The first national study on Hispanic health risks and leading causes of death in the United States by the Centers for Disease Control and Prevention (CDC) showed that similar to non-Hispanic whites (whites), the two leading causes of death in Hispanics are heart disease and cancer. Fewer Hispanics than whites die from the 10 leading causes of death, but Hispanics had higher death rates than whites from diabetes and chronic liver disease and cirrhosis. They have similar death rates from kidney diseases, according to the new Vital Signs.
Health risk can vary by Hispanic subgroup. For example, nearly 66% more Puerto Ricans smoke than Mexicans. Health risk also varies partly by whether Hispanics were born in the United States or in another country. Hispanics are almost three times as likely to be uninsured as whites. Hispanics in the United States are on average nearly 15 years younger than whites, so taking steps now to prevent disease could mean longer, healthier lives for Hispanics.
“Four out of 10 Hispanics die of heart disease or cancer. By not smoking and staying physically active, such as walking briskly for 30 minutes a day, Hispanics can reduce their risk for these chronic diseases and others such as diabetes,” says CDC Director Tom Frieden, MD, MPH. “Health professionals can help Hispanics protect their health by learning about their specific risk factors and addressing barriers to care.”
This Vital Signs report recommends that doctors, nurses, and other health professionals
• work with interpreters to eliminate language barriers when patients prefer to speak Spanish.
• counsel patients with or at high risk for high blood pressure, diabetes, or cancer on weight control and diet.
• ask patients if they smoke and, if they do, help them quit.
• engage community health workers (promotores de salud) to educate and link people to free or low-cost services.
Hispanic and other Spanish-speaking doctors and clinicians, as well as community health workers or promotores de salud, play a key role in helping to provide culturally and linguistically appropriate outreach to Hispanic patients.
The Vital Signs report used recent national census and health surveillance data to determine differences between Hispanics and whites, and among Hispanic subgroups. Hispanics are the largest racial and ethnic minority group in the United States. Currently, nearly one in six people living in the United States (almost 57 million) is Hispanic, and this is projected to increase to nearly one in four (more than 85 million) by 2035.
Despite lower overall death rates, the study stressed that Hispanics may face challenges in getting the care needed to protect their health. Sociodemographic findings include:
• About one in three Hispanics have limited English proficiency.
• About one in four Hispanics live below the poverty line, compared with whites.
• About one in three has not completed high school.
These sociodemographic gaps are even wider for foreign-born Hispanics, but foreign-born Hispanics experience better health and fewer health risks than U.S.-born Hispanics for some key health indicators, such as cancer, heart disease, obesity, hypertension, and smoking, the report said.
The report also found different degrees of health risk among Hispanics by country of origin:
• Mexicans and Puerto Ricans are about twice as likely to die from diabetes as whites. Mexicans also are nearly twice as likely to die from chronic liver disease and cirrhosis as whites.
• Smoking overall among Hispanics (14%) is less common than among whites (24%), but is high among Puerto Rican males (26%) and Cuban males (22%).
• Colorectal cancer screening varies for Hispanics aged 50 to 75 years.
• About 40% of Cubans get screened (29% of men and 49% of women).
• About 58% of Puerto Ricans get screened (54% of men and 61% of women).
• Hispanics are as likely as whites to have high blood pressure. But Hispanic women with high blood pressure are twice as likely as Hispanic men to get it under control.
“This report reinforces the need to sustain strong community, public health, and health care linkages that support Hispanic health,” says CDC Associate Director for Minority Health and Health Equity, Leandris C. Liburd, PhD, MPH, MA.
As the United States becomes more of a melting pot, encouraging and nurturing a workplace that welcomes the different cultures, ethnicities, and lifestyles of staff are paramount to optimal collaboration, productivity, and success. In health care, where diversity increasingly is exemplified among patients as well as employees, such an embrace is critical to achieving best outcomes.
Health care institutions across the country are heeding the call for inclusion. Many have implemented initiatives to not only attract diverse staff, but also to keep and engage them.
The Mayo Clinic in Rochester, Minnesota, for instance, launched the Multicultural Nurses Mayo Employee Resource Group (MNMERG) in July 2014 to recruit and retain nurses from diverse cultures and offer them professional support and networking opportunities. The MNMERG also mentors and educates Mayo’s diverse nurses and involves them in community programs.
With some 25 members, the MNMERG welcomes all Mayo staff. It meets monthly at the hospital, but this year will add quarterly dinners off site and is evaluating online technologies such as Skype and Sharepoint to “engage a 24/7 workforce,” says MNMERG cochair Deborah A. Delgado, MS, RN-BC, a nursing education specialist in psychiatry.
Mayo Employee Resource Groups (MERGs) have been an important component of Mayo’s overall diversity initiative; the goal is to have the following five core MERGs—African American, LGBTI, Hispanic, Disability, and Veterans—at Mayo’s three major clinical sites. Each MERG has an executive sponsor who is a leader at Mayo, but not a member of the group. For example, the MNMERG’s sponsor is a male cardiologist with experience in developing family/patient advisory groups. All of Mayo’s MERGs have formally chartered to align with at least one of the organization’s strategic diversity goals.
“These range from culturally competent care to inclusion and addressing health disparities,” says Sharonne N. Hayes, MD, FACC, FAHA, director of diversity and inclusion and professor of medicine at the Women’s Heart Clinic at Mayo. She notes that the groups share innovations and hold cross activities. “By that collaboration,” she says, “you get more hands to do the work obviously, but you also get a wonderful side product of some cross-cultural mentoring and some cross-cultural experience.”
While the MNMERG is in its infancy, feedback has been positive. “By being visible, by engaging, and by contributing, it just leads to retainment,” Delgado offers. “People want to stay because they’re able to use all of their gifts and talents to affect the organization’s purpose and goals.”
The Clinical Leadership Collaborative for Diversity in Nursing (CLCDN) at Massachusetts General Hospital in Boston has realized recruitment and retention success with diverse students of nursing. A scholarship and mentoring program established in 2007 by Partners HealthCare (PHC), an integrated system of which Mass General is a member, the CLCDN draws applicants from the nursing program at University of Massachusetts Boston.
Students must demonstrate leadership qualities, have cumulative general and nursing GPAs of 3.0 or higher, and must be entering their junior year of study since the CLCDN will carry them through their senior year. They link with racially and ethnically diverse nurse mentors, attend unit meetings and social and educational events, and observe nurses and nursing leaders in action. Additionally, they receive a stipend and financial support for tuition and fees with the expectation they will pursue employment at a PHC institution after graduating.
“When you’re a minority and you’re going into an environment where you might be the only diverse person on your clinical unit, as an example, it can be really challenging; it can be very lonely,“ says Gaurdia E. Banister, PhD, RN, FAAN, the PHC CLCDN liaison to UMass Boston and executive director of the hospital’s Institute for Patient Care. “We wanted to put mechanisms in place to ensure the success of our students and, certainly once they graduated, the best possible [career] alternatives,” she says.
Mass General diverse nurse leaders who have successfully navigated such waters can “provide these wonderful, wonderful pearls of wisdom and support and encouragement and listening skills,” explains Banister, and they serve as mentors, as do CLCDN graduates. Of the 54 mentors to date (32 from Mass General), some are repeats. Other statistics are just as impressive—such as PHC’s 82.6% hiring rate among the 69 graduates thus far (47.8% of whom have been employed by Mass General) and the almost 80% retention rate for these graduates.
“They love being a nurse. It’s exactly what they anticipated their career to be,” says Banister. “They are constantly promoting how positive it has been for them and that they feel like our organizations are becoming much more of a welcoming and diverse place to work.”
At the Cleveland Clinic, location-specific Diversity Councils at each of the enterprise’s community hospitals and family health centers are effectively supporting and sustaining an inclusive work environment. These employee-led councils implement action plans and sponsor activities based on strategies and goals defined by an Executive Diversity Council, all aimed to enhance employee engagement and cultural competence.
While the Executive Diversity Council works “to set the tone and the agenda,” the location-specific councils “serve as the tactical team,” explains Diana Gueits, director of diversity and inclusion. The main-campus council, for one, formed the Nursing Cultural Competence Committee and the Disability Task Force; the task force, in turn, developed the Disability Etiquette Lunch ’n Learn, a program to assist caregivers in their interaction and communication with disabled individuals that has since been taken enterprise-wide. Gueits notes the councils share and cross-pollinate ideas.
Cleveland Clinic’s chief nursing officer sits on the Executive Diversity Council, and many nurses participate in the location-specific councils with several diverse nurses serving in leadership roles (the councils overall represent a cross-section of the clinic’s workforce). Two cochairs and a cochair-elect lead each council, act as local ambassadors for diversity, engage with executive leadership, and provide feedback to the Office of Diversity and Inclusion, which facilitates the business-like, SMART-goals approach of the councils.
“This is a passion for them,” says Gueits of the cochairs, who are selected based on their experience in leading transformative teams and their commitment to diversity and inclusion. “I think that what the councils provide them is an opportunity to see, to actually be part of an initiative and be part of that process from A to Z.”
Cleveland Clinic has 21 location-specific councils, a number that is sure to increase as the enterprise expands. “That is the intention,” Gueits says, “to make sure that we embed diversity and inclusion in our commitment to all our locations and give an opportunity or platform for all our caregivers to be engaged.”
Julie Jacobs is an award-winning writer with special interest and expertise in health care, wellness, and lifestyle. Visit her at www.wynnecommunications.com.
Shifting demographics and other market conditions have created a greater need for minority nurses, particularly in certain roles. With a growing multicultural and aging population in the United States, the need for medical case managers to serve patients of various ethnic and minority groups has significantly increased. Regulatory reform—specifically, the enactment of the Patient Protection and Affordable Care Act, which ushered in new preventable readmission requirements for hospitals, along with new models of care (e.g., patient-centered medical homes and physician-hospital organizations) and more prevalent consumer-driven health care plans—has created new opportunities for minority nurses in case management. For minority nurses whose goals are to help serve these largely underserved patient populations and advance in their careers, it is important to understand the changing health care landscape.
Let’s look first at our nation’s changing demographics. The graying of America has resulted in more Americans living longer with more age-related, chronic medical conditions, ranging from arthritis, hypertension, and heart disease to hearing impairments and cataracts. According to the National Academy on an Aging Society (NAAS), almost 100 million Americans have chronic conditions, with millions more developing chronic conditions as they age. By 2040, the NAAS estimates that the number of people in the United States with chronic conditions will increase by 50%. The cost of medical care for Americans with chronic conditions could approach $864 billion in 2040—almost double what it was in 1995. While the most common chronic conditions are the same for blacks and whites, the conditions are generally more serious among minority populations, particularly individuals with lower incomes.
Another major factor in our changing health care landscape is the higher percentage of racially and ethnically diverse individuals. An AARP Bulletin article titled “Where We Stand: New Realities in Aging” reported that minorities are expected to comprise 42% of the American population by 2030. Currently, the United States has 150 different ethnic cultures represented within its population, with over 300 different languages spoken and a wide range of cultural nuances reflected. For health care providers, this broad spectrum of cultural diversity in its patients introduces higher incidences of certain conditions, while also posing challenges relating to care and communications.
Addressing Cultural Challenges
On the disease front, we know that certain ethnic groups are more prone to certain medical conditions. Many health care providers and insurers are responding with targeted initiatives, such as: the Chinese Community Health Plan’s Diabetes Self Management: A Cultural Approach initiative to enhance diabetes knowledge and management in the Chinese population; Excellus Health Plan’s Healthy Beginnings Prenatal Care program to decrease NICU admission rates for African American teens; and Med One Medical Group’s Adherence to Hypertension Treatment and Measurement project to educate English, Arabic, and Vietnamese-speaking hypertensive patients.
Beyond the obvious language and communication barriers that can prevent quality health care delivery and optimum patient outcomes, there are cultural issues that, if mismanaged, can also interfere with providing quality health care. For example, in Latin culture, religious healing, praying to certain saints, and relying on religious symbols to address health issues are not uncommon. Patients of African descent are inclined to believe in the healing power of nature and their religion. Within Asian groups, achieving balance between yin and yang, using certain herbs and foods, and relying on acupuncture to unblock the free flow of energy (chi) are common practices. Health behaviors also vary among ethnic groups. Armenians are tolerant of county health facilities, whereas the Vietnamese regard them and the related bureaucracy associated with government facilities as degrading. They, therefore, prefer receiving care in a physicians’ office, even if higher costs are incurred.
There also are differences relating to how certain minority and ethnic groups want to hear about their medical conditions. Did you know that the majority of African Americans and European Americans believe patients should be informed of terminal illnesses, while fewer Mexican Americans and Korean Americans agree? Family values relating to health care decisions also differ among minority and ethnic groups. Within the Mexican, Filipino, Chinese, and Iranian cultures, for example, there is the belief that a patient’s family should be first informed about a loved one’s poor prognosis so they can decide whether or not the patient should be informed. Obviously, these variables and many others are important for health care professionals to understand when caring for a patient. This is an area where minority nurses of different backgrounds and cultures can be a tremendous asset to their patients and to the overall health care system. Studies have demonstrated that case managers help strengthen primary care. This is particularly true when patients have complex or multiple medical conditions—as many elderly people do—or chronic conditions such as diabetes or chronic obstructive pulmonary disease.
Combating Disparities in Health Care
It is widely known that disparities exist in the care of minority patients. While this is more pronounced in rural primary care practices, it holds true across the board. An Institute of Medicine report found that “racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as insurance status and income, are controlled.” Other studies also have explored these disparities, including Aetna’s “Breast Health Ethnic Disparity Initiative and Research Study” and Health Alliance Plan’s “Addressing Disparities in Breast Cancer Screening.” Collectively, they further make the case for minority nurse case managers to advocate for minority patients.
Related research supports the fact that, where minority case managers are in place, there is a significant improvement in patient outcomes. This was evident in a study of rural African American patients with diabetes mellitus where it was found that they were able to better control their blood sugar levels with a redesigned care management model, which incorporated nurse-led case management and structured education visits into rural primary care practices.
From Public Sector to Hospitals, Physicians’ Offices, and Entrepreneurial Settings
There is no question that, given today’s health care landscape, minority nurses have a great opportunity to help make a difference in the care of minority groups and enjoy heightened career fulfillment and potential advancement. Among the settings minority nurses can consider are:
• The public sector—serving within the Veterans Health Administration system for our veterans, many of whom are minorities, or the Indian Health System for our nation’s native American populations;
• Hospitals—helping hospitals achieve lower rates of preventable hospital readmissions, caring for minority and ethnic patients, and serving as a patient advocate and liaison with family members;
• Physicians’ offices—facilitating patient-physician communications, assuring appropriate records are communicated between treating physicians, monitoring patients’ adherence to treatment plans, and identifying any family and/or home issues that might affect a patient’s well-being;
• Financial advisors and estate planning attorneys—working with these professionals who are becoming increasingly more involved in the financial aspects of their clients’ health care and the costs associated with their care, as well as protecting their clients’ estates;
• Independent practice—working for a case management firm or establishing your own practice.
Independent practices present an opportunity for minority nurses to shape their own destiny and financial reward. Through one’s own practice, a minority nurse can focus more fully on his or her patients’ well-being without the over-emphasis on cost containment we see in many other practice settings, especially hospitals. These nurses can decide that they want to specifically dedicate their practice to a certain minority and/or ethnic group. They can establish a truly patient-centered care management business model, performing health risk assessments, providing health coaching, disease education and management, assisting with patient transitions of care, coordinating health care resources on behalf of their patients, reviewing hospital bills, helping patients assemble their health records, and providing end-of-life care coordination.
Based on a 2013 survey by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, nurses from minority backgrounds represent 17% of the registered nurse (RN) workforce. Currently, the RN population consists of 83% white/Caucasian, 6% African American, 6% Asian, 3% Hispanic/Latino, 1% American Indian/Alaska Native, 1% Native Hawaiian/Pacific Islander, and 1% other. Given the increasing shortage of nurses, combined with the growing demand based on our shifting demographics, it appears that the time has never been better for minority nurses, while fewer in number, to take center stage in case management.
Catherine M. Mullahy, RN, BS, CRRN, CCM, is president of Mullahy & Associates www.mullahyassociates.com, and author of The Case Manager’s Handbook, Fifth Edition.
Where nurses work, as well as their education level and specialty, can all influence how much they earn in salary. But all in all, respondents to the third annual Minority Nurse salary survey report making more this year than they did last year.
With rising salaries, the outlook for nurses may be getting brighter, but there are still some differences in pay by ethnicity.
Last year, nurses reported earning a median $68,000, and this year they reported an increase that brought their median salary to $71,000—a $6,000 jump over what they’d said they earned five years ago.
While African American nurses reported earning more this year than last, a median $60,200 in 2014 as compared to this year’s $70,000, they still took home slightly less than the overall median. Hispanic and Asian nurses said they earned slightly more than the overall median salary, and more than they reported earning last year, while white nurses reported a salary close to the overall median salary and similar to what they reported taking home last year.
To collect this data, Minority Nurse and Springer Publishing e-mailed a link to an online survey that asked respondents about their jobs, educational background, ethnicity, and more.
Nearly 2,400 nurses from a variety of backgrounds and filling different job descriptions responded to the survey to provide a glimpse into their day-to-day roles, their plans for the future, and their current and past salaries.
The respondents work in various aspects of nursing from patient care to education and research, and have certifications in critical care, advanced practice nursing, and family health, among others. The nurses also work for a range of employers, from large organizations with more than 10,000 employees to ones with a hundred or fewer employees, and from public hospitals to colleges to home health care services.
Drilling down deeper into the data, wider gaps in pay start to emerge. For instance, white nurses working at private hospitals earn a median $80,000, while African American nurses earn a median $62,000. Similarly, at public hospitals white nurses earn $79,500, and African American nurses $71,000. However, nurses employed by college or universities reported largely similar salaries falling between $70,000 and $80,000, with African American and Asian nurses reporting receiving the higher end of that range.
Salaries also vary by region in the United States. Nurses take home the most in the Northeast, followed by the West, though there also appear to be slight variations by ethnicity as white and Hispanic nurses living in the western US earn a median $80,000, while African American nurses earn a median $73,000.
Education also affects take-home pay, and nurses reported higher salaries with increased education. Nurses with associate’s-level degrees reported earning $67,000, while nurses with bachelor’s-level degrees said they earned $70,000. And that increased further with advanced degrees as those with master’s degrees reported taking home a median $72,000 and those with doctoral degrees said they made $82,000.
There, too, were slight differences by ethnicity. For instance, African American nurses with associate’s-level degrees reported taking home a median $65,119, less than the overall median, while white nurses took home a median $68,320, slightly more than the median. At the bachelor’s and doctoral levels, though, African American and white nurses reported earning approximately the same salary.
Despite rising salaries—and recent raises—more than a third of nurses still said they are contemplating leaving their current jobs in the next few years. When they left previous jobs, respondents said it was mostly to pursue better opportunities, and this year’s respondents reported that the best-paying places to work are in private practice or at private or public hospitals.
Inclusion tops the list of many workplace must-haves. But what exactly does inclusion mean?
According to G. Rumay Alexander, EdD, RN, FAAN, clinical professor and director of the Office of Multicultural Affairs at the University of North Carolina at Chapel Hill, when people talk about inclusion they can’t ignore one very important fact – inclusion means something different for each person.
“You have to define terms and explore it and explain it a little more carefully,” says Alexander, who recently moderated the American Nurses Association webinar Diversity Matters: Create an Inclusive Nursing Culture that Leads to Better Outcomes. “A prime example is that people talk about respect. The fact of the matter is that ten different people have ten different definitions of respect.”
How can you begin talking about inclusion?
1. Define It
Nurses excel at critical thinking skills, says Alexander, so sitting down to talk about what inclusion means in your workplace should be the first step.
2. Think About What Inclusion Means to You
“Self-awareness is so key to the work of an inclusive space,” says Alexander. “Understanding and knowing yourself is important. Know what pushes and doesn’t push your buttons.” Use honest self examination of your biases and prejudices so you become aware of them and realize how they could impact your work. Everyone has had different experiences, says Alexander, and each of those can change your outlook. The important work is understanding how that happens and making sure it doesn’t invade your work.
3. Be Willing to Change
When you do some honest reflection, you might realize where you need to make changes. That’s not a bad thing. Almost everyone needs to do something better, so having an open mind and understanding that you are part of a team trying to change takes the personal sting out. Be willing to learn. “Understand that your private decisions have public ramifications,” says Alexander. “You can’t talk your way out of what you behaved your way into.”
4. Change Your Culture
“Culture will trump strategy every time,” says Alexander. If everyone isn’t on board, any changes and any strategies put in place won’t hold. Understanding workplace culture means understanding who shapes the culture and how they interact. “You have to understand culture,” says Alexander. “Culture is the way you approach your work.”
5. Be Patient
“You have to understand when you are changing culture you are dealing with a process and that takes time,” says Alexander. A new environment won’t happen overnight, but it will happen with self reflection, new approaches, and honest and open communication.
When sick and injured patients arrive at hospitals for treatment, they also bring with them their unhealthy prejudices and biases. On the frontline of health care and healing, nurses may find themselves dealing with patients who prefer a caregiver who is of the same race. Patients—or their loved ones—may express their racial preference with negative comments and intolerant behavior, or directly voice their desire for another nurse. In a perfect world, hospital management would not cater to racially biased requests or demands. But real life is imperfect.
One blatantly racist incident involving an African American nurse made national headlines in 2012 when a white, swastika-tattooed father demanded that no black nurse care for his sick baby at a Michigan hospital. That case served as a springboard for several lawsuits and as a template for health care providers of exactly what not to do. Tonya Battle, a 25-year nurse at Flint’s Hurley Medical Center, worked in the neonatal intensive care unit when she met the white parent. After introducing herself, she was told by him to get her supervisor. The father relayed his racial preference to the supervisor, who reassigned Battle.
According to the Lansing State Journal, Battle said that a note was posted on the assignment clipboard reading: “No African American nurse to take care of baby.” Hospital officials removed the sign from the assignment chart after a short time. Still, black nurses were not assigned to care for the infant for about a month “because of their race,” according to the lawsuit. Battle’s case has since been settled.
While such overt incidents are isolated, no one should be shocked by racist patients, says Roberta Waite, EdD, APRN, CNS-BC, FAAN, associate professor of nursing and assistant dean of academic integration and evaluation of community programs at Drexel University’s College of Nursing and Health Professions.
“Racism is prevalent within our society. At times it’s been more covert and other times it has been more overt. It’s much more covert now,” says Waite, although it depends on geographical areas. “The more shocking component is: what do we do about it? How do we talk about it? How do we work with our students if we work with them at all? And how do we have these discussions amongst our colleagues?”
Whatever the solutions may be for patients who discriminate against nurses based on race, physicians need them, too. A 2010 survey of emergency room doctors found that patients often reject the physician assigned to them and request a doctor of the same race, gender, or religion. Their requests are routinely accommodated. If the patient request came from someone who was female, non-white, or Muslim, it was more likely to be granted.
“It’s medicine’s open secret,” Kimani Paul-Emile, an associate professor of law at Fordham University, told The New York Times. Paul-Emile did not respond to Minority Nurse’s requests for an interview but has written extensively on the topic. “The medical profession knows this happens but doesn’t want to talk about it,” she wrote in an article in the UCLA Law Review titled “Patients’ Racial Preferences and the Medical Culture of Accommodation.”
So, how do nurses of color handle patient encounters they believe stem from bigotry?
For Stephanie Stith, RN, a travel nurse for the past 10 years of her 15-year career, staying calm is a coping strategy. “I just mainly look [at them]. I give myself some time, because it’s not worth losing a job for.” She recalled one experience involving a patient who told her he was a member of the white supremacist Aryan Nation. “He looked at me and said, ‘I hate niggers.’ I said, ‘Good, so do I.’”
No other nurse was available to treat him, so she assumed her medical duties. As she worked, he continued his racist rant until she reminded him it was not smart to deride the person helping him stay alive. “I wanted him to know that I have the power over your life, and you are calling me names? Not that I was going to do anything; I just wanted him to think,” explains Stith, who says she deals more with slights than outright racism. For example, patients sometimes assume she is a medical tech instead of a registered nurse because she is black.
Stith also refrains from becoming emotional when responding to racist patients. “I need a paycheck. It doesn’t benefit me to get indignant. You can call me ‘nigger’ and say whatever you want, but at the end of the week I cash my paycheck. I am contracted to perform a service. I can’t change anybody’s mind or attitude. All I can do is be the best I can.”
Retired nurse Dinah Penaflorida, RN, MPH, MSN, agrees. Her advice for new nurses dealing with such requests is to remember that “the patient’s comfort and trust comes first. It is more important to be patient-centered in the care than to take the patient’s request personally. When the patient is in pain and suffering, it is not the time to talk about race and discrimination.”
Penaflorida was born and raised in the Philippines. At 16, she received an American Field Service Scholarship to spend a year in Hutchinson, Kansas. As a staff nurse at Kansas University Medical Center in the 1980s, she encountered a few patients who requested a Caucasian nurse instead of her. When it occurred, she went to the charge nurse to comply with the request to “create a more comfortable environment for the patient to heal.” She left those experiences behind her when she moved to the West Coast. “Working in California was different. I did not experience that,” says Penaflorida.
Focusing on caregiving instead of the patient’s name-calling or other forms of intolerance is the best strategy, nurses say. “l always keep in the back of my mind that I had the best training going because I am a nurse of color,” says Deborah Bowser, RN, who has a master’s degree in health services administration and is a practice administrator in Richmond. “Most of my instructors were nurses of color and they dealt with worse situations than I have. They always instilled in us that ‘you will be judged by the color of your skin and it will be assumed you are not a RN, and you do not have the experience.’ They took no slack from us. We were the best of the best.”
Bowser recalled being rebuffed by two white patients during her 43-year career. Both incidents happened in New York during her night shift. Each time, her supervisor told the patient she was one of the best nurses. “One patient decided they did not want to be treated by me because I was black, so I informed my supervisor. The patient was extremely ill, so I said, ‘You have a choice; let your prejudices go by the side and let me take care of you. I know what I am doing.’ In one incident the patient said ‘yes,’ and in another the patient said ‘no’ and did not get care for a very long time because there was no other nurse who was Caucasian who could care for that patient.”
Bowser says she would like to think in this day and age that race-based requests would be nonexistent, “but you are going to have people who do not want people of color touching them” regardless of their expertise. For any young nurse of color who encounters such patients, “carry yourself with pride and get a mentor to help you,” she advises.
Racist patients can overwhelm young nurses, says LaDonna Northington, DNS, RN, BC, professor of nursing and director of traditional undergraduate studies at the University of Mississippi Medical Center (UMMC) School of Nursing. “A young nurse would probably be intimidated and wouldn’t know what to do but leave out of the room, so they have to find a mentor to help them… problem solve through a situation like that. A seasoned nurse is able to take a high road. If you try to take care of the patient, they can call it assault,” so a nurse must learn how to accommodate a patient from a legal standpoint, she explains.
“For a young nurse, they should get their charge nurse or head nurse to intervene. It’s a tough call,” says Northington, who has not dealt with a racist patient during her 35-year career.
“I can’t recall an incident when I was on the floor taking care of patients where I felt like a patient did not want me to take care of them because I was black…and you would think if it was anywhere blatant, it would be in the South where we are. I haven’t heard the students talk about it. It could be in pockets [of communities] or people deal with it in a different way.” The UMMC School of Nursing addresses sensitivity and cultural awareness and understanding, she says, adding it’s possible that black patients may reject white nurses. “An elderly black person who has never trusted white people because of Tuskegee and those kinds of things and Mississippi history” may request a black nurse.
Discussing race makes many people uncomfortable, but nurses say it’s part of the solution. “When you are talking about the elephants in the room, we talk more openly about religious differences… and gender or sexual orientation, but when you get to race, there is so much more hostility and changing the subject,” says Waite. “It’s not talked about openly… oftentimes not at all. I’m not shocked that those incidents occur; I am actually surprised it doesn’t occur more often.”
Waite uses a social justice framework to talk about such topics as power, privilege, oppression, “and every ism” in a leadership course she teaches all undergraduate health profession students, including nurses. “I explicitly talk about it. However, most often within nursing clinical courses the topic is called ‘cultural competence.’ That’s the catch-all phrase that overlays issues of culture and diversity. That phrase is probably in everybody’s syllabus; however, how each person operationalizes what they do in teaching their students will vary,” she says. It will come down to how comfortable that faculty member is in guiding or leading or discussing issues regarding race, she adds.
At the University of Texas-Pan American nursing department, the curriculum emphasizes culture and cultural differences among people, says Carolina G. Huerta, EdD, RN, FAAN, nursing department professor and chair. In one required course, undergraduate students spend at least two weeks listening to lectures and discussing the impact of culture on nursing care, with particular attention paid to debunking stereotypes and focusing primarily on each person’s uniqueness. The course aims to sensitize students to issues related to racism and stereotyping.
“Once admitted to our program, every student must address cultural implications of their nursing care following each of their clinicals,” explains Huerta. “There is a section on their assigned clinical paperwork that must be turned in that deals strictly with cultural implications of care. The students are asked to reflect on the patient that they cared for and address any cultural implications, whether these deal with the foods the patient ate, religious affiliations, overt or covert racism, family issues, et cetera.”
While some patients will always express a racial preference for nurses, what matters most is how the institution and administration respond to such requests. “If you cater and say ‘no black people will work with you,’ that’s the problem,” Waite argues. “A patient has the right to decide who will care for them, but they can’t do it in a discriminatory manner. Instead, the response could be ‘Everyone here is competent to take care of you. If you choose to [reject care from a specific nurse] that is fine, you can go to another hospital.’”
Most of the hospitals that have been in the news “gave in” to racial preferences, Waite notes. Hopefully, most hospitals have a statement within their policy on how to engage and work with clients if anything like this surfaces. Talking about these issues is key, she adds.
“I think oftentimes today, people think either you are racist or not. It’s not that you are racist or not; racism is a spectrum,” says Waite. “All of us continuously struggle to deal with prejudice and bias because no one is perfect. When trying to understand where these thoughts come from and not feed into it, we move society forward. And it’s going to move forward as we are able to have these open and authentic conversations with one another.”
Robin Farmer covers health, business, and education as a freelance journalist. Based in Virginia, she contributes frequently to Minority Nurse magazine and website. Visit her at www.RobinFarmerWrites.com.