses in the Denver trial did not display significant benefits in cognition or in reading and math achievement. 

Possible reasons for the disparity, the researchers said, include that “the benefit of the nurse-delivered program for children born to low-resource mothers is most pronounced for families living in highly disadvantaged neighborhoods.” The families studied in Memphis tended to live in more disadvantaged neighborhoods than those in Denver.

Control-group children in Memphis had a lower average IQ than their counterparts in Denver, and the benefit of the program could be greatest where there is most room for improvement, the researchers noted.

Study abstract: http://archpedi.jamanetwork.com/article.aspx?articleid=1785480

Nurse-Family Partnership: http://www.nursefamilypartnership.org/

Source: Nurse.com 

By Jackie Farwell, BDN Staff

After a routine mammogram in the fall of 2011, Laurie Thornberg learned she had breast cancer. Over the next nine months, as the Oakland woman endured surgery and rounds of chemotherapy, she watched as friends and loved ones attempted to explain her condition to their children.

Some struggled. One person described Thornberg’s cancer to her children “like I had the plague,” she said. Others were more comfortable, including a close friend and neighbor Thornberg ran into while out for a walk.

“[She] told her children in a kind and gentle way,” Thornberg, a registered nurse, wrote in an email.

Thornberg chronicled the encounter with her neighbor in her new children’s book, “Julie’s Dream,” which she hopes families will use as a tool to talk with their children about cancer and its treatment, as well provide hope to cancer victims and their loved ones.

“Children, even young ones, can be very aware of their surroundings and have questions when they notice family members being upset, someone who is sick a lot, or even as simple as a person suddenly has no hair,” Thornberg said.

In the book, Thornberg’s neighbor explains to her children, “See our friend? She wears that bonnet to cover her head because she got sick and had to take a special medicine that made her hair fall out.”

One of the children turns to Thornberg, asking, “Why don’t you take off that bonnet? I’m sure you’re beautiful under there.”

The book goes on to detail the main character’s dream about magically being healed. Thornberg’s friend and the book’s illustrator, Juliana Muzeroll, had that very dream about her, Thornberg said.

“I liked this approach a lot because it gives the reader freedom to interpret the outcome to fit their own personal situation,” she said. “Meaning, that whether the loved one survives or passes away, there is always healing at the end of a cancer journey.”

Thornberg remains in remission 18 months after her last round of chemotherapy. She now realizes that the disease freed her from stressing over the demands of a life as a full-time hospital nurse, mother, and daughter caring for her disabled mother, said Thornberg, who now works in home health care and said she’s able to focus on what’s really important in life.

“Getting cancer took me away from my excessive stress,” she said. “I often say ‘cancer healed my life.’”

“Julie’s Dream” is available in softcover or as an e-book on amazon.com, barnesandnoble.com, and authorhouse.com, by searching the title and author together.

Source: Bangor Daily News

By Debra Anscombe Wood, RN

Some patients are trached and vented. Other patients are on dopamine drips or receiving total parenteral nutrition. This sounds like a critical-care unit, but hundreds of children in New York and New Jersey are receiving this type of intensive care at home from nurses and other healthcare professionals. 

“There are many more children (with complex care needs) going home,” said Ana L. Pacheco, RN, MS, director of patient services at Montefiore Medical Center Home Health Agency in New York City. “There’s more high-tech in the home. It’s incredible. Being in their home is so much better for the children and parents.”

Bringing the child home despite needing complex care reduces the risk of nosocomial infection and often is easier on the family than continued hospitalization, said Kathy Pfeiffer, RN, BSN, director of pediatric clinical operations for BAYADA Home Health Care, headquartered in Mount Laurel, N.J.

“These kids are acute,” Pfeiffer said. “The homes are set up like an ICU.” 

St. Mary’s Home & Community Programs in New York City has experienced an increase in home care volume as medical advances have allowed premature and other medically needy children to survive longer with a better quality of life. 

“We’re getting sicker kids home, and their needs are much greater,” said Lois Long, RN, nurse coordinator at St. Mary’s Home Care. “Our job is a little more challenging because of that.”

Children may receive home care because they have been diagnosed with pulmonary and cardiac diseases, congenital defects, traumatic injuries and other conditions. They range in age from newborns to young adults. Some may live in shelters or in foster care. 

Certified agencies provide intermittent care and licensed agencies offer hourly or shifts of care, including accompanying the child to school. Some organizations, such as St. Mary’s, offer both types of home services. 

Teaching and doing

Nurses teach parents how to care for the child while still in the hospital, but once discharged, home care nurses reinforce that education, fine tune techniques, perform treatments such as peritoneal dialysis, tube feedings and nebulizer and monitor the patient’s condition and the family’s progress with providing care. “We do a lot of education,” said Anne Calvo, RN, BSN, MPS, assistant vice president at the Winthrop-University Hospital Home Health Agency in Mineola, N.Y. 

Home health nurses collaborate with physicians, parents and a multidisciplinary home team, including rehabilitation therapists, social workers and home health aides. 

“We do a lot of care coordination,” said Eno Onda, RN, MEd, coordinator of care in the Children & Family program at the Visiting Nurse Service of New York. “It is patient-centered, family-centered care, and we have to keep good lines of communication.”

VNSNY focuses on short-term care with extensive education to strengthen families to manage the complex care needs of their patients, Onda said. Nurses draw on scientific knowledge, research and nursing theory as they identify needs and coordinate care. 

“What the nurse does is very challenging,” Onda said. “You have to know your values and emotions, so you can [hear] the stories people are telling you and put everything together.” 

Staying for hours at home, school

Some children require constant care. When their parents go to work or sleep, home care nurses often fill in, even accompanying the child to school to perform necessary treatments and medications, according to physician orders and company protocols. 

“They are fragile (children with complex care needs), but despite that, they are kids,” said Donna McNamara, RN, MPA, assistant vice president of community programs at St. Mary’s. “You want to support their growth and development and cognitive function.”

St. Mary’s nurses try not to intrude on family life but become part of the daily flow of activities. McNamara said it takes a team approach to keep these children at home. At BAYADA, a transitional care manager meets with the family in the hospital. Then a clinical manager makes the initial home assessment, collaborates with physicians and other members of the team, and ensures supplies are in the home and the nurse caring for the child is competent to provide treatments. BAYADA conducts simulation drills to hone responses to emergency situations, such as a trach tube coming out or a seizure lasting longer than expected, and reassesses competencies annually.

“In a hospital, you have a team and can call out if there’s a crisis,” said Lisette Alicea, RN, RRT, clinical manager at BAYADA’s Hackensack, N.J., office. “We have to make sure we have the orders [for various situations] and train our nurses to know what to do.” 

Challenges and rewards

In addition to providing highly technical care employing the latest equipment and products, home care remains highly personalized. Nurses offer support, while watching for stressors or signs of abuse and neglect. 

“It’s difficult for parents to have a sick child, whether born premature or (born) healthy and something happens,” said Alyson Bolton, RN, CPN, BAYADA transitional care manager. “The family dynamics are challenging.”

Nurses help by showing parents they are capable of taking care of the child and identifying what the child can do, added Shawn Carroll, RN, clinical manager at BAYADA in Hackensack. 

Psychosocial issues present some of the greatest challenges for nurses. 
“We work with child protective services when needed and with social work,” Calvo said. “We are totally involved in the care.”

Home-care nurses collaborate with others on the team and community resources, such as homeless shelters, counseling and housing authority officials, to resolve concerns.“You become part of the families from day one and then watch them grow and become more self-sufficient,” Carroll said. “It’s a special type of nursing.”

Jeanette Carter, RN, team coordinator at St. Mary’s Home Care, agreed it is rewarding to care for patients who came into the program as fragile infants and watch them improve as they become young adults. 

Despite poor prognoses, many children experience positive outcomes, walking or talking when experts doubted it possible. 

“The good outcomes are really rewarding,” Calvo said. “You see the children blossom.” 

Source: Nurse.com

Not Holuba. She’s different. She’s a nursing student in the pediatric nurse practitioner program at Johns Hopkins University, but she’s also a classically trained soprano whose soaring voice can transport her listeners far beyond the sterile confines of a hospital or clinic.

In between classes and studying, Holuba dons the fanciful gowns of fairytale characters and performs for pediatric patients and their families. Sometimes she gives them a full-on presentation, complete with storytelling and grand gestures and songs. And sometimes, she sits next to a child, holds her hand, and quietly croons her to sleep. She takes her cues from the children.

Either way, she is grateful for the chance to use her gift to help sick children feel better. Even just for the length of a song.

“It’s a great thing to see my dream of fusing my passions--nursing and music--happen,” said Holuba, 23.

As a little girl in New Jersey, Holuba spent many hours visiting a young relative in the hospital, which gave her some natural comfort with the hospital environment. Later, as a teenager, she participated in high school and community theater, honing her performing skills. Remembering her own family’s experience, Holuba called up the local children’s hospital and asked if she could come entertain the children.

She had a calling.

When she was a sophomore in high school, her father was diagnosed with multiple myeloma. Over the years, he received treatment at Memorial Sloan-Kettering Cancer Center in New York, including three different stem cell transplants. As she observed his nurses at work, the idea of a possible career in nursing was first planted.

Holuba eventually went on to major in psychology at Columbia University, graduating in three years. Then she enrolled in the accelerated BSN program at Johns Hopkins. She even recorded a CD of beloved Christmas songs, at her father’s encouraging.

“He really loved it,” Holuba said. “He took full credit for it being his idea…We played it for him that last Christmas, and it was really great to see his smile while it was on.” She was privileged to spend some time with her father before he died in January 2012.

After returning to school, she finished her BSN during the summer and began her current master’s degree program.

In Baltimore, Holuba had discovered Dr. Bob’s Place, a palliative-care home for terminally ill infants and children. Ever since that discovery, she has committed herself to weekly visits. Even when she’s trying to juggle all the demands of her program, she always finds time to visit the children.

“I make the time for this as if it were a job,” she said. “It’s really important to me, and I know how much it means to the families. I’ve been that family member where the hours can’t pass quickly enough.”

She loves seeing the children respond to her costume and to the music. She always takes requests from the young patients. She’s equally enthusiastic about slightly off-key group renditions of “Heads, Shoulders, Knees and Toes” and “Twinkle, Twinkle Little Star” as she is about the big Broadway-style numbers that she performs. And when children ask her to sing songs that she doesn’t know, she just encourages the children to teach them to her.

“It’s always fun to make music with them.”

She sees them as children who love music and singing and dancing, not just “sick kids.” “I think that’s a nice change for them,” she said.

With all of her experience, Holuba believes strongly in the value of good end-of-life care and palliative care. Many people don’t want to talk about death or dying, but she realizes it is part of the life process. She hopes to continue exploring her devotion to helping people at such a vulnerable time in their lives.

Her future will certainly include music, too. This spring, Holuba plans to begin visiting the pediatric patients at Johns Hopkins, in addition to Dr. Bob’s. She’ll also continue her course work, with her dream of becoming a pediatric nurse practitioner still in mind. She’s considering a future working with children with cancer in an outpatient setting.

“It’s really just about sharing the music and sharing the time,” she said.

The Nontraditional Career Resource Center encourages students to look beyond gender when choosing a career.

At a middle school in Brick Township, N.J., two eighth-graders developed a presentation that expressed the joys and hardships of their lives in immigrant families. At a high school in Marlboro, N.J., a young woman started a project to help kids in India whose parents are incarcerated. And at a school in Bergen County, N.J., a student started an intramural club for classmates who weren’t on any sports teams.  

Three projects. Three distinct visions of compassion and social justice. One common source: the Nontraditional Career Resource Center at Rutgers University.

The center, a state-funded program and part of the School of Management and Labor Relations, worked directly with those students, and others, to help them develop social-action projects.

Located in the Center for Women and Work, the NCRC’s principal mission is to raise awareness about career paths that are considered nontraditional—those jobs in which one gender comprises 25 percent of the workforce or less. The center employs a range of outreach efforts—guest speakers, workshops, partnerships with employers and educators, and programs for students in grades 7 through 12—that allows it to reach many different audiences.

“What we want people to understand is that at the heart of it all, choosing a career should not be based on your gender,” said Glenda Gracia-Rivera, associate director. “Girls may not be encouraged to go into the sciences or building trades because those are defined as male jobs. Boys may not be encouraged to become nurses or teachers because they are not considered nurturing enough.”

One of the center’s hallmark programs, the Career Summer Institute, began July 11 and brings 90 high-school students to Cook Campus at Rutgers for an intensive, one-week residential program that will focus on how to go about choosing a career. Students will learn about various careers, participate in workshops, and receive leadership training, all geared to developing their decision-making abilities. And like their predecessors, they’ll be encouraged to develop social-action projects so they can take the values they learn during the week back to their communities. The projects, which are called Step Up!, aim at addressing inequities in the students’ schools or towns.

“The kids come out super energized,” Gracia-Rivera said. “So we help them come up with an issue. We tell them, ‘you don’t have to change the world, you just have to address something at the local level.”’

Indra Murti, who attended the institute two years ago and is now a Rutgers undergraduate student, came up with a project that went far beyond the local level. During a visit to India in the summer of 2008, she became aware of a residential school for children of parents in jail or deceased. After visiting and volunteering at the school, Murti said she was moved to do more for the kids, who are supported entirely by the nuns who run the school.

Returning to Marlboro High School, she formed a student club devoted to maintaining a relationship with the school in India. The American students and the Indian students became pen pals.

“When I saw the kids (in India), and I felt their enthusiasm, it made me really want to help them,” Murti said.

Two eighth-graders in Brick Township, meanwhile, who attended the center’s program for younger students, The Academy of Leadership and Equity, came up with an idea that inspired everyone in their school. The students, one of Indian descent and the other of Mexican origin, worked with their ESL teacher, Theresa Ryan-Botello, to develop an oral presentation that expressed their hopes and fears as immigrants in America.

“They felt they were misunderstood by teachers,” Ryan-Botello said. “So our approach was: ‘Instead of complaining, let’s do something positive.’”

The presentation, “Many Worlds into One World,” told of the students’ ethnic background, examined the demographic changes in the middle school, and offered gentle tips on how to foster respect and greater communication within the school.

“They spoke from their heart, and that was really touching,” Ryan-Botello said. “Many of the teachers were in tears.”
 
All told, 10 students attending programs at the NCRC completed social-action projects, prompting the center’s staff to hold an awards dinner for the kids and their families last spring at the Labor Education Center. The students received certificates and other prizes.  

“Here are young people doing amazing things,” Gracia-Rivera said. “I felt like they needed to be honored and recognized for their efforts.”

Reprinted from Rutgers Today – RutgersToday.rutgers.edu.

From http://www.diversityinc.com

Federal healthcare law changes dramatically impact how the  industry—hospitals, health-insurance companies and pharmas—do business today. University Hospitals in Cleveland has been aggressively reaching out to the newly insured, predominantly Blacks and Latinos. University Hospital’s Case Medical Center’s Rainbow Babies & Children’s Hospital, known asUH Rainbow, is receiving a $12.8-million grant to implement a Physician Extension Team, which works to improve the healthcare of about 68,000 children on Medicaid with high rates of emergency-room visits.

Dr. Drew Hertz, medical director for UH Rainbow Care Network and an assistant clinical professor at Case Western Reserve University School of Medicine, was a guest speaker at DiversityInc’s Innovation Fest! event where he explained how this innovative program will provide 24/7 access to nurses and doctors for referrals, advice and healthcare coordination. University Hospitals is one of the 2012 DiversityInc Top 5 Hospital Systems. View the video below.