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DiversityNursing Blog

Trading on innocence

Posted by Alycia Sullivan

Fri, Sep 13, 2013 @ 11:51 AM

innocence resized 600
By Cynthia Saver, RN, MS

Human sex trafficking can be illustrated in one sentence: "I can sell a kilo of cocaine once and I'm out of product, but I can sell a woman over and over 25 times a night 365 days a year and make a quarter of a million dollars off one girl." That observation a pimp made to Mary de Chesnay, RN, DSN, PMHCNS-BC, FAAN, editor of the book "Sex Trafficking: A Clinical Guide for Nurses," sums up why human sex trafficking has become a growth industry.

"Trafficking is a $32 billion a year business, more than Starbucks, Nike and Google combined," said de Chesnay, a professor in the WellStar School of Nursing at Kennesaw (Ga.) State University. "It's the most lucrative criminal enterprise behind drugs."

Many people think sex trafficking happens only in third-world countries, but it's also pervasive in the U.S. "It's not just an international problem, it's a national problem," said Patricia Crane, RN, MSN, PhD, WHNP-BC, DF-IAFN, associate professor at University of Texas Medical Branch Galveston and a specialist in forensic nursing. Victims include U.S. citizens and people from countries such as Mexico, Eastern Europe, Asia and South America.

The early 1970s is when de Chesnay first met a child who was being trafficked. When she asked the 11-year-old girl with an ectopic pregnancy about the baby's father, the girl replied, "It could be my father, my four brothers, or the men who come to party on the weekend."

That child was the first in a long line of girls and women (and some boys and men) de Chesnay has seen during her career. Accurate numbers are hard to come by, but the Polaris Project, an advocacy group that combats human trafficking, estimates that 100,000 children are involved in the sex trade in the U.S. each year. The average age of a U.S. victim is 12 to 14 years old.

Nurses are in a prime position to identify possible victims of sex trafficking when they seek medical treatment in the ED, free clinics, physician offices and other locations. But too often those opportunities are missed. According to the Family Violence Prevention Fund, a study found that 28% of trafficking survivors had contact with a healthcare provider during the situation, but the abuse wasn't recognized. 

Preying pimps

How do victims become entangled in sex trafficking? de Chesnay said many victims are "runaways or throwaways, they have bad home lives." Pimps hang out around bus stops and other locations to meet the runaways. The "Romeo" pimp first befriends girls (most victims are female). Soon the girl moves in with him. Selling the girl might start with the pimp simply asking her to date his friend. Soon she is on the street, at hotels or even in the pimp's home being sexually abused. de Chesnay said Romeo pimps are the most common, but a second type is the violent pimp, who isn't interested in establishing a relationship. In rare cases a victim might be kidnapped.

Poverty is another factor. "They get involved because it's an opportunity to make some money," said Donna Sabella, CRNP, PhD, MEd, MSN, PMHNP-BC, director of global studies and the office of human trafficking at the College of Nursing and Health Professions at Drexel University in Philadelphia. "They may also need money for an addiction."

So why don't victims just leave? "If they were functioning well like us, they would find a way," said de Chesnay. "But these girls are broken in spirit. They have no self-worth and are damaged mentally and physically."

Fear is another contributing factor, Sabella said. "The pimps say they'll hurt them, their family or their children," she said. 

Identifying victims

Victims of sex trafficking have "all kinds of medical and psychological issues," de Chesnay said. Physical signs and symptoms of potential trafficking include burns, dislocated limbs or fractures, missing teeth, vaginal or rectal trauma, persistent or untreated sexually transmitted diseases or urinary tract infections, malnutrition and problems with the jaw or neck. Other signs include not being able to produce identification, having inconsistent stories about their lives and how injuries occurred, hypervigilance, and the presence of tattoos that might be "brands."

A victim might seem submissive, allowing the accompanying person, who might be his or her pimp, to respond to questions. Sabella said it's important to get the patient alone. She suggested saying, "It's hospital policy that we speak to patients alone."

Crane said that another option is to have the person with the victim fill out paperwork or ask him or her to stay in the waiting area while the nurse obtains a specimen. Once alone with the patient, nurses should choose their words carefully. "Don't ask them it they are being trafficked," Sabella said. "They won't understand the term."

Instead, Crane suggested questions such as: Can you come and go as you please? Where do you sleep and eat? Has anyone threatened your family? Is anyone forcing you to do anything you do not want to do?

Crane advises conveying messages such as, "We are here to help you. We can find you a safe place to stay. If you are a victim of trafficking and you cooperate, you won't be deported."

When faced with a trafficking victim, "the immediate problem is the medical condition," said de Chesnay. "Be kind, nonjudgmental and provide access to services." (See resources below story.)

She said nurses shouldn't present themselves as rescuers because victims don't always want to be rescued. Nurses should let victims know what to do when they are ready by providing them with information about resources such as the national hotline.

Sabella added that nurses should be aware that the victim doesn't know them and is in a difficult situation. "Don't be surprised if someone doesn't jump up and say thank you," Sabella said. "Be prepared when people say no."

In some cases, the nurse might be laying the groundwork for helping a victim leave in the future. "One woman went home because her pimp said he would kill her dog," Sabella said. "She came back the next day with the dog." She suggests telling victims they can call the hospital if they change their mind. If possible, the same nurse who saw the patient could do a follow up call in a few days, allowing another opportunity for contact. Crane said if a woman won't admit to being a victim, Crane will set up another visit to provide another chance to talk with her.

Some experts recommend giving the victim a card with the hotline number written on it, but de Chesnay advises not giving victims materials. "If pimps see it, they will beat them up," she said, adding that Georgia recently passed a law requiring the posting of signs with the hotline in places such as hospitals and hotels.

Nurses also should watch for victims in their own backyards. "A lot of this [sex trafficking] takes place in neighborhoods," Sabella said. 

Reporting & recovery

If the victim is a child, mandatory reporting laws for abuse apply. In addition, some states require reporting in the cases of victims of domestic violence. Nurses should tell the patient if they are required to file a report. Reporting gives victims access to an advocate who can help with resources. For example, in March 2013, President Obama signed the latest reauthorizaton of the Trafficking Victims Protection Act, linking it to the Violence Against Women Act. "VAWA money can now be used for sex trafficking victims in a domestic violence situation," said Crane. The victim has to agree to cooperate in prosecuting the pimp to receive funds that can help her or him escape from the situation.

Unfortunately, few residential recovery programs exist in the U.S. — Sabella estimates 10 to 15. She was a founding member of Dawn's Place, a residential recovery program for trafficked and prostituted women in Philadelphia. Sabella modeled the one-year program after a program in Phoenix. Such programs often must depend on volunteers because little funding is available for these efforts.
Besides needing treatment for physical problems such as injuries from beatings and gynecological issues, survivors will need care for psychological conditions such as post-traumatic stress disorder, anxiety and depression.

"Slavery didn't end with the Emancipation Proclamation," de Chesnay said. "Nurses can step up and play a role in ending it for good. The crucial first step is awareness, people need to be educated about human trafficking, learn the warning signs and memorize the hotline number."

Nurses can request their facilities hold a seminar on the topic. Sabella and de Chesnay, who both teach a course on human trafficking, said that the subject should be part of nurses' basic education.

The next step is to work with law enforcement to develop policies for the facility where the nurse works. "Many nurses do not act because they do not know what to do once they become aware," de Chesnay said. "The protocol must spell out clearly the steps to take if a human trafficking victim walks through the door." 


Topics: United States, Awareness, sex trafficking, nurse research, prevention

Prescription for change

Posted by Alycia Sullivan

Fri, Jul 12, 2013 @ 01:51 PM

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AMERICA’S hospitals are the most expensive part of the world’s most expensive health system. They accounted for $851 billion, or 31%, of American health spending in 2011. If they were a country, they would be the world’s 16th-largest economy. And they are in the midst of dramatic change, much of it due to the “Obamacare” health reforms.

The most visible change so far is that big hospital companies are getting bigger. In the latest of a string of recent mergers and takeovers, on June 24th Tenet Healthcare said it would buy Vanguard Health Systems for $4.3 billion including debt. The combined group will have 79 hospitals and 157 outpatient clinics.

Others are going further, turning the industry’s business model on its head. In Massachusetts, Steward Health Care Systems is trying to drive patients out of its hospitals and into cheaper clinics. The pace of change varies from one hospital group to the next. But beneath the shift is an argument—by politicians, insurers, patients and some investors—that the old business ways of hospitals are untenable.

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America has more than 5,700 hospitals, with non-profits outnumbering for-profits by nearly three to one. Most of these share a familiar business model: sell as many services as possible at the highest price. This bodes ill for those who pay, whether employers, the government or patients themselves. Doctors receive a fee for each treatment, so there are few financial incentives to keep patients well. And since the health market has the transparency of a concrete bunker—patients usually do not know the price of treatment until after they have received it—American hospital stays are unusually expensive (see chart). It is little wonder that health spending overall accounts for nearly a fifth of GDP.

This dysfunctional system will welcome millions of new patients next year. Obamacare requires everyone to have some form of health insurance from 2014. To that end it expands Medicaid, the government’s insurance scheme for the poor, and subsidises private insurance policies which will be offered via new exchanges to be set up in each American state. More people with insurance should mean more patients seeking treatment, so the reforms would seem to herald a golden era for hospitals. Indeed, hospital shares have soared since the Supreme Court upheld the health law’s constitutionality a year ago.

Nevertheless, hospitals face mounting pressure to change. In recent years the volume of patients at most hospitals has been flat at best. The recession is partly to blame, since sacked workers lose their insurance. The shifting of some treatments to outpatient clinics has undercut some hospital revenues. And employers have increasingly required their workers to make out-of-pocket contributions towards the cost of their health care, which makes them a bit less likely to seek treatments.

Obamacare itself is not all good news for hospitals. It will bring revenue from newly insured patients. But it will also cut the rates the government pays for Medicare, the health scheme for the old. By 2019 these will cancel each other out, reckon analysts at Bank of America Merrill Lynch. And the Medicare cuts already announced may not be the last. The reforms may create fewer new patients than expected: some people may ignore Obamacare’s “mandate” to buy insurance, since the penalties are small. State and federal officials are scrambling to get the exchanges ready in time. Some Republican governors are refusing to expand Medicaid.

Obamacare also includes incentives for hospitals to provide quality, rather than quantity, of care for publicly insured patients. Medicare will penalise hospitals that discharge patients only for them to return within 30 days. Groups of doctors and hospitals can apply to be designated as accountable-care organisations, or ACOs, which will be rewarded for keeping the cost of Medicare patients’ treatments below a certain level. (They thus have broadly similar aims to health-maintenance organisations, or HMOs, a type of private health plan that pays a fixed fee to doctors and hospitals for the patient’s care).

Last month the Obama administration opened another line of attack on hospital costs by publishing their price lists. These showed huge variations. In practice, insurers negotiate special rates, and these remain mostly hidden. But scrutiny of prices is likely to intensify, as more members of employers’ health schemes are forced to shop around for treatments.

Physician, know thy costs

The reforms, and the other pressures on the hospitals, have prompted them to launch a big efficiency drive. The well-respected Cleveland Clinic is offering shared medical appointments: a doctor tells several patients how to manage diabetes, rather than counselling them individually. Robert Kaplan and his colleagues at Harvard Business School are helping hospitals measure their costs. Many do a poor job of recording how much each type of treatment costs them in terms of doctors’ and nurses’ time, materials consumed and so on.

Hospitals are also seeking economies through dealmaking. All sorts of combinations are being seen, says Martin Arrick of Standard & Poor’s, a credit-rating agency: big, stockmarket-listed chains like Tenet and Vanguard are merging; Catholic hospitals are getting ecumenical with non-Catholic ones; and non-profit outfits are partnering with for-profits. There were more than 200 such deals in 2011-12, according to Irving Levin Associates, a research firm. This does not include many purchases by hospitals of doctors’ clinics.

The combined Tenet and Vanguard will have hospitals and clinics across 16 states. This will make it easier to standardise clinical practice, get discounted supplies and make the most of investment in new medical technology. Most important, a bigger firm will have more clout in negotiating prices with health insurers.

The most seismic shift, however, is the move away from the fee-for-service model. How can a hospital profit from delivering fewer services, when it is organised to deliver more? HCA, a quoted company with 156 hospitals in 20 states, is all but ignoring the question. Vanguard is one of few listed chains to have started looking for answers, including taking part in ACOs.

Steward, which is only three years old, seems to be the most ambitious in embracing change. It was created when Cerberus, a private-equity firm, bought a struggling chain of Catholic hospitals in 2010. Steward does not aspire to have the best hospitals in America—indeed it sends its most complex cases to a rival medical centre in Boston. What it wants to offer is good, convenient, reasonably priced care. Steward has signed up as a Medicare ACO and also has contracts with private insurers that reward it for keeping patients well as opposed to paying it by quantity of treatments. The company has 11 hospitals, up from six in 2010, and a network of 2,900 affiliated doctors, up from 1,100.

Steward is making efforts to ensure that patients do not suffer expensive relapses: nurses scroll through records to confirm that patients have collected their prescriptions and had their check-ups; more home visits are being made to recently discharged inpatients. But it is unclear overall whether such efforts will boost profits, or indeed lower America’s health spending, let alone both. Large hospital chains, thanks to their clout with insurers, are more likely to raise prices than cut them. Steward’s prices are lower than Massachusetts’s most expensive hospitals, but higher than those of some competitors.

As for ACOs, they have had a good start: more than 250 have been formed so far. But their success is difficult to predict. ACOs are responsible for the costs of a given set of patients, but those patients can seek treatments outside the group of providers that form the ACO. This may make it hard to contain their costs.

George Clairmont, who leads a doctors’ group that partners with Steward, is excited by the prospect of a new era. “We are part of a major change in health care that we haven’t seen since the beginning of the 20th century.” But like a novel treatment for a chronic ailment, the cure for America’s bloated hospital industry will need careful monitoring for side-effects.

Topics: change, quality care, United States, expensive, healthcare

Comprehensive Review Of Laws And Regulations Affecting Advanced Nursing Practice In Every State

Posted by Alycia Sullivan

Tue, Feb 05, 2013 @ 02:03 PM

The most comprehensive review of new legal and regulatory issues affecting advanced nursing practice across the United States is now available in the "25th Annual Legislative Update," presented exclusively by The Nurse Practitioner: The American Journal of Primary Healthcare.The Nurse Practitioner is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health. 

Compiled by Susanne J. Phillips, MSN, FNP-BC, the annual supplement presents a comprehensive review of the legislative proceedings, bills, and laws pertaining to advanced practice registered nursing (APRN) practice in every state. The 25th Annual Legislative Update is now freely available on the journal website. 

Progress in Evidence-Based Reforms Improving Access to APRN Care 

The 25th Annual Legislative Update incorporates current information provided by state nursing boards and APRN associations about the "hot topics" affecting APRN practice in their states. "Despite attempts by medical boards to limit current practice authority, APRNs succeeded in improving access to APRN care in several states," writes Phillips. 

The special edition provides an essential update on recent legislative and regulatory activity promoting access to APRN care, prompted by decades of peer-reviewed research demonstrating the quality and safety of APRN practice. Efforts are ongoing to standardize laws and regulations governing APRN practice across states, and to establish effective consumer protections. 

Yet legislation continues to be "vehemently opposed" in many states, according to Phillips. She discusses steps APRNs can take to "empower legislators to move beyond the outdated, evidence-lacking arguments that APRNs are not educated enough, safe enough, or credentialed enough to care for the nation's residents." 

This year's update presents a rundown of the latest developments in the areas of legal authority, reimbursement, and prescriptive authority for all 50 states. It also includes a table summarizing practice authority for nurse practitioners in every state and the District of Columbia, along with updated statistics and the total number of APRNs reported by state boards of nursing. 

Nurses Encouraged to Work Together to Meet Challenges 

The past year has seen several important improvements in legal authorization of APRN practice, including passage of legislation and promulgation of regulations in 17 states. In addition, eight states reported statutory or regulatory activity leading to improvements in prescriptive authority. 

But challenges remain, including reports of defeated bills and unsuccessful regulatory reform efforts in five states. In addition, two states - Kentucky and Missouri - passed legislation limiting APRN practice in specific ways. Phillips urges APRNs and others interested in ensuring access to evidence-based healthcare to support state APRN organizations. 

Nurses are also encouraged to check out the Future of Nursing Campaign for Action, supported by the Robert Wood Johnson Foundation and AARP, to see what steps are being taken and participate in efforts to improve nursing practice. Phillips adds, "This is a great way for all of the APRN organizations to work together to implement the recommendations and improve practice in your state."

Article adapted by Medical News Today from original press release.

Topics: laws, United States, challenges, regulations, APRN care, reform

2013 Nursing Job Projections

Posted by Alycia Sullivan

Fri, Jan 18, 2013 @ 12:34 PM

Which states will need nurses most in 2013?

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Topics: United States, 2013, job projection, US Bureau of Labor Statisitics, nurses

Registered Nurse: Salary

Posted by Alycia Sullivan

Fri, Nov 30, 2012 @ 02:35 PM

Article from U.S. News

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#1 in U.S. News Best Jobs 2012

Overall Score: 8.2

Number of Jobs: 711,900 Median Salary: $64,690
Unemployment Rate: 5.5% Job Satisfaction: MEDIUM

Salary Outlook

The Bureau of Labor Statistics reports the median annual wage for a registered nurse was $64,690 in 2010. The best-paid 10 percent of RNs made approximately $95,130, while the bottom 10 percent made approximately $44,190. The highest wages are reserved for personal care nurses, or those working for private-sector pharmaceutical or medical device manufacturers. By location, the highest-paid positions are clustered in the metropolitan areas of northern California, including municipalities in and around San Jose, Oakland, and San Francisco.

Average Registered Nurse Pay vs. All Healthcare Jobs

Registered nurses make an average salary of $64,690, which is pretty good pay compared with some of the other Healthcare Jobs on this year's list of The Best Jobs of 2012. That's comparable to the pay of occupational and physical therapists. Medical assistants take home far less money in a year—approximately $35,830 less in 2010 than the average RN earned that same year. And with an average salary that's a little more than $30,000 per year, paramedics also have a lower average salary than nurses.

Best Paying Cities for Registered Nurses

The highest paid in the registered nurse profession work in the metropolitan areas of San Jose, Calif., Oakland, Calif., and San Francisco. The Salinas, Calif. area also pays well, as does the city of Napa, Calif..

San Jose, Calif.

Salary: $116,150

The annual median wage of a registered nurse working in San Jose, Calif. is $116,150, which is $51,460 more than the average pay in the profession.

» See Registered Nurse Jobs in San Jose, Calif.

Oakland, Calif.

Salary: $100,900

The annual median wage of a registered nurse working in Oakland, Calif. is $100,900, which is $36,210 more than the average pay in the profession.

» See Registered Nurse Jobs in Oakland, Calif.

San Francisco

Salary: $97,600

The annual median wage of a registered nurse working in San Francisco is $97,600, which is $32,910 more than the average pay in the profession.

» See Registered Nurse Jobs in San Francisco

Salinas, Calif.

Salary: $97,450

The annual median wage of a registered nurse working in Salinas, Calif. is $97,450, which is $32,760 more than the average pay in the profession.

» See Registered Nurse Jobs in Salinas, Calif.

Napa, Calif.

Salary: $97,090

The annual median wage of a registered nurse working in Napa, Calif. is $97,090, which is $32,400 more than the average pay in the profession.

» See Registered Nurse Jobs in Napa, Calif.

Topics: United States, RN, salary

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