DiversityNursing Blog

By ABIGAIL ZUGER, M.D.
NYTimes.com

 
When a book is heavy with glossy photographs, you seldom expect too much from its words. In “The American Nurse,” though, it’s the narrative that hits you in the solar plexus.

Take the comments of Jason Short, a hospice nurse in rural Kentucky. Mr. Short started out as an auto mechanic, then became a commercial trucker. “When the economy went under,” he says, “I thought it would be a good idea to get into health care.” But a purely pragmatic decision became a mission: Mr. Short found his calling among the desperately ill of Appalachia and will not be changing careers again.

“Once you get a taste for helping people, it’s kind of addictive,” he says, dodging the inspirational verbiage that often smothers the healing professions in favor of a single incontrovertible point.
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Some of the 75 nurses who tell their stories in this coffee-table book headed into the work with adolescent passion; others backed in reluctantly just to pay the bills. But all of them speak of their difficult, exhilarating job with the same surprised gratitude: “It’s a privilege and honor to do what I do,” says one. “I walk on sacred ground every day.”

They hail from a few dozen health care settings around the country, ranging from large academic institutions like Johns Hopkins in Baltimore to tiny facilities like the Villa Loretto Nursing Home in Mount Calvary, Wis., home to 50 patients and a collection of goats, sheep and other animals on a therapeutic farm. Some nurses are administrators, some staff wards or emergency rooms, some visit patients at home. Many are deeply religious, a few are members of the military, and a handful of immigrants were doctors in their home countries.

All describe unique professional paths in short first-person essays culled from video interviews conducted by the photographer Carolyn Jones. Their faces beam out from the book in Ms. Jones’s black-and-white headshots, a few posing with a favorite patient or with their work tools — a medevac helicopter, a stack of prosthetic limbs or a couple of goats.

But even the best photographs are too static to capture people who never stop moving once they get to work. For a real idea of what goes on in their lives, you have to listen to them talk.

Here is Mary Helen Barletti, an intensive care nurse in the Bronx: “My whole life I’ve marched to a the beat of a different drummer. I used to have purple hair, which I’d blow-dry straight up. I wore tight jeans, high heels and — God forgive me — fur (now I am an animal rights activist). My patients loved it. They said I was like sunshine coming into their room.”

Says Judy Ramsay, a pediatric nurse in Chicago: “For twelve years I took care of children who would never get better. People ask how I could do it, but it was the most fulfilling job of my life. We couldn’t cure these kids, but we could give them a better hour or even a better minute of life. All we wanted to do was make their day a little brighter.”

Says Brad Henderson, a nursing student in Wyoming: “I decided to be a nurse because taking care of patients interested me. Once I started, nursing just grabbed me and made me grow up.”

Says Amanda Owen, a wound care nurse at Johns Hopkins: “My nickname here is ‘Pus Princess.’ I don’t talk about my work at cocktail parties.”

John Barbe, a hospice nurse in Florida, sums it up: “When I am out in the community and get asked what I do for a living, I say that I work at Tidewell Hospice, and there’s complete silence. You can hear the crickets chirping. It doesn’t matter because I love what I do; I can’t stay away from this place.”

The volume is not entirely about selfless service: It was underwritten by Fresenius-Kabi, a German health care corporation and leading supplier of intravenous drugs in the United States. Presumably, crass public relations motives lurk somewhere in the background. But that’s no real reason to be meanspirited about the result, a compelling advertisement for an honorable profession.

Young people with kind hearts and uncertain futures might just sit themselves down with the book, or wander through the Web site featuring its video interviews, www.americannurseproject.com, and see what happens.

By Angela Hill

Shyanne Reese prefers to call herself a "conqueror" rather than a survivor of breast cancer. She revels in her personal triumph, defeating the foe that threatened her life in 2008, and is now moving forward with poise and purpose.

However, Reese didn't always feel so confident. In fact, as an African-American, she says cultural myths long held her back from seeking treatment or even giving herself breast exams.

"Culturally, it's been taboo to discuss cancer in the African-American community, so a lot of women suffer in silence or don't seek treatment when they should," said Reese, 59, who works in the insurance industry and volunteers as a community health advocate for the Women's Cancer.

Cancer "conqueror" Shyanne Reese, who volunteers for the Women's Cancer Resource Center, is photographed in Oakland on Sept. 12, 2012. (Kristopher Skinner/Staff) Resource Center in Oakland. She reaches out to women at churches and health expos, leading the center's Sister to Sister support group for black women and even helping them navigate the health care system. "And I had my own personal battles. My mother had instilled in me a belief that it was wrong or sinful to touch myself, so I had never done self exams."

 Indeed, as health advocates work to draw attention to the disease for all women during October's National Breast Cancer Awareness Month, many point to recent studies -- such as one from Sinai Urban Health Institute in Chicago, which examined statistics from 25 major U.S. cities -- that confirm a fact physicians and advocates have known for decades: while Caucasian women have a higher incidence of breast cancer, women of color are more likely to die from it, chiefly because of cultural, social and economic factors that lead to late detection and treatment.

"There's a history of silence around cancer in the African-American community," said Peggy McGuire, executive director of the Women's Cancer Resource Center, which provides programs for low-income black women and Latinas. "Part of the problem is that they see themselves as the caregivers of the family and put themselves second. There's a reluctance to admit they are ill."

In addition, many say there's embarrassment and guilt -- as though a woman has done something to cause the disease. That combined with a "what I don't know won't hurt me" mentality is a recipe for avoidance behavior.

"There's also distrust of the medical community," McGuire said. "And, of course, poverty is the most significant factor because women likely lack health insurance, have poor nutrition -- even just living in neighborhoods with violence is a factor. The stress accompanying that has a significant effect on immune systems."

At Latinas Contra Cancer in San Jose, advocates have encountered unique cultural barriers for Latino women.

"For Latinas, cancer is often seen as a death sentence. It's kind of, 'If I've got it, that means I'm gonna die, so I don't want to know,' " said Ysabel Duron, Latinas Contra Cancer founder, KRON-TV news anchor and a cancer survivor/conqueror. "And there are religious barriers. Some see it as a punishment from God, that they must have done something wrong and deserve it. Or they'll say their husbands won't let them get a checkup -- no other man should be touching them.

"These are the things we try to break through. It's really about getting into those communities and literally taking them by the hand and navigating them through this."

Angelica Nuno, 24, of Oakland, did just that with her aunt a few years ago, helping her with translations, filling out forms, sitting with her in the doctor's office. Nuno now volunteers as a community health advocate for the Women's Cancer Resource Center.

"I saw how hard it was for my aunt with the language barrier, so I wanted to help," she said. "A lot of women in that situation are scared to even approach a hospital. They don't know you can get free mammograms and support."

While the medical community is learning more about societal issues affecting Latinas and African-American women with breast cancer, even less research has been done for Middle Eastern, Pacific Islander or other groups, Duron said.

"They're where African-American and Latinas were 15 years ago as far as research goes," she said.

Advocates in nonprofit assistance organizations hope health care reform will address some of the disparities in mortality rates by increasing cultural sensitivity training for mainstream care providers, Duron said. In the meantime, much of that kind of support falls to independent groups. And to volunteers like Reese.

By 2008, Reese was making big changes in her life. She had reached her weight-loss goal, dropping 101 pounds. And through her increasing education about women's health, -- which she said she had to go outside her family to find -- she had finally become comfortable with self breast exams.

"Something felt different," she said. "I didn't know if it was because of the weight loss. But going in to get it checked out -- I still felt embarrassment and guilt, like maybe I had caused this myself somehow because of carrying the weight for so long."

When her cancer was diagnosed, the same week she was laid off from her job, she was asked at the hospital if she wanted to have a social worker as a support person. She said no.

"It was all just overwhelming, and when I did decide I needed support, I wanted someone who looked like me, but there was no one available. It was so embarrassing to say that I needed help that way. African-American women are taught they don't need help and suffer isolation sometimes. So the challenge was to say, yes I want help."

Reese, who had surgeries on both breasts, has been cancer-free for nearly three years now.

"For me, breast cancer has been a gift," she said. "I knew I had a purpose in life, and it's finally been revealed -- to do what I do now, to reach out and help other women."

From diversityinc.com

In the fall of 2005, Alister Martin seemed the most unlikely candidate for Harvard Medical School. Laid up in the hospital with “my face so swollen my mother didn’t recognize me,” he says, the high-school senior was recovering from a brutal gang attack. The situation had escalated to a point that law enforcement advised Martin’s mother, a Haitian immigrant, to pull her son from Neptune (N.J.) High School to avoid further trouble.

So Martin’s mom secured a $15,000 loan and sent her son to the private Bollettieri Tennis Academy in Florida, where he completed his GED online while practicing 16 hours a day. Martin’s drive and unwavering desire to become a physician pointed him to Rutgers University’s Office for Diversity and Academic Success in the Sciences (ODASIS), whose Access-Med program prepares promising Black, Latino and other undergrads from underrepresented and economically disadvantaged groups for careers in medicine.

Four years later, Martin graduated from Rutgers with a 3.85 GPA and will begin Harvard Medical School this fall. “A miracle happened,” says Martin.

Each year, ODASIS serves roughly 500 at-risk undergrads, and nearly 800 of them have graduated since the program’s founding in 1985. Among the ODASIS class of 2009, 86 percent were accepted to medical school, up from 70 percent in 2007.

Still, Black, Latino and American Indian med students are rare. Three years ago, more than 40,000 people applied to medical school in the United States, with Blacks, Latinos and American Indians making up only about 15 percent of the applicant pool, reports the Association of American Medical Colleges (AAMC), while comprising about one-third of the population. That same year, only 8.7 percent of doctors were from these underrepresented groups, according to a study published in the Journal of Academic Medicine.

The latest AAMC data shows only slight improvement: Among the 42,269 med-school applicants in 2009, only 16 percent were Black, Latino or American Indian. And this disparity extends beyond the potential physician pool—a mere 6.9 percent of people from underrepresented groups ended up as dentists in 2007, only 9.9 percent were pharmacists and just 6.2 percent were registered nurses.

But it’s critical that people from underrepresented groups be recruited into healthcare and other science, technology, engineering and math (STEM) fields because it will increase the quality of care for those groups and spur innovation. Black, Latino and American Indian/Pacific Islander physicians are nearly three to four times more likely than whites to practice in underserved communities, reports the AAMC.

The dearth of diversity in all STEM professions is what inspired the launch of ODASIS. In 1986, when the initiative first began, only one Black student from Rutgers was accepted to medical school, and he eventually became a radiologist.

STEM-Enrichment Success

ODASIS is a rigorous program that offers four years of step-by-step supplemental instruction, academic enrichment and career advice designed to increase the pipeline of underrepresented talent in all STEM fields. The program is managed by Trinidad native Dr. Kamal Khan, a tireless instructor and caring mentor. He ensures that a four-year academic plan is developed for each incoming freshman so he/she stays on track and pursues the appropriate opportunities.

As a result, these students, often the first in their families to attend college, gain self-confidence. Before ODASIS, says Martin, “I never really believed in myself.”

Academic customization and an integrated-learning approach have helped make ODASIS a success. As part of the Access-Med program, for example, Khan formed collaborative relationships with local healthcare institutions to provide students with research training, professional learning and hands-on experience. Most unique to this pipeline program is the seven-month MCAT (Medical College Admission Test)/DAT (Dental Admission Test) prep course.

Khan often starts working with students who have been identified as having an interest in the sciences the summer prior to their first semester at Rutgers. To facilitate the transition for these incoming freshmen, Khan developed a five-week summer prep program to expose students to basic math and chemistry that allows them to earn college credits toward their degree. This summer, with financial support from Merck & Co., Khan and his team are working with 25 students to help hone their basic math skills “so they can hit the ground running” when they enter college.

“Students were coming in not prepared to take science courses,” he says. “They didn’t have the basic college math to take a college science course. So [we'd have] to support them in the basics. And then by the time they finished the basics, they were in their second year and would say, ‘I don’t want to take the sciences. I’m going to be here forever.’”

But thanks to the support of local organizations, the Educational Opportunity Fund Central Office and Johnson & Johnson, Khan is creating a feeder pool of potential ODASIS students by working with local students as early as ninth grade. The goal: to provide laboratory exposure, SAT-prep instruction, college-admissions counseling and career advice. This year, more than 300 12th-grade students attended the ODASIS Saturday Scholars Academy, one of four separate college-prep programs Khan oversees.

“We also do workshops with parents,” he says. “We get parents very involved.”

What motivates ODASIS students to succeed? Setting high standards and being held accountable for their actions, says Khan. “If you walk into class late or you miss a session and get three red flags, you’re out of the program,” he says. “Why so strict? If you want to be a doctor and you miss the operation, someone dies. So we try to teach them to become mature at a young age.”

In addition to their regular coursework, ODASIS students are required to attend roundtable-style academic support sessions, study halls (up to 9 hours a week for freshmen), testing, motivational workshops and more. They also meet one-on-one with advisers twice a month to review their progress.

“If you’re not doing well, they will call your family,” warns Mekeme Utuk, an ODASIS graduate who just completed her first semester at Harvard Medical School.

In exchange, the students, who often come from economically disadvantaged backgrounds, appreciate the support and opportunity. “All that I could take tutoring for, I took. I thought, ‘Why not? It can’t hurt; it’s just extra practice,’” recalls Utuk, whose parents are Nigerian immigrants.

The program also teaches undergrads how to study, critical for challenging courses such as organic chemistry. “I really didn’t know how to study. In high school, I would just cram for exams. But I didn’t know how to break down a chapter and take good notes … and learn through repetition,” says Utuk. “ODASIS made me a better thinker.”

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.

This is a great snapshot done by CareerBuilder of Diversity in the workplace.

By: Lanette Anderson

In nursing school, we are taught to respect the rights and dignity of all clients. As the “world becomes smaller” and individuals and societies become more mobile, we are increasingly able to interact with individuals from other cultures. Cultural competence and respect for others becomes especially important for us as nurses and patient advocates.

We all begin the process of learning the behaviors and beliefs of our culture at birth. We become assimilated into that culture, and the way that we express it is often without conscious thought. Our culture can have a definite and profound effect on how we interact with others, and also how we relate to the health care system.

Diversity is prevalent in our society and the clients and our co-workers in our health care system today clearly demonstrate that fact. The development of cultural competence first requires us to have an awareness of the fact that many belief systems exist. At times, the healthcare practices of others may seem strange or meaningless. The beliefs that others have about medical care in this country, and sometimes their aversion to it, may be difficult for us to understand. We must remember that we don’t need to understand these beliefs completely, but we do need to respect them.

Barriers to cultural sensitivity can include stereotyping, discrimination, racism, and prejudice. There are situations in which we may portray a lack of sensitivity without realizing it or intending to offend someone else. Simple steps such as addressing clients by their last name or asking how they wish to be addressed demonstrate respect. Never make assumptions about other individuals or their beliefs. Ask questions about cultural practices in a professional and thoughtful manner, if necessary. Find out what the client knows about health problems and treatments. Show respect for the client’s support group, whether it is composed of family, friends, religious leaders, etc. Understand where men and women fit in the client’s society. For example, in some cultures, the oldest male is the decision-maker for the rest of the family, even with regards to treatment decisions. Most importantly, make an effort to gain the client’s trust. This may take time, however all will benefit if this is accomplished. If the client does not speak your language, attempt to find someone who can serve as an interpreter.

Cultural competence is the ability to provide effective care for clients who come from different cultures. It requires sensitivity and effective communication, both verbally and non-verbally. As a nursing profession, we are far from representative of the populations that we serve. Members of minorities make up only a small percentage of nurses in the U.S. This number has been estimated to be as low as ten percent. The important issues of recruitment into the profession should specifically include efforts to recruit minorities and individuals from other cultures. When working with these individuals, the same principles apply as those listed above. Respect each other as a part of the health care team; we all are working towards the same goals of providing safe patient care.

Cultural sensitivity and cultural competence are an important part of the nursing care that we provide. Respect for others is discussed in our basic introductory courses in nursing school. It may have been a while since we heard how important it is in the development of an effective nurse/client relationship, but unlike some aspects of nursing, this will never change.

By Shantelle Coe RN BSN - Diversity and Inclusion Consultant

Creating an environment that embraces diversity and equality not only attracts the most qualified nursing candidates, but an inclusive environment also helps to assure that the standards of nursing care include “cultural competency.”  Cultural differences can affect patient assessment, teaching and patient outcomes, as well as overall patient compliance.

Lack of cultural competence is oftentimes a barrier to effective communication amongst interdisciplinary teams, which can often trickle down to patients and their families.

With the increase in global mobility of people, the patient population has become more ethnically diverse, while the nursing forces remain virtually unchanged.  Nursing staff work with patients from different cultural backgrounds.  Consequently, one of the challenges facing nurses is the provision of care to culturally diverse patients.  Hospitals and healthcare agencies must accommodate these needs by initiating diversity management and leadership practices.

According to Cross, T., Bazron, B., Dennis, K., and Isaacs, M. (1989); these are the 5 essential elements that contribute to an institutions ability to become more culturally competent:

• Valuing diversity

• Having the capacity for cultural self-assessment.

• Being conscious of the dynamics inherent when cultures interact.

• Having institutionalized cultural knowledge.

• Having developed adaptations of service delivery reflecting an understanding of  cultural diversity. 

A culturally competent organization incorporates these elements in the structures, policies and services it provides, and should be a part of its overall vision.

From all levels, the nursing workforce should reflect the diversity of the population that it serves.  A more diverse workforce will push for better care of underserved groups.  It’s important to note that that diversity, inclusion, and cultural awareness isn't just about race or ethnicity.  We must always keep in mind socioeconomic status, gender, and disability in our awareness.

Becoming more inclusive is a shared responsibility between nurses and healthcare agencies.  Becoming an “agent of change” within your facility can inspire awareness and affect attitudes and perceptions amongst your peers. 

Nurses and healthcare workers must not rely fully on the hospital and healthcare systems to institute an environment of cultural awareness.   

Nurses can increase their own cultural competencies by following a few guidelines:                                   

• Recognizing cultural differences and the diversity in our population.

• Building your own self-awareness and examining your own belief systems.

• Describing and making assessments based on facts and direct observation.

• Soliciting the advice of team members with experience in diverse backgrounds.

• Sharing your experiences honestly with other team members or staff to keep communication lines open.  Acknowledging any discomfort, hesitation, or concern.

• Practicing politically correct communication at all times –  avoid making assumptions or stereotypical remarks.

• Creating a universal rule to give your time and attention when communicating.

• Refraining from making a judgment based on a personal experience or limited interaction.

• Signing up for diversity and inclusions seminars.

• Becoming involved in your agencies diversity programs – find out what your resources are - most institutions have something in place.

By incorporating a few of these steps into your daily nursing practice, you are taking steps towards becoming culturally competent.

Inclusive nurses demonstrate that we are not only clinically proficient and culturally competent, but are the essence and spirit of the patients that we care for.

By Christina Orlovsky, senior writer, and Karen Siroky, RN, MSN, contributor

As the nation’s population becomes more diverse, so do the needs of the patient population that enters U.S. hospitals. As caregivers with direct contact with patients from a wide spectrum of races, ethnicities and religions, nurses need to be aware and respectful of the varying needs and beliefs of all of their patients.

In its position statement on cultural diversity in nursing practice, the American Nurses Association (ANA) states that: “Knowledge of cultural diversity is vital at all levels of nursing practice…nurses need to understand: how cultural groups understand life processes; how cultural groups define health and illness; what cultural groups do to maintain wellness; what cultural groups believe to be the causes of illness; how healers cure and care for members of cultural groups; and how the cultural background of the nurse influences the way in which care is delivered.”

Additionally, the Joint Commission requires that all patients have the right to care that is sensitive to, respectful of and responsive to their cultural and religious/spiritual beliefs and values. Assessment of patients includes cultural and religious practices in order to provide appropriate care to meet their special needs and to assist in determining their response to illness, treatment and participation in their health care.

There are a number of ways to comply with the requirements for providing culturally diverse care.

First, be self-aware; know how your views and behavior is affected by culture. Appreciate the dynamics of cultural differences to anticipate and respond to miscommunications. Seek understanding of your patients cultural and religious beliefs and values systems. Determine their degree of compliance with their religion/culture, and do not assume.

Furthermore, respond to patients’ special needs, which may include food preferences, visitors, gender of health care workers, medical care preferences, rituals, gender roles, eye contact and communication style, authority and decision making, alternative therapies, prayer practices and beliefs about organ or tissue donation.

Kathleen Hanson, Ph.D., MN, associate professor and interim executive associate dean for academic affairs at the University of Iowa, summarized the importance of learning cultural diversity in nursing education.

“Cultural competency is threaded throughout the nursing school curriculum. We teach every course with the idea that there’s content that may need to be explained for a diverse student group,” Hanson said. “In nursing, cultural competency has been around for a long time. I think that’s probably something that the nursing profession recognized maybe a bit before some other disciplines. We’ve always worked in public health, so we have always seen the diversity of America.”

Hanson concluded: “We need to be able to care for diverse populations because our country is growing increasingly diverse. Oftentimes persons who are in minority groups or who are underrepresented have different health care needs. It’s important for us to have a student population that is as equally diverse as our client; we need to prepare a workforce that not only knows how to work with diverse peoples, but also represents them.”

This table shows the number of students enrolled in generic (entry-level) Baccalaureate, Master's, and Doctoral (research-focused) programs in nursing from 2002 to 2011.

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