DiversityNursing Blog

By Sarah Cutrufello, RN, MSN, OCN

As an oncology nurse, I witness how ordinary people living with cancer cope with their extraordinary disease; how common people summon the uncommon strength to receive the toxic cocktail of chemicals that medical professionals call “treatment.” Each case is different, each patient unique.

About two years ago, I was fortunate to develop a relationship with a woman who had a special way — quiet, gentle, dignified — of handling her disease. At 66, she had been diagnosed with acute myelogenous leukemia. 

When we first met, she looked up at me from her hospital bed and solemnly said, “I should be in Switzerland today … .” Her husband finished the thought — they had booked a week-long trip to Germany and Switzerland. Recently retired, the couple had reserved a place in their minds for that special spot to drink tall glasses of wine in a cabin overlooking the Alps. 

Yet here they were, in a hospital room in Philadelphia. Their updated itinerary consisted of eating tasteless scrambled eggs and lying on an uncomfortable mattress overlooking the brick buildings of the hospital’s sprawling city complex. It was not fair. 

In that moment of our first meeting, I felt a profound sadness. This woman had an exciting life that she shared with her husband, who one could instantly tell was head over heels for his wife. Cancer was robbing her of this life.

She never said she was scared or upset or angry. She was appreciative of everything I did. When the physician’s team came in, she fooled them with her sweet smile and upbeat attitude. It almost was worthy of some kind of perverse Oscar award for “Best Performance in a Terminally Ill Role.” 

But I could see through the act to the deep pain and hurt of the “actress” lying in bed; someone who was struggling to come to terms with the fact that as recently as a month prior she was enjoying a vibrant life with her husband and friends back home.

A few weeks later, on St. Patrick’s Day, she could barely wait to tell me as I walked in, “I should be at a great party today.”

“A great party? Tell me about this party,” I said.

Her face lit up as she told me how her neighborhood opened its homes on St. Patrick’s Day to hold a sort of bar crawl. Again, though, there was the hint of disappointment. 

I listened with a smile on my face and said — as I always said when we talked about events she could no longer attend — “When you get out of here, you will do these things. I promise.” These words felt like equal parts truth, lies and hope mixed together in some kind of phrase that needs to be said on such occasions.

Later, as I was unhooking her blood transfusion, I noticed she had found a few moments to sleep. I stood there for a moment, silently, my eyes filling with tears. It occurred to me just how disappointed she must have been every time she woke up and was confronted with the reality that is cancer. 

She was not in Switzerland or Germany or enjoying a great St. Patrick’s Day party with friends. The life she had known before cancer stopped her in her tracks was happening someplace far removed from where she was. She would die about a year and a half after I met her. 

Above all else, this experience taught me the importance of approaching patients with open ears and an open heart. Dealing with anxiety, anticipation, fear, loneliness, uncertainty or any number of other emotions, our patients often need a kind of nursing care that goes beyond administering their prescribed treatment.

At the close of that day’s shift, I said to another clinician, “I feel her sadness. She breaks my heart.” To which the other person gave a quick chuckle and said, “She’s not sad.” 

I thought to myself: another Oscar-worthy performance. 

Source: Nurse.com

By Debra Anscombe Wood, RN

Psychiatric emergencies can be as serious as a medical condition, but in traditional EDs, mental health patients may wait for treatment. Specialized psychiatric EDs serve that population quickly and efficiently. “They come in with everything from the need for prescription refills to being actively suicidal,” said Brian Miluszusky, RN, BSN, director of nursing in the emergency medicine department at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York. “A suicidal person is as much at risk of dying as someone having an MI (myocardial infarction).” 

As demand for emergency care has increased, so has the number of mental health patients seeking services. A study from the Carolina Center for Health Informatics at the University of North Carolina at Chapel Hill reported in 2013 that nearly 10% of ED visits in North Carolina from 2008-2010 were for mental health diagnoses, and the rate of mental health related visits increased seven times more than overall ED visits. Mental health related ED visits increased by 17.7%, from 347,806 to 409,276 from 2008-2010. Stress, anxiety and depressive disorders were most common. 

A January 2012 American Hospital Association Trendwatch report said, “In 2009, more than 2 million discharges from community hospitals were for a primary diagnosis of mental illness or substance abuse disorder. ... Among children, mental health conditions were the fourth most common reason for admission to the hospital in 2009.”

The report said there were more than 5 million visits to EDs in 2009 by patients who had a primary diagnosis of mental illness or a substance abuse disorder. “Access to [psychiatric] care is not easily found [in the community], but if you are having a mental health crisis, you can walk into our emergency department 24/7 and be seen by a psychiatrist within a couple of hours,” said Jennifer Ziccardi-Colson, RN, MSN, BSW, MHA, vice president for nursing services at Carolinas Medical Center-Randolph, a behavioral health center with a psych ED and 66 inpatient beds in Charlotte, N.C. 

Psych EDs serve patients with acute episodes of behavioral health diagnoses, including feeling suicidal, anxious or depressed or abusing substances. “When patients come to us, they are assessed and seen promptly,” Ziccardi-Colson said. “People can feel comfortable coming to our environment to receive care.” 

Not all patients with mental illnesses receive care in a psych ED. Even at those hospitals with a dedicated psych emergency unit or a stand-alone psychiatric emergency services facility, patients with acute medical conditions, such as an MI or a broken hip, are treated in the regular ED. The ED provider must determine if a medical problem is contributing to mental status changes or if the problem is solely psychiatric in origin. 

Some psych EDs, such as San Francisco General Hospital and Carolinas Medical Center care for children as well as adults. Children and teens receive emergency psych services at Carolinas Medical Center-Randolph. Younger children, ages 3 to 6, come in with situational stress related to family dynamics, such as divorce or custody battles; depression or anxiety, often related to bullying at school or at home; suicidal ideation; conduct disorders; and behavioral issues related to autism or developmental delays. “In the emergency room, it’s crisis stabilization,” said Tez Bertiaux, RN, MSN, nurse manager for the ED at Carolinas Medical. “A lot of these children are followed in the community by a mental healthcare provider.”

The hospital’s social worker will arrange outpatient care for children who do not have a current therapist. Many are admitted to inpatient care. The psych emergency services program treats about 700 children and adolescents monthly, and the hospital admits about an equal number to its inpatient units, said Bertiaux.

Pediatric ED visits tend to increase during the school year, with school staff workers referring students for care. Some of the children are in foster care or are homeless or living in shelters. Some parents and guardians will stay during the stabilization and others do not. “It’s a very complex dynamic, because you are not just treating the patient — the family is involved,” Bertiaux said. 

Bertiaux said many of the mental health issues that bring children into the ED are related to their environment. “And that can be challenging,” she said.

Patients seeking care at a psych ED may be treated and discharged, but others require admission to a psychiatric bed for stabilization. Physicians at NewYork-Presbyterian and San Francisco General admit about 30% of their psych ED patients to the hospital. But treatment begins in the psych ED. “It’s amazing how much we can help people,” said Andrea Crowley, RN-BC, interim nurse manager in psychiatric emergency services at San Francisco General. “Some just need someone to talk to and bring them down from the crisis they are in. It makes you feel you are making a difference, and it’s a visible, tangible thing.” 

Psych care a growing need

Carolinas Medical has seen a steady increase in psych ED volume during the past several years. It treats about 18,500 patients annually with a variety of psych disorders and continuously operates at 100% occupancy. Construction is under way to double the psychiatric hospital’s inpatient beds to 132. 
Johns Hopkins Hospital in Baltimore’s psych ED census has experienced a 30% jump this year. “People are sicker, and there are fewer resources in the community,” said Kate Pontone, RN, MSN, nurse clinician 3 and nursing service line leader for Psychiatric Emergency Services at Johns Hopkins. “Outpatient programs that had space available are no longer options. People are running out of medications or cannot afford transportation. Many of the same reasons emergency departments are crowded.” 

A March 2012 Congressional briefing by the National Association of State Mental Health Program Directors reported, “the economic downturn has forced state budgets to cut approximately $4.35 billion in public mental health spending over the 2009-2012 period,” a trend it expects will continue. While at the same time, there was a 10% increase in consumers receiving state-supported mental health services. 

In July 2012, the Treatment Advocacy Center released the paper “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” which found nationwide, closures of such hospitals “reduced the number of beds available in the combined 50 states to 28% of the number considered necessary for minimally adequate inpatient psychiatric services.” And “in the absence of needed treatment and care, individuals in acute or chronic disabling psychiatric crisis increasingly gravitate to hospital emergency departments, jails and prisons.”

Volume at San Francisco General’s psych ED has jumped from 500 per month to 600 per month. “It could be due to closures in programs,” Crowley said. “We are starting to see a fallout from lack of services in the community.” 

Volume also has increased at NewYork-Presbyterian where, typically, a dozen or more psych patients are waiting in the regular ED for a bed in the psych ED, Miluszusky said. Difficulty transferring patients to an inpatient bed clogs up the EDs. A lack of insurance complicates transfers, and patients may end up boarding in a regular or psych ED. 

Patients may walk in, arrive by ambulance or with a petition for involuntary commitment, because they are deemed dangerous to themselves or others. First responders may take a mental health patient to a psych ED rather than to a community hospital without such specialized services. “This is a growing population, and emergency rooms will have to evolve,” Miluszusky said. “The population is getting so big; we are going to have to think of new ways to handle it.” 

Benefits of a separate psych ED

Psychiatric emergency services programs typically are staffed with behavioral health professionals, allowing mental health interventions to begin quickly, and often the onsite team can stabilize the patient, avoiding a hospitalization, according to the article “Treatment of Psychiatric Patients in Emergency Settings” in the journal Primary Psychiatry. “You don’t have agitated psych patients in the emergency room with all of the sick people,” Crowley said. “It’s a specialized environment where you can begin treatment better.”

Nurses and other members of the psych ED team have a solid understanding about different mental health conditions and their treatment. They can begin therapeutically talking with patients immediately. “Our patients appreciate being cared for by someone who is familiar with their medications and their symptoms and can intervene when they begin to decompensate,” Pontone said. “You get specialized care and the rooms are safe,” said Miluszusky, who adds that improves outcomes. 

Psych EDs often are locked units and feature specially outfitted rooms, with no sharp corners, no cords, nonexposed plumbing and a calm atmosphere. The safety features prevent patients from harming themselves or creating tools to harm others. “Our main priority is patient safety,” Ziccardi-Colson said. “There’s no potential for suicide or other negative outcomes.”

Ziccardi-Colson reported Carolinas Medical’s psych ED operates cost effectively, in part because of its ability to begin treatment and stabilize. “We’re able to process people more quickly than a medical ED,” Ziccardi-Colson said. 

Miluszusky said having a psych ED can be cost effective, because it reduces overtime pay necessitated by providing one-on-one oversight of a psych patient in the medical ED. 

Nurse staffing varies by institution, often with psychiatric nurses providing care, such as at San Francisco General’s psych ED. “It’s an exciting job, where you see a wide variety of people,” Crowley said. “You have a profound effect on people’s lives.”

Emergency nurses, who have received specialized training in the care of mental health patients and de-escalating situations, staff the psych ED at NewYork-Presbyterian. Nurses from a Johns Hopkins inpatient psych unit covers the emergency room, and Pontone describes significant interest from the inpatient staff. The hospital also cross-trains the ED nurses, so they can step in during an emergency. Pontone says nurses who love psychiatric nursing are interested in the management of the acutely ill patient, who needs as much care and support as they can get in a safe environment. “We like to be there when patients are in crisis and need help,” she said. “And we are good in a crisis.”

Ziccardi-Colson said every day presents challenges, but the reward of helping patients to wellness is inspiring and keeps nurses motivated. “Those who like it, love it,” Crowley said. “And for those who are not into it, we are happy to do it for them.” 

Source: Nurse.com

As nurses we are taught that we are professionals and we must maintain a certain emotional distance with our patients. It’s a boundary that encompasses the therapeutic relationship: nurses as caregivers, patients as the recipients of the care. But now, working as a nurse, I have found that while most of my professional boundaries are well defined, sometimes the line between a professional and personal relationship with a patient can become blurred.

I work on an orthopedic surgical unit where most patients are coming in and going out very frequently. That makes it hard to get to know anyone too well. But there are some patients that we never forget, for good or bad reasons. Most of the time these patients stay with us because, for whatever reason, one of us crossed the invisible boundary nurses set for themselves.

Recently, I cared for two patients who touched me so deeply it was impossible to maintain a professional distance. My grandfather had recently passed away, and both of these men reminded me of him. My grandfather, or “Grand-Daddy” as we all called him, was one-of-a-kind, and one of the kindest and most generous people I’ve ever met. He was hard of hearing but constantly fiddled around with his hearing aids, so it was wise to always be prepared to repeat yourself once or twice. He had an extraordinary memory until the day he died, and was one of the funniest people I’ve ever known.

One day at work, an older man arrived on my floor after a total hip replacement. As I worked to admit him to our care, his room was crowded with half a dozen family members who surrounded him with love. I asked him about his family, and he told me about his eight children, 30 grandchildren, and a couple of great-grandchildren too. It was uncanny how much this man reminded me of my grandfather, who also had a large family of six children, 28 grandchildren and three great grandchildren.

I smiled as I watched my patient fiddle with his hearing aids, and tears welled up in my eyes as he answered all of my questions with a familiar, “What did you say?” I didn’t mind repeating myself, and for a moment, it was as if I was speaking with my grandfather again.

After I was finished admitting him and settling him in, I found myself constantly peeking back into his room asking if he was O.K. and if he needed anything. He was pretty low-maintenance and never really needed much, and eventually, he was gone. I never told him that he reminded me of my grandfather, or how he tugged at my heartstrings, and I often wonder if I should have. But I worried that in showing this man a little extra attention, I had somehow breached the therapeutic relationship.

Not long after that, another patient came up to the floor. The report said he was an older man who was in “comfort care.” This essentially means that no lifesaving efforts would be made on his behalf; we were there to keep him comfortable during his final days. When this patient came up to the floor, I was quite taken by him. His gruff, Irish exterior belied his sweet nature. Medically, he had a lot of issues, but when he came up to the floor, the only thing he wanted was a bowl of oatmeal. When his tray came, he found cream of wheat instead. He was so disappointed, but I was determined to find him a bowl of oatmeal.

Miraculously, after a search through our floor kitchen, I found oatmeal and delivered it to him. He was delighted and blew me a kiss and gave me a wink. His chart said he needed assistance to eat, but he dug right in. Sure, he made a mess, but he managed just fine on his own.

Watching him eat that oatmeal reminded me of some of my last meals with Grand-Daddy. Grand-Daddy never was the neatest eater, and we would always laugh about what a mess he made. But he didn’t care — at his age, he just wanted what he wanted when he wanted it. My patient’s personality was strikingly similar to that of my grandfather. As he lay curled up in the bed, I thought about the strong man he must have been a long time ago.

When his wife and children came to the room, I felt a pang of familiarity. His wife remained so graciously composed during her visits. It brought back memories of my grandmother during my grandfather’s last days. Despite her deep sadness and fear of what was to come, my grandmother kept full composure and took care of not only him but also everyone around her. I still am amazed by how strong and selfless she was during that time: a true role model for unconditional love, and I saw these saintly qualities in this man’s wife.

The following day, the man was sent back to a nursing home where comfort care would be resumed. When the transporters came to get him, I started to feel emotional, like someone I loved was going to leave me. Even though I knew he was going to a nice and comfortable facility, I didn’t want him to go. We transferred him onto the stretcher and I made him cozy in his blankets. His family was sincerely thankful, and I remember telling them with tears in my eyes how much we enjoyed taking care of him, and how much we would miss him.

The tears continued to well up as I watched his stretcher go around the corner and out of sight, because I knew I would never see him again. I felt like I was saying goodbye not only to him, but also to my grandfather all over again. But once again, I stopped myself from sharing these feelings with my patient or his family. They knew I cared, but they never knew how much caring for him meant to me personally.

Looking back, I still don’t know if I did the right thing, keeping my feelings to myself. I now realize that both of these patients were helping me heal, even as I was helping them. Watching them leave was like letting go of my grandfather again, but they also gave me the gifts of laughter and reminiscence, right when I needed them most.

I know that, ultimately, I am still just the nurse, and they are still just my patients. But I think it’s better for both the patients and myself if we both sometimes allow ourselves to feel something more than a professional bond. Nurses and patients move in and out of each others’ lives so quickly, but we are nonetheless changed by every encounter.

I became a nurse because I want to care for people and make a difference. Being touched in return is an added bonus.

Source: The New York Times

By Samantha Cronk

For Berkeley County native Dorothy Leavitt, 93, the desire to help people is natural, so when the call came for volunteers to assist soldiers wounded in World War II, Leavitt needed no other prompting.

While she was aware of WWII and its effects, the war became personal for Leavitt after she helped care for eight severely wounded soldiers who were recovering in an army hospital in Martinsburg.

Leavitt graduated from Martinsburg High School in May 1937 at 18 and by September, she began training to become a nurse. In 1940, Leavitt graduated as a registered nurse as part of a graduating class of fewer than 10 women.

Journal photo by Samantha Cronk
Berkeley County native Dorothy Leavitt, 93, used her profession as a nurse to help soldiers wounded during World War II who were sent to recover at the Newton D. Baker Hospital in Martinsburg.

"I knew even when I was a young girl that I wanted to be a nurse. My mother had her babies at home and the nurses would be helping the doctor, and I just always wanted to be a nurse," she said.

It was during her time as a nurse that Leavitt chose to volunteer her services to wounded World War II soldiers at the Newton D. Baker Hospital, a military hospital, in Martinsburg. In 1946, the Newton D. Baker Hospital became the VA Medical Center as part of the Veterans Administration.

"I always worked in the paraplegic ward. There were about five cubicles, and each one had eight men in it. They were all young men in their 20s, paralyzed from the waist down. We always went back to the same eight men, so those eight are the ones you say you took care of," Leavitt said.

"We worked during the daytime and then every night for 18 months we went down from 7 to 10 p.m. or later, because sometimes they had to pull us away," Leavitt said.

Leavitt described her job as anything that would make the men comfortable, including rubbing their backs, washing their faces and changing their sheets.

Eventually, the men Leavitt cared for were transferred to hospitals close to where the men lived. Along with other nurses who volunteered in the paraplegic ward, Leavitt helped form the Newton D. Paraplegic Group, which kept soldiers and nurses connected.

Through the group, soldiers and nurses would stay in contact through letters and meet at least once a year for food and fellowship.

As a nurse, Leavitt worked for several local doctor's practices as well as in private duty. She also worked at the VA Center for one year in the medical ward.

Through her career as a nurse and life in Berkeley County, Leavitt has experienced many professional milestones, including working with Martinsburg's first radiologist, as well as witnessing almost a century's worth of change to Martinsburg.

"I liked to take care of patients, and I just didn't want to be behind a desk. At the time I was going for my training, it was just a job. Now, I've had some time to think back, and I realize that some of that stuff I saw during my nursing career was really miraculous," Leavitt said.

Leavitt's thumbprint can be found throughout Martinsburg. Of the 64 acres Leavitt and her late husband Charles owned as orchards, Leavitt retains 53 acres. On some of the land she sold sits the Martinsburg water tank and Orchard View Intermediate School.

"The amount of change, it's amazing. It's still a good place (to live). You can see the changes. Of course they paved the roads, we get mail and they've changed the name of (Delmar Orchard Road) so many times," Leavitt said.

Leavitt can recall living through the Great Depression, claiming that her family was fortunate to avoid the harsh conditions many families found themselves in during that time. Leavitt credits her father with providing for her mother and siblings, saying that he worked hard to find work and always provided them with new shoes and textbooks before every school year.

"I went to a two-room school house through the eighth grade. When we finished eighth grade, we had to go to the old Martinsburg High School and take a test for two days to see whether or not we were allowed to go to high school. I made the second highest (grade) in the county. You remember that kind of stuff," Leavitt said.

Leavitt said her parents supported her ambition to become a nurse. Although it has been many years since she has worked professionally, Leavitt still considers herself a nurse.

"Once you're a nurse, you're always a nurse," she said.

Source: The Journal 

By Heather Stringer

By 2043, the U.S. is projected to become a majority-minority nation for the first time in its history, according to the U.S. Census Bureau. Both the Hispanic and Asian populations will more than double between 2012 and 2060, and the black population will increase by 50% during the same time period. These statistics illustrate that nurses will be caring for a progressively diverse patient population and the increasing urgency to build a diverse RN workforce. 

“Patients come with an expectation that the caregiver will understand all of their care needs,” Deidre Walton, RN/PHN, MSN, JD, president and CEO of the National Black Nurses Association based in Silver Spring, Md., said. “When you have a diverse workforce, you have people with knowledge and skills to meet the diverse needs of patients. The patient’s cultural identification, spiritual affiliation, language and gender can all affect the care they need, and it is very important that the nurse understands that.” 

Although Walton said the healthcare community is far from reflecting the demographics of the American population, she has hope as she looks into the future because diversity in the nursing workforce is being highlighted as a critical priority by more than minority nursing organizations. 

“I am excited because organizations such as the Robert Wood Johnson Foundation and AARP have a diversity agenda, and that makes me hopeful that there will be change,” she said.

Increasing diversity in the workforce, as illustrated on the following pages, will take individual and group efforts. 

Job titles of minority nurses

According to the 2008 National Sample Survey of Registered Nurses, the largest sample to date, minority nurses were more likely to hold staff nurse positions than white, non-Hispanic nurses.

Black nurses comprise 5.4% of the RN workforce, and 13.8% are in management positions, which is higher than any other ethnic group. Walton, however, said far more black nurses still are needed in leadership positions because this 13.8% is taken from a small pool of nurses. 

“Some organizations have very active programs to promote diversity in leadership, but the diversity gap in leadership continues,” Walton said. “There is a gap between how many minorities are recruited and how many are actually hired. These minorities in leadership roles are able to participate in making changes to improve the practice environment and outcomes, and this is very important.” 

Can patient ethnicity affect care?

According to a 2012 report from the Agency for Healthcare Research and Quality, racial and ethnic minorities face more barriers to care and receive poorer quality of care when they can get it. Findings from the report included:

Blacks received worse care than whites, and Hispanics received worse care than non-Hispanic whites for about 40% of quality measures.

American Indians and Alaska Natives received worse care than whites for one-third of quality measures.

Blacks had worse access to care than whites for one-third of measures, and American Indians and Alaska Natives had worse access to care than whites for about 40% of access measures.

Hispanics had worse access to care than non-Hispanic whites for about 70% of measures. 

Would a more diverse RN workforce correct some of these disparities? "Absolutely,” Walton said. “Diversity will improve patient-nurse communication, collaboration and clinical practice for patients of all backgrounds. If an African-American woman comes to the ED with abdominal pain, what is the likelihood that she will be diagnosed with a sexually transmitted disease as the cause of the pain rather than [staff] conducting other tests for a definitive diagnosis? When you have a culturally diverse RN workforce, they may not as easily dismiss symptoms and will advocate for a more intense work-up.” 

According to the 2008 National Sample Survey of Registered Nurses, only 0.3% of the RN workforce is American Indian or Alaska Native. This small percentage who are accepted into nursing school, earn their degree and enter the workforce often have overcome significant challenges, Bev Warne, RN, MSN, one of the founders of the Native American Nurses Association based in Phoenix, Ariz., said. “A survey in 2010 showed that 51% of Native American high school students graduate, so the drop-out rate is very high,” Warne said. “There are complex reasons for this. Studies show that many grow up in families that are poverty-stricken, so they suffer from poor nutrition and difficult family situations, and by the time they are in junior high they are already behind.” 

Warne believes the preparation to attain a formal education begins with good prenatal care, proper nutrition and support for parents. Even after Native Americans are accepted into nursing school, there are other challenges they may face.

“There are differences in values among Native people and Western people,” Warne said. “Generally Native Americans are raised in more of an extended family where there is an emphasis on inclusiveness. When they go into the college setting outside the reservation, they may confront Western values that promote individualism and competition, which is often the opposite of how they were raised. To be successful in this new setting, it is important for educators to get involved with students to discuss this new reality.”

It also can be difficult to transition to the Western medicine paradigm, Warne said. “In the Western hospital setting, caregivers tend to look more toward the physical aspects of illness, but from the Native perspective, they are accustomed to a holistic way of viewing a person.” 

Power to promote

Although it may seem difficult to make time to promote nursing to minorities within the community, here are a few simple strategies that are making a difference. 

Celia Besore, executive director and CEO, National Association of Hispanic Nurses: 
“I believe stories are really what lead people to consider nursing. The personal stories of nurses who were maybe the first to go to college in their families and now are very successful are the ones that inspire people. Our chapter members go into the community and do career fairs and visit schools, and that is when nurses can share their stories. There have been times when people have discouraged Hispanic students from going to nursing school because they think the students will not succeed, and our nurses can give them hope. We also tell young people that 30% of our members are student nurses, so they know they will not be alone.

“During these events, we also explain that now is a good time to be a minority in healthcare,” she continued. “We get calls from places that are desperately looking for Latino nurses. The word is starting to get out that it is an asset to understand the culture and language of minority patients, and hospitals want people with this experience.”

Mildred Crear, RN, MA, MPH, chairwoman for nursing and community education, Bay Area Black Nurses Association:
“Our chapter sponsors community health events like blood pressure drives, and this gives people in the community a chance to see us and ask what it takes to be a nurse. We share this information and then invite them to our meetings. We also do a lot of health fairs with churches and black sororities and fraternities where we do presentations about nursing, and this has been a really effective way of promoting the profession.”

Sharon Smith, RN, MSN, FNP-BC, president of the San Diego Black Nurses Association:
“I think it is critical to connect with people when they are young and try to mentor them. You can meet youth through church, in the community or through the events sponsored by your minority association. Our chapter visits high schools to recruit students, and we will go into the tough neighborhoods where it is harder for students to believe that they can do it. I share my own story that I grew up in North Carolina in one of the poorest counties, and I was told I would never finish high school. I told myself, ‘This is your thought, and not mine,’ and I went on to earn a BSN, a master’s degree and now I am pursuing a doctorate. You can do simple things like take them to work or communicate online, and this will show students the positives of a career in nursing.” 

It starts in the schools

Diversity in the nursing workforce is dependent upon a pipeline of diverse students who graduate from nursing school. This much-needed diversity among students, however, requires focus and resources, Julie Zerwic, RN, PhD, FAHA, FAAN, professor and executive associate dean at the University of Illinois at Chicago, College of Nursing, said. “Our school went through a period of time when there was no staff focused on watching diversity, so the number of underrepresented minorities in the program dropped,” she said. “If no one is paying close attention, you can lose momentum.” 

For example, the school recognized that a number of underrepresented minorities were not finishing their applications and would benefit from having a staff member available to receive phone calls and answer questions. The school also started offering application workshops. 

Although Zerwic hopes to see even more diversity among undergraduate nursing students, her institution has had significant success in recruiting graduate minority students. Zerwic credits a National Institutes of Health-funded program, the Bridges to the Doctorate Program, that helps the school to support potential minority doctoral students through mentoring, funding and coursework. 

Like the University of Illinois, diversity became a high priority in the School of Nursing at The University of Texas Health Science Center. “We knew that about 62% of the population in San Antonio was Hispanic, and to provide competent healthcare we needed to increase the number of Hispanic nursing students,” Hilda Mejia Abreu, PhD, MS, BA, associate dean for admissions and student services at UTHSC San Antonio, said. 

During the spring and fall, staff members travel throughout the U.S. to college fairs, schools, nursing association recruitment fairs and other activities to recruit minority students. The local Spanish-language channel also regularly features a 15-minute segment in which Mejia Abreu explains the college preparatory classes needed to apply for nursing school and how to finance an education. 

By comparison, below are the national diversity statistics for nursing schools:

Race/Ethnicity of Students Enrolled in Entry-Level 
Baccalaureate Nursing Programs in the U.S. in 2011
White, non-Hispanic: 72%
Black: 10.3%
Hispanic: 7%
Asian, Native Hawaiian or other Pacific Islander: 8.8%
American Indian or Alaskan Native: 0.5%

(Source: American Association of Colleges of Nursing) 

Overcoming the language barrier

For nurses who have arrived in the U.S. as adults and learned English as a second language, there typically are two distinct challenges they will face when communicating: being understood by Americans and understanding Americans, said Victoria Navarro, RN, MSN, MAS, president of the Philippine Nurses Association of America. 

“In the Philippines, we were colonized by Spain for about 400 years, so the Filipino language (Tagalog) that evolved has root words based in Spanish,” Navarro said. “We pronounce every syllable. In English, you have words with silent syllables or letters, so that in itself is something that we need to learn.” 

In addition to pronunciation, healthcare workers use jargon to communicate, and this is even more complicated when English is a second language. Navarro remembers when a physician told a Filipino nurse to get the “lytes.” The nurse turned off the lights, when in fact he had meant electrolytes. Other communication challenges Filipino nurses confront in the U.S. include:

In Tagalog, there are no long vowels, so it takes time and practice to learn to pronounce these sounds. 

There are no pronouns such as ‘he’ and ‘she’ in Tagalog, and there are no singular or plural verbs. It takes time to know when to say the proper pronoun or verb. Many people make mistakes initially.

Mental processing in the native language happens before responding in English. The literal translation from Tagalog to English could change the intent of the sentence.
In the Philippines, people have high respect for elders and do not speak unless they are asked something directly. For this reason, Filipino nurses may be considered passive by peers or patients. 

Navarro and Joseph Mojares, RN, BSN, president of the Philippine Nurses Association of Northern California, say proficiency can come with practice and time and made the following suggestions:

Do not be embarrassed to ask questions to clarify what others mean so you can learn the correct pronunciation and terminology.

Constantly immerse yourself in English-speaking environments and expose yourself to mainstream media at work and at home. 

Challenge yourself by taking classes in communication, leadership and public speaking so you can improve your English. 

Find mentors and preceptors who can encourage you and give you suggestions about how to present yourself and communicate. 

Tips for scholarship success

Jasmine Melendez, the scholarships and grants administrator at the Foundation of the National Student Nurses Association, has an insider’s view into the world of financial assistance. She has seen hundreds of scholarship applications, and said reviewers are looking for three things from applicants: financial need, high academic achievement and involvement in community health activities. 

“It is important to maintain a high GPA, but students who make time for some form of community service really set themselves apart,” Melendez said. 
Another way to stand out from the competition is to turn in well-crafted, accurate essays. “What I’ve been noticing is that students need to learn to write well,” she said. “When you convey a message, you want to make sure you convey it in a clear, concise manner with no spelling errors or grammar mistakes.” 

Here are other tips she suggests:

Get comfortable with the Internet because most scholarships are found on the Web. Websites that can help minority students find scholarships include: 
DiscoverNursing.com/Scholarships 
MinorityNurse.com/Find-Scholarships 
NursingSociety.org/Career/CareerAdvisor/Pages/Scholarships_opps.aspx 

Check with minority-owned businesses to see whether they offer scholarships, and ask the financial aid office at your school about scholarships and applications.

The hospital association in your state may have access to scholarship information.

Don’t make the mistake of thinking scholarship deadlines are only in the first part of the year. There are scholarships available every quarter of the year.

Don’t disqualify yourself by not applying. Apply for everything and let the committee say no. 

Source: Nurse.com

By Karen Long

While all nurses evaluate the four vital signs of temperature, pulse, blood pressure and respiratory rate, Ellen Cunningham, RN, MSN, is among many RNs who assess a fifth: pain.

"Every patient has the right not to suffer in pain," said Cunningham, nurse manager at the Interventional Pain Center at North Shore-LIJ Health System’s Syosset (N.Y.) Hospital.

But assessing the pain of patients in the critical care setting can be difficult, especially if they have cognitive impairments or can’t speak. 

"Inability to provide a reliable report about pain leaves the patient vulnerable to under-recognition and under- or over-treatment," the American Society for Pain Management Nursing stated in a July 2011 position paper about pain assessments in patients unable to self-report. "Nurses are integral to ensuring assessment and treatment of these vulnerable populations."

How to assess a critically ill patient

Determining a nonverbal patient’s pain is "definitely like unpeeling an onion," Cunningham said. Many nurses follow a hierarchy for pain assessment to evaluate the pain of a patient who cannot self-report, said Barbara St. Marie, ANP, PhD, GNP, ACHPN, pain specialist and former member of the American Society for Pain Management Nursing’s board of directors. The ASPMN outlines the steps in its position paper as follows: 

Try to have the patient self-report pain. It often is difficult with critically ill patients, Cunningham said. Obtaining that information "may be hampered by delirium, cognitive and communication limitations, altered level of consciousness, presence of endotrachael tube, sedatives and neuromuscular-blocking agents," according to the position paper. Those patients might not be able to rate pain on a scale of one to 10, but could use a gesture such as grasping the nurse’s hand or blinking their eyes to indicate pain, St. Marie said.

Identify potential causes of pain. That could include surgery, trauma, catheter removals, wound care or constipation, Cunningham said.

Observe patient behavior. Several tools also exist to help nurses assess pain in patients who are unable to speak, said Donna Gorglione, RN, BSN, clinical nurse manager of the ICU and progressive care unit at Hudson Valley Hospital Center in Cortlandt Manor, N.Y. For patients who are aware but not able to voice their pain, nurses can use the Wong-Baker FACES Pain Rating Scale, said Maggie Adler, RN, MSN, WCC, associate director of standards and quality at HVHC. 

The Pain Assessment in Advanced Dementia Scale measures behaviors such as restlessness, agitation, moaning and grimacing that can indicate pain. Nurses observe the patient and score a zero, one or two in five areas — breathing independent of vocalization, negative vocalization, facial expression, body language and consolability — then add up the score. Zero equates to no pain while 10 means severe pain. Nurses then treat the patients based on the pain score, Adler said. For example, a two might indicate the patient’s pain could be eased with Tylenol, while a seven would dictate a more serious intervention, such as narcotics.

The critical care pain observation tool and Face, Legs, Activity, Cry, Consolability tool also are useful, St. Marie said. Changes in blood pressure, heart rate or respiration could be indicators of pain. "I always say that if someone has a physiologic indicator, that’s the point where you start investigating more," she said.

Obtain a proxy report. Parents of young children or caregivers and family members of the elderly can provide vital information about what is causing patients’ pain, Cunningham said. "Credible information can be obtained from family members who know the patient well and may be a very consistent caregiver throughout their illnesses," St. Marie said.

Try an analgesic trial. If the other methods to determine pain yield inconclusive results, a trial could help, St. Marie said. Nurses administer low doses of any number of opioids and look for the patient to settle down, change facial expression or otherwise indicate a decrease in pain. According to Cunningham, any of those would indicate the patient had pain and not distress.

Pain management treatments

After assessing the patients’ pain, level of consciousness and respiratory status, nurses look at other indicators such as comorbidities, kidney and liver function, estimated blood loss from surgery and amount of opioids received in the OR and PACU. Nurses can use a variety of treatments to block pain through multiple receptors and pathways, St. Marie said.

Medications — such as nonsteroidal anti-inflammatory drugs, opioids, acetaminophen, local anesthetic agents and antiepileptics — through various pathways are common ways to treat pain. "Pain mechanisms involve our entire body, so it’s not just one pathway" that pain is transmitted through, St. Marie said. Nurses can now help block pain at many of those pathways.

Not all pain can be eliminated, Gorglione said. In some cases, a patient’s goal is to reduce pain to a tolerable level. "That’s an important piece of pain management," she said. "Sometimes we can’t get your pain to zero. If you can tolerate a level of three or four, we can get your pain there, and you can perform your activities of daily living."

Besides medications, patients can benefit from holistic therapies including music, massage or even hand-holding or warm blankets, Gorglione said.

"The tendency with medicine is to run right to the medicine cabinet," Adler said, noting other therapies can be effective. For some patients at HVHC, music has made a difference. "We’ve had patients and patients’ families thank us for the special attention and how relieved they were and how much it helped," Gorglione said. An integral part of pain management is reassessment after treatment. Nurses should use the same tool they used for assessments to determine whether the patient has a lower level of pain, St. Marie said.

Challenges in treating pain

Along with determining the right treatment, nurses face a variety of challenges in pain management. For example, some patients think pain is a normal part of their illnesses and refuse pain medication, Adler said. Elderly patients often have anxiety about becoming dependent on medications, Gorglione said. In those cases, educating the patient about pain management can help.

In other situations, the challenges come from providers. Patients who arrive in the ICU and have addiction issues often are stigmatized or marginalized because providers blame the victim, St. Marie said. But a patient going through withdrawal needs "serious pain control," she said.

Nurses have to overcome the challenges to be able to assess, treat and reassess patients’ pain, Cunningham said.

"No matter how old someone is, no matter how cognitively impaired they might be, it never takes away that they might be in pain," she said.

Source: Nurse.com

By: Shazia Memon

I didn't figure this out until last summer. I was at a friend's place helping her move out some old furniture. Right after I lifted her hardwood coffee table, it broke apart, and the heavier piece dove straight onto my toe. After the initial shock, the pain hit, and then the picture was not pretty. I hopped around the living room erratically, alternating between standing and sitting as I tried to find some position of relief. I kept muttering phrases to my friends like "you guys just need to relax" and "calm down, everyone just calm down." They observed in silence, wide-eyed.

After several laps of limping, I ended up on the couch with my foot propped up. My friends put a frozen bag of peas against my toe and then finally said, "We are calm Shazia. YOU need to calm down."

I looked at their faces, stopped my sighing short, and thought about the situation at hand. They were right. I had kind of lost it.

As a pediatric critical care nurse, I deal with my fair share of screaming toddlers, stressed parents, and anxious kids. We hold the hands of children as they undergo painful procedures (sometimes at the cost of adequate circulation to our own hands). There are always worried parents who need reassurance that we are doing everything possible for their sick child. And during the most unpredictable of emergencies, we maintain a cool composure in hopes that the patient and our colleagues will follow suit.

Basically, calming down panicked people is a huge part of the job description. But when that table hit toe, my role had reversed. In hindsight, of course I see how ridiculous I was acting. And that got me wondering more generally about when nurses become patients. How do they handle being in the bed, as opposed to at the bedside?

Turns out that many do not handle it well. After talking to a few co-workers, I realized that nurses can be some of the worst patients. My personal opinion is that it's a dysfunctional coping mechanism; we don't know how NOT to be calm and in control. So the rare times that we don't feel those ways, we project our anxiety through behaviors that are just as unfamiliar to us.

To put it bluntly, we can be kind of obnoxious.

Take, for example, my coworker who was in the hospital and put on a medication that had possible side effects of nausea and vomiting. The doctor's orders stated to give anti-nausea medication if needed--only for if and when the patient displayed the symptom. But my coworker decided that her orders superseded the doctors---a classic mindset of nurses who become patients. She had no intention of feeling any of the side effects.

"I want that anti-nausea medication around the clock. I don't want to have to call you. I don't want to have to wait for it. I want it every six hours, on the dot," she demanded from her nurses.

Some of her nurses initially protested, saying the medication wasn't supposed to be given preventatively. Others knew that it was a battle not worth picking. Regardless, she got her way and spent the entire hospital stay without feeling any nausea. Or making any new friends.

In other cases, we see nurses taken out of the hospital environment but not able to let go of hospital policies. One PICU nurse went to her primary doctor after a few days of coughing, congestion, and fever. In our unit, there are a lot of children with multiple underlying health issues. We usually respond to a fever and respiratory distress with a series of tests to pinpoint exactly what the cause of those symptoms are. But when an otherwise healthy person shows a mild presentation of these symptoms, the first line of treatment is usually a round of antibiotics. That is exactly what her doctor prescribed after a thorough assessment. But my coworker had a hard time being 'written' off, albeit as a prescription.

"But ... are you sure you don't want to take a chest X-ray?" she inquired, followed by a strategic cough.

The physician smiled and nodded, explaining to her why he deemed an X-ray unnecessary at this point. She wasn't convinced but let it go. As they parted ways, she made sure to take some purposefully labored breaths. Just for emphasis.

Her case of the common cold was cured within a few days--without any unnecessary exposure to radiation. In the back of her head, she knew her request was unreasonable. She just didn't know how to do anything other than what she was used to. Other nurses also admitted to parallel behaviors in primary care settings--the urge to impose hospital protocols isn't easy to shake.

It's also not unusual to find nurses believing that they are above the rules when the tables turn on them. One rule we reinforce to patients and families is not to touch or handle the pumps and machines around them. When one of my colleagues had still not gone to the bathroom twelve hours after his surgery, his nurse and doctor discussed inserting a foley catheter--that is, a tube through his urethra into his bladder to drain it.

"Give me until 7 am. If I don't go by then, you can put it in," he bargained.

They reluctantly conceded. As soon as he was alone, he reached to the pump that was infusing fluids through his IV. After a fleeting pause of guilt, he cranked up the rate to 3 times what it was set at. His plan to over-hydrate himself was not the right or safe answer, but luckily he woke up at 4 AM with an overwhelming urge to relieve himself. He knew it didn't necessarily happen as a result of his medical manipulation, but was desperate to avoid any discomfort down there.

Nurses also make their caretakers work hard to earn their trust -- harder than they really need to sometimes. One of my coworkers has no shame in interrogating her own doctors on their credibilities, and doesn't take them seriously unless she approves of their medical school, residency, and fellowship (fellowships are a given in her book). Another nurse I work with frequently trains new graduates and employees. When it comes to education and advancing the nursing profession, she is always at the front line.

Except when it was her turn to have a breathing tube placed for a surgery. As she was signing consent for this, she looked suspiciously at the badge of the woman obtaining her signature. The woman was a nurse anesthetist.

"I totally respect your profession. But I would feel more comfortable with a physician intubating me," she said.

The nurse anesthetist was slightly taken aback, but offered to speak to the fellow to see if he could do it.

"Actually I'd like the attending to do it," my co-worker responded.

So much for promoting the nursing profession. Or even encouraging the general endeavors of a teaching hospital -- she dismissed every step on the learning ladder by only trusting the attending.

But in this scenario, she was on the receiving end of care, and totally out of her element. Just as I felt when that coffee table fell on my toe. Our comfort zone is nurturing patients and serving as the foils to their fear. When we step out of it and into a position of fear ourselves, we lose our way. Some a little more than others. And some not at all. But for those who do, their healthcare providers should remember -- nurses are generally good, warm, loving people. They might just have passive-aggressive tendencies when they feel anxious, that's all.

As for me, I'd like to think I learned from their stories. If I am ever in a state of vulnerability again -- or rather, when I am -- I'll do my best to stay calm and cool, to be an easy patient. 

As long as everything goes my way, of course.

Source: The Atlantic

By: Ambriel Maji

Every student nurse needs to have a strong understanding of culture and ethnic considerations so that they may be able to care for their patient's as whole. Many nurses when not faced with diversity are not fully understanding to exactly what culture is.

Culture is a set of learned values, customs, practices and beliefs that are shared by a group of people or are passed from one generation to another. A subculture shares many of the same characteristics with a primary culture but they may have patterns of behavior or ideals that differ and separate themselves from the rest of a cultural group.

Not all members of a culture will have the same behavior though; some of the differences are age, religion, dialect, socioeconomic backgrounds, geographic locations, gender identities, gender roles, and the degree of values that are adopted in a current country.

Stereotyping is something a nurse must learn not to do because culture can influence each person in varies ways and not each person from a certain culture may feel the same way as another person. Stereotyping is a generalized feeling about one group that is formed based on behavior, of an individual or a group. Ethnic stereotyping is a fixed concept of how all members of a certain group may think or act.

Race is considered a group of people who share biologic and physical characteristics, while ethnicity is a group of people who share a common social and cultural heritage based on beliefs, traditions, and national origin, physical and biologic characteristics.

Transcultural nursing is the understanding and integrating of the many variables in culture and subculture practices into all the aspects of nursing care. Different cultures have a variety of practices that may relate to response to illness and death, care of people of different age groups, childbirth, diet and nutrition, and even health care in general and treatment methods.

The nurse must be aware of personal culture beliefs and practices of their patient and understand that these beliefs put influence on their ability to care for those patients of different cultural backgrounds. By understanding these personal beliefs it gives the nurse the ability to react to different cultures with understanding, respect, openness, and acceptance of the differences between them. Depending on the location you work you may come across many different cultures and subcultures it is a nurse's duty to become versed in the different patients they may take care of.

Source: Yahoo Voices

Patient satisfaction scores soar after hospital trains staff to treat patients — and each other — with respect.

When Laurent Gueris took over the housekeeping department at Providence Little Company of Mary Medical Center in San Pedro, Calif., the staff of 15 was well-trained in cleaning, but any people skills they had, they'd picked up on their own. Some entered rooms without knocking, did their jobs wordlessly with heads down, and then rushed out. Wanting to be invisible, they instead came off as sullen and unhelpful.

"They would do their little cleanup and leave," recalls Gueris' boss, Providence CEO Nancy Carlson. "They were very intimidated by other staff in the hospital and they were not being respected and valued."

At first, Gueris, manager of environmental services, concerned himself with easy fixes in his department, like purchasing paper towel dispensers that didn't have to be changed as often and swapping out conventional mops for microfiber ones. But a trip to France to visit his dying mother in the hospital prompted him to think about bigger issues, such as getting his workers to say "hello," be pleasant, even chitchat occasionally with patients.

"One day, I would see a housekeeper who was very friendly and connected with my mom," he says. "And another day, somebody would just go into the room and not even knock on the door."

Gueris became a student of the hospital's staff, noticing how some were able to defuse difficult situations and others made it worse. He also saw how a few pleasantries — and treating difficult patients as otherwise decent people reacting with fear and anxiety to a very stressful situation — made a big difference.

Back home, Gueris introduced role-playing sessions. Every morning, the staff met to rehearse interactions with patients. Gueris offered guidelines, something they hadn't had: Knock on the door. Ask permission to come in. Introduce yourself and tell them you're from housekeeping.

At first, Gueris played the patient, really throwing himself into his role. Sometimes, he'd be angry, sometimes insulting — whatever he knew would push a particular worker's buttons. After the session, he gave pointers on such matters as looking people in the eye or defusing an overly flirtatious patient with "Thank you very much, I appreciate that, but I'm not interested."

Gradually, the staff started coming around. After six months, they grew confident to the point that they wanted to take turns playing the patient.

"They give each other a real hard time," Carlson says. "They come up with scenarios that really challenge their peers."

They also began challenging Gueris.

"I'd say, 'You didn't look me in the eye,' and they'd say, 'Yes, Laurent, I did.'" So he started recording the morning sessions, which the staff would watch, discuss and then erase.

He was expecting resistance with the videotaping, but didn't get much. "I'd been working with them for a while to build that trust," he says. "We did the first video, it broke the ice and, by the next day, they were fine with it.

"Seeing it on their own was very powerful," he adds. "Not just the eye contact, but their facial expressions, their body language. Maybe they thought they did not look nervous, but they were [twitching] their legs."

They now follow a script: "Hi, I'm here; my name is …. I'm here to clean your room. I'm hoping you're having a good day today; here's a flower," then hand the patient a card with a flower printed on it. Once the room is clean, they ask whether the patient would like his or her curtains open or closed and whether they need anything else.

"Even though they can't answer a clinical question or stop an IV from alarming," says Carlson, "they can move a telephone closer, get a blanket, or ask a nurse to come in and respond to a clinical concern or question."

The housekeepers' patient satisfaction scores have jumped from the 60th to the 70th percentile to the 90th percentile in 2012. For his efforts, the Hospital Association of Southern California named Gueris a Hospital Hero for 2012.

Gueris' training techniques are now rolling out to other parts of the hospital, starting with nurses' aides and administrative staff. "Our goal is to roll it out to anybody who has interaction with a patient, including the phlebotomist who comes in, sticks a patient with a sharp object and leaves," Carlson says.

Source: H&HN