Would you tell a bright, promising student that he or she just doesn’t have what it takes to be a nurse–before he/she has even been accepted into a nursing program? All too often, this kind of prejudice is exactly what students with disabilities encounter when they apply to nursing schools. Just ask Susan Fleming, MN, RN, a nurse who was born without a left hand. Fleming has been a nurse for more than 20 years and currently teaches nursing at Washington State University (WSU) in Spokane, yet she was once denied admission to a nursing program because the school automatically assumed—incorrectly—that she would not be able to perform certain essential nursing skills with only one hand.
To inspire students with disabilities to not give up on their dreams of becoming a nurse, and to promote disability awareness among nursing school admissions committees, faculty and nursing skills labs, Fleming has collaborated with Donna Maheady, EdD, ARNP, to develop a new DVD, “Nursing with the Hand You Are Given: A Message of Hope for Nursing Students with Disabilities.” Maheady is the author of the award-winning book Nursing Students with Disabilities: Change the Course and founder of ExceptionalNurse.com, an online community for nurses and students with disabilities.
The DVD is presented through the eyes of a nursing student with a disability, who interviews Fleming about how she taught herself to perform a variety of nursing skills with one hand. Fleming takes the student into the nursing skills lab, where she demonstrates such skills as putting on sterile gloves, giving an injection, lifting a patient and applying a sterile dressing.
Produced with support from WSU Intercollegiate College of Nursing, the film is also designed for use by state departments of vocational rehabilitation and disability services staff at universities, colleges and technical schools to encourage students with disabilities to pursue nursing careers.
The “Nursing with the Hand You Are Given” DVD can be purchased for $45 plus tax and shipping. For more information, or to order, contact the WSU Intercollegiate College of Nursing Multimedia Library at (509) 324-7321 or [email protected].
The end of the year was dreamlike. Not only was I accepted into an accelerated nursing program, the school also selected me as a recipient for a prestigious scholarship award. The honor of being among an elite group chosen to represent the ideal future “face” of nursing leadership was an incredible sensation. But those exciting days quickly spiraled into a nightmare.
Many of us belonging to ethnic and racial groups experience disturbingly disparate health, educational, and economic outcomes, and we have committed ourselves passionately to improving the well-being and quality of life of individuals from populations from which we ourselves are drawn.
My faculty advisor for the scholarship program was so impressed with my curriculum vitae and scholarship application essay that she strongly encouraged me to pursue scheduling a meeting with the director of the Ph.D. program to discuss a seamless progression from a B.S. to an M.S.N. to a Ph.D. One week later, I met with my faculty advisor again to discuss some initial temporary feelings of anxiety I had about the program. I sought to proactively inquire about accessing resources and strategies to succeed in the program, with my diagnosis of depression and anxiety disorder. The next day, in a meeting with my advisor and one of the school’s deans, I was urged to voluntarily withdraw my admission and cancel my acceptance.
The experience was unfathomable; literally within a week, I went from being encouraged to complete all levels of nursing education at the school to being told “this is a very intense program,” “we want you to be well,” “there are other seconddegree programs,” and “when one opportunity closes another opens.” A week after the scholarship orientation and on the fourth day of classes, they concluded that I lacked the emotional fortitude to handle the rigors of the intense, accelerated program. Additionally, when I called several weeks later to honor my end of the scholarship contract with the organization, I was informed that the school had already contacted the organization the day after my withdrawal and requested that the scholarship funds be given to another fi nalist. Along with the frustration inherent in the situation, I was very disappointed with the enduring stigma of mental illness, so pervasive that my health condition superseded the accomplishments that resulted in my selection as a prestigious scholar.
About a month after the experience, I traveled overseas for a service mission trip. An uncanny experience served to maintain my resolute desire to be a nurse, in spite of the indignant and vilifying event.
As the service team of approximately 60 volunteers waited to begin our five-day service mission, the warm community residents greeted us individually. One young girl caught my attention, as she was wearing a bright pink shirt, decorated with the word “princess” (printed in English) and a rhinestone-studded tiara. It reminded me of something I would have worn at her age. Speaking in Spanish, I said, “I really like your shirt.” She tilted her head, her eyes downcast. Her facial expression indicated that she heard me, but she didn’t respond to my compliment. I then proceeded to tell her how pretty it was and called her Princess. Again, I received no response and little eye contact. I finally asked her if she understood me, as I didn’t rule out the possibility that my Spanish was rustier than I realized, but she answered “yes.”
When I walked off I watched the young girl and noticed she was aloof from the other girls and women who were waiting to enter the clinic area. I had two initial thoughts: first, this young girl needs to see a provider and feels shame or embarrassment, or she is extremely shy. Several hours into the afternoon, I saw her again and asked her age. She clearly responded with her head lifted, making eye contact: “16.” Then she became reticent to speak again, and I watched her from a distance and noticed that she remained aloof.
I asked one of the missionaries of a partnering organization about the average age of parity and the familial structure. He said couples are usually partnered anywhere from 12 years to adulthood. I asked our pharmacy manager if we had pregnancy tests. We didn’t.
I saw the Princess again for the third time in the late afternoon but didn’t find an appropriate opportunity to speak with her in an inconspicuous manner. The next day, I spoke with the pediatrician about my assumption, and when I spotted the young lady, I discreetly pointed her out. My hope was that she could be examined and referred to the permanent clinic, about a 30–40 minute walk, to receive the care I believed she needed. A few minutes prior to leaving for my service project worksite, I greeted her with a wave and a smile and it was reciprocated with a partial wave and smile. The next day, I discovered that a teenage girl was seen by one of our providers and that she indeed thought she might be pregnant but was afraid her mother was unaware of her potential pregnancy.
I shared my experience with my student mentor assigned to me at the time of my admission offer to the scholarship program. She expressed her concern about the information I revealed and reasoned that as a black female ostensibly entering a predominately white women’s profession, disclosing my mental health condition might not have been the action of my better judgment. I respectfully, wholeheartedly disagree.
Not only does concealment fuel stigma, but carrying this unnecessary burden hinders one’s ability to achieve a complete and whole state of wellness. Additionally, I candidly shared with her that my father was a physician, trained in the ’70s, who labored under the stigma and shame of his depression for 30 years, unbeknownst to most of his colleagues. Out of fear of losing his medical license and the respect of his colleagues, he concealed his illness and failed to receive the appropriate level of treatment he needed during a crisis episode. As a result, his lifelong battle with depression ended in suicide. His family, friends, colleagues, fellow community members, and former patients were absolutely devastated and angry that he never reached out for adequate help.
My very considerate and compassionate student mentor addressed a relevant and poignant concern, one I also believe has been inadequately examined in society: in a country that professes a desire for diversity, but where racial prejudice still exists and opportunities to render a racial/ ethnic minority as incompetent can be exploited, how does one handle a having a mental illness?
While this question should by no means be ignored, I’ve debated my decision to disclose my mental health history and the physical manifestations that I experienced. My conclusion? I unequivocally have no regrets. One of the main roles of a nurse is to be a patient advocate. I believe that if I can effectively advocate for myself, I’m well qualifi ed to be a uniquely effective advocate for a patient.
Finally, to my father, I’m so very proud of you for dedicating your life, service, and passions to helping others, even as you did your best to address your own struggles and challenges. Thank you for giving me the resiliency and courage to pursue my passions and dreams amidst obstacles and adversity. I love you.
If you are struggling with depression and/or anxiety, we encourage you visit the National Alliance on Mental Illness website at www.nami.org or the National Institute of Mental Health at www.nimh.nih.gov.
Another year, another record-breaking number of applicants, and another group of nurses and soon-to-be nurses that overwhelmed us with their determination, dedication, compassion, and intelligence. Choosing our scholarship winners has always been a difficult task, and this year was no exception. But after much deliberation, we are so proud and thrilled to introduce our winners to you! We hope their stories resonate with you just as they did with us.
And just as we reveal this year’s winners, we invite you to send in your applications for next year’s scholarship. To apply for the Minority Nursescholarship, you must:
- Be a racial or ethnic minority.
- Be enrolled (as of September 2013) in either the third or fourth year of an accredited B.S.N. program in the United States or an accelerated program leading to a B.S.N. degree (such as R.N.-to-B.S.N. or B.A.-to-B.S.N.) or an accelerated master’s entry program in nursing for students with bachelor’s degrees in fields other than nursing (such as B.A.-to-M.S.N.). Graduate students who already have a bachelor’s degree in nursing are not eligible.
- Have a 3.0 GPA or higher (on a 4.0 scale).
- Be a U.S. citizen or permanent resident.
We encourage you to apply for the 2013 scholarship and look forward to reading your application!
First-Prize Winner, Shylisa Hicks
Born in San Diego, Shylisa Hicks now lives in Bastrop, Louisiana, and attends Grambling State University. She belongs to a litany of nursing associations, volunteers her time, and has bright plans for the future.
But it is Shylisa’s life story, one of overcoming seemingly crushing adversity, that truly inspires. Her father was killed when she was five years old. Child Protective Services removed Shylisa from her mother’s home at 10 years old. She went to live with her grandmother, then aunt and uncle, where she stayed.
Originally two grades behind her peers, Shylisa persevered and eventually graduated high school early as an honors student. She continued her honors course work at Grambling State.
Bubbly and laughing, Shylisa says she calls her aunt and uncle mom and dad. “I wouldn’t be anywhere with out my parents,” she says. “I appreciate it all.” She also credits her success to her supportive husband—also her high school sweetheart. She hopes to one day have two children of her own.
“I really wanted a big family,” Shylisa says, and she grew up with three siblings. “I love kids . . . especially to make them feel better when they’re sick.” She currently treats children and families in their homes. “I just fell in love with it,” Shylisa says.
Shylisa plans to obtain a doctoral degree and become a certified Sexual Assault Nurse Examiner (SANE). “Somebody has to do it,” she says. “I want it to be me….I’ve had a rough life myself.”
“It’s been a bumpy road, but I love it,” Shylisa says of her nursing education. She is excited for the future, and she intends to go back to school to become a Nurse Practitioner, eventually going on to establish a pediatric clinic.
Runner-up, Sandrine Nankap
Now living in Winchester, Virginia, where she attends Shenandoah University, Sandrine Nankap grew up in Cameroon, on the West coast of Africa. Hundreds of people in her country live in poverty and die of AIDS due to lack of knowledge and resources, she says. Though she volunteered with children and teens to teach them about HIV/AIDS prevention, Sandrine wanted to do more.
The fourth of seven children, Sandrine says her parents could only afford to send one of them to school. “They put all their money on me,” she says. “They did their best to encourage me in everything I wanted to do.” In her culture only men are thought to deserve schooling, to lead a family, Sandrine says. “I had a lot of pressure to be a successful woman.”
Ranked high in her secondary school class, Sandrine wanted to educate others and make a difference in their lives, so she went to nursing school, graduating in 2004. In 2008 she was “blessed with the opportunity to come to America,” hoping to become a nurse educator, combining two professions in which she believed strongly.
But upon arriving in America, Sandrine found she did not have enough money to support the continuing education needed and her two young children. “As a single mom, I started to work as a coffee maker at Dunkin Donuts for almost one year.” She was promoted to assistant manager. “Working with that company, I kept some money that allowed me to go for my nursing assistant training.”
Within two months, Sandrine took a job as a nurse assistant. It was one of her lucky breaks, she says. The other nurses counseled her, taught her. “They helped me achieve my dreams,” she says. “I passed [the NCLEX] on the first try and today, after all this struggle and tears, I am proud to be a registered nurse.” She still wants to become a nurse educator, teaching both in the United States and Cameroon.
In five years, she’ll be pursuing her doctorate, Sandrine says, and she’s starting her master’s course work next year. “I like to learn. I love knowledge,” she says in a soft yet steady voice. “I worked so hard for everything that I have….I have a lot of ambition.”
Sandrine says she wants to send her younger siblings to schools as well. She sends them whatever money she can so they can come to America too. Sandrine also wants to return to Cameroon to help other young women become nurses. “I’m really grateful for this opportunity to be what I want to be in life,” she says.
Runner-up, Cerilene Small
“Every morning I wake up and begin my daily rituals of feeling the left region of my face,” says Cerilene Small. She keeps her eyes shut, afraid she will open them and be unable to see. It’s happened in the past, and because she has multiple sclerosis, it could happen again. Cerilene was diagnosed in 2009.
A competitive African dancer, Cerilene first knew something was wrong when she lost feeling in her body—but her mother thought it was due to her dancing all night. Then, after months of inconclusive tests, she learned she had MS.
“It was really hard” going into senior year, Cerilene says. She was scared of going anywhere, hopeful but cautious of what her future might hold. Originally from Brooklyn, Cerilene applied to New York University undecided, but after spending a month in the hospital, she says she realized she wanted to become a nurse. “My nurses really had a strong impact on my recovery,” Cerilenesays—so much so that she redid her college applications.
Now enrolled at NYU, Cerilene started classes in February 2011, and she had her first MS “flare up” not long after. She says she has about one flare-up each semester, but she’s trying and adjusting to the effects of a new treatment.
Being an honors student, a high school valedictorian, and a first-generation student, they all pale in comparison, Cerilene says, to being able to take advantage of every day “as a leader.” She mentors other first-generation students and one day hopes to open a youth health center offering free clinical services. She aspires to pursue a five-year dual degree (B.S.N./M.S.N.) in pediatric nursing.
Become familiar with the population you want to serve, Cerilene advises soon-to-be nurses. “Try to get involved before clinicals.” Know that the work is hard, but learn to “be a leader on your own.” After that, just “have faith,” she says. “You’ll do fine.”
A recent Institute of Medicine report documented evidence that minorities in the United States received lower levels of mental health care, even when variables such as insurance status and income were controlled, says Debbie Stevens, P.M.H.C.N.S.-B.C., a doctoral student at Emory University’s School of Nursing in Atlanta, Georgia. That’s because nurses play a major role in helping reduce these disparities by educating patients, families, and their communities, Stevens says.
Overcoming cultural barriers
Finding treatment for an illness, such as depression, can be difficult for members of minority groups because they may face stumbling blocks to care, says Vicki Hines-Martin, Ph.D., R.N., F.A.A.N., a professor in the University of Louisville School of Nursing in Louisville, Kentucky.
A major barrier is a perceived cultural stigma of mental health issues. Hines-Martin says some minority populations don’t talk about suicide or depression because it’s seen as shameful. “You may have people who say, ‘I know about suicide, but it has nothing to do with my family or my group,'” she says.
Another problem is that many people may not understand the seriousness of their needs, says Harriett Knight, R.N., a nurse at Sinai Hospital in Baltimore, Maryland. Some people may initially seek an appointment with a specialist, but if treatment involves ongoing medication for an illness, such as depression or schizophrenia, the patient may be resistant to taking the drug as prescribed, or they don’t fully accept that they should continue to take it, says Knight.
Sylvia Hayes R.N., M.S.N., is a nurse in the mental health unit of Peninsula Regional Medical Center in Salisbury, Maryland. She says many patients she sees also don’t accept that mental health is a specific medical science. “They tend to believe their issues are caused by a physical problem,” she says. So they may seek help for a persistent headache, when the real issue may be anxiety related, she says.
In many cases, if a patient realizes that his or her medical issue does involve mental health, they may face another barrier—the fear of being stigmatized. Hayes says she’s seen many African American patients who are afraid that they’ll be “labeled” if they admit to having mental health issues.
“They don’t want to be considered ‘crazy,’ and their family doesn’t want them to be considered ‘crazy,'” says Hayes. “They may be afraid their family will isolate them if they seek help, because then they’ll become an embarrassment.”
Of course, many families support their loved ones suffering from mental illness, regardless of any perceived social stigma. In fact, when relatives are accepting of their loved ones and are willing to help them find care, they can be a vital part of the recovery plan. Many patients will even turn to family members for help before they turn to the medical system, says Hayes. This is good, as long as well-meaning relatives encourage patients to seek professional help when necessary. “It can be a negative if the family delays the patient from receiving the treatment they need,” she says.
Many families actually hold the key to helping patients understand their medical histories, Hayes says. “I’ve seen people with family secrets. They had an uncle or aunt who may have dealt with the same mental health issue,” she says. But if the family shunned that aunt or uncle, the patient may not be as open to finding help.
Family cooperation is also important in treating children and teens. Hayes says many mental illnesses are present at a young age. “I’ve worked with kids as young as two years old,” she says.
However, it may be difficult for well-meaning families to receive satisfactory care. A recent press release from the National Alliance on Mental Illness (NAMI) reports “63% of families reported their child first exhibited behavioral or emotional problems at seven years or younger,” but at the same time, “only 34% of families said their primary care doctors were knowledgeable about mental illness.”
Language and cultural obstacles present another challenge for mental health patients. If a person can’t find a medical professional they can simply talk to, they are less likely to seek medical care, says Patricia Lazalde, Ph.D., Director of Behavioral Health at San Ysidro Health Center in San Diego, California.
San Ysidro serves many Spanish-speaking Latino clients, so it’s important for minority nurses to be able to speak Spanish too, she says. “Minority clients may come in with a variety of stressors, but due to language issues they often don’t seek help until it reaches a crisis,” says Lazalde.
Immigrants of various backgrounds encounter similar stressors. In Louisville, Kentucky, there are increasing numbers of members in immigrant and refugee communities, particularly form Somalia and Myanmar, says Hines-Martin. “They’re newcomers, and they’re dealing with the stressors of changing from one environment to another,” she says. “How they deal with these stressors and whether they want to talk about them is important.”
Members of minority populations may also postpone or avoid seeking care for mental health issues, Hines-Martin says. It’s not so much related to an ethnicity or racial group, but it’s associated with people who hold more traditional values related to their culture, and are less likely to follow mainstream care, she says. “People who are less acculturated into the general population may be less likely to seek help if their culture says it’s not something they should do.”
Financial stress and mental health
The slow economy is also creating a barrier to care for some people, even as it’s identified as a stressor for many. Patients are dealing with the stress of lost jobs, eviction, and foreclosure, says Hines-Martin. She recently completed a study of 127 people in a low-income area and found that poorer residents had almost double the rate of depression as the general public.
“When you look at the economic factors they have to deal with, it makes perfect sense,” Hines-Martin says. The stress of constantly figuring out how to survive can wear down a person, and those factors are associated with depressive systems, she says. “If you have problems in several areas of your life, it can affect your mental health.”
Obviously, financial setbacks don’t always cause mental illness, but they can exacerbate problems in people who are vulnerable, says Knight. “A lot of patients don’t know they’re getting sick until there’s a trigger,” she says. For example, a person may get a call from their mortgage company informing them that they’re being foreclosed on, and they can’t handle their emotions, she says.
Lazalde agrees that whenever there is a loss of financial status within the family, nurses tend to see people with increased levels of depression and anxiety, particularly with wage earners.
“Traditionally, Latino males are the primary breadwinners for families, so the loss of a job and the inability to properly care for the family can really create an additional sense of anxiety, depression, and worry. It’s because they can’t live up to the more traditional roles that they would typically fulfill for the Latino family,” Lazalde says. As a result, there’s an increase of male Latinos coming to seek help for depression and anxiety, she says. The issues affect the entire family. “It creates marital problems. Parents are fighting, and we see the kids coming in with levels of anxiety as well,” Lazalde says.
Residents often have to move out of their homes and move in with relatives and extended family because of financial problems, she says. “Family members have to change schools and meet new friends, and there are not a lot of places they know to go to in terms of seeking resources and finding a shoulder to cry on,” Lazalde says.
Financial problems can also limit access to health care, including treatment for mental health needs. “Many clients are losing medical or health insurance coverage,” says Lazalde. This means fewer people can afford their doctor visits, and they have a more difficult time paying for their prescriptions.
Immigration issues are another stressor in many minority communities. There’s a lot of anxiety and depression when people hear about immigration reform on the news, and they’re worrying about what the outcomes and changes will be, says Lazalde.
“Many of our families are being impacted. A number are split up, with half the family living in the United States and the other half in the native country,” Lazalde says. As a result, wage earners have to support two homes, while they’re responsible for the cost of attorneys and other fees. “They have the stress of keeping the family together.”
One way nurses can help patients deal with their stresses, and improve mental health care overall, is to become active in the communities they serve. This helps build trust between residents and medical professionals, says Hines-Martin.
She says that’s a goal of the Office of Disparities within the University of Louisville’s School of Nursing, where she serves as the center’s Director. The office was started because the school of nursing identified a need to focus on how nursing education, practice, and research could help populations that experience disparities in health, Hines-Martin says.
The Office of Disparities sponsors a variety of programs, including faculty and student activities. Hines-Martin’s most recent project involves working with an entire low-income public housing community. “There are about 700 people in a one-block area,” she says. “It’s a way for us for us to see how economics, food, and trans-generational housing affect how people cope.”
Hines-Martin and her nursing students have found they don’t necessarily see people who are actively engaged in behaviors that are detrimental, such as self-inflicted violence or substance abuse. “But I do see people taking risky behaviors because they don’t care anymore,” Hines-Martin says. These people put themselves in dangerous situations, such as drinking excessively, and the drinking is actually related to depression or a depressed state of mind, she says.
There are many challenges, but the program is yielding results for patients who receive care, says Hines-Martin. She says she’s seen people who received help for psychological conditions and didn’t need to be readmitted to a medical facility after receiving treatment.
There’s also been a decrease in the number of people who have been evicted from their homes because of problems that could be tied to mental illness, such as drug use, says Hines-Martin.
“The community is in partnership with us,” Hines-Martin says. “We’ve learned that people are really invested in having a better understanding of their lives and mental health. It makes it easy to partner with them and invest in them.”
Another way to help build trust is to work with other professionals and community leaders to help educate the population about mental health topics. “Many Latino families aren’t likely to go to a behavioral health specialist initially. Instead, they’re more likely to seek help from clergy or a medical doctor,” Lazalde says. With regards to minority nurses, if they are connected to these influencers, they can help patients find needed behavioral care more quickly, she says.
Identifying red flags
Finding good mental health care is not simply a task reserved for nurses who specialize in behavioral health. Minority nurses in all specialties can help identify red flags that a patient may need a referral for a behavioral health specialist, Lazalde says.
When a nurse in any practice area sees a patient, he or she should look for issues such as a high frequency of usage, she says. The primary care doctor is usually the first person a potential mental health patient will visit, Lazalde says. If a patient has historically only visited the doctor’s office once or twice a year, but now they’re visiting two or three times a month, that’s a red flag, she says. These patients tend to have physical complaints with no apparent cause, so the real issue could be stress or anxiety related, she says.
Minority nurses also need to pay attention to comments patients make during their visits. “They may see a doctor and complain about a headache, or pain in the chest or back, but at the end of the session they bring up family problems,” Lazalde says.
Another red flag could be visits from multiple family members. “If you’re seeing a mom, dad, and siblings for physical problems, all within the space of a month, it could be a sign that there’s some sort of turmoil in the family,” Lazalde says.
And nurses shouldn’t wait until the visit is nearly over before addressing mental health issues. “I think it’s really important for nurses to ask questions early on,” says Lazalde. “Ask how things are going in the family and at home. If the questions are addressed by the medical provider or nurse, it normalizes the situation and allows the family to speak more freely,” she says.
When nurses are rushed for time, sometimes really important pieces of information fall through the cracks. This can be prevented by having a patient fill out a survey at the start of their visit, Lazalde says. She encourages the use of a questionnaire, such as the Generalized Anxiety Disorder 7-item scale (GAD7), to help assess a patient’s mental health needs. “It only takes a few minutes and can be completed in the waiting room, and it doesn’t take away the nurse’s time,” she says.
If it’s determined that a patient should receive specialized care, Lazalde recommends that referrals be “normalized.” For example, when nurses make a referral to a provider who’s an oncologist, it’s normal because the oncologist is simply a member of the health care team, she says.
“So we have to find a way to make the behavioral health provider a member of a team. Instead of making the client feel as if there’s something wrong with them when they receive a referral, they’ll know that they’re just meeting another member of the team,” she says.
Lazalde also has another important piece of advice for minority nurses: don’t give up on your patients. “It often takes more than one referral to be successful. Sometimes we have to refer the patient three, four, and five times,” she says. If nurses approach their roles knowing that it takes multiple referrals before they reach a successful linkage to the other provider, then nurses may be less likely to get discouraged, she says. “We’ll know that the family hears the referral more times and there’s a higher likelihood the patient will go and complete the referral and receive the services they actually need.”
Perhaps the most disappointing barrier minorities face are the ones caused by the attitudes of medical professionals. Minority nurses can exhibit the same biases about their patients as anyone else, and if they’re not careful, they may start to form negative opinions that could affect their levels of care, says Stevens. “Just because a nurse is a minority doesn’t mean they’re immune to stereotyping,” she says.
Some nurses, particularly those who serve low-income communities, fall into the trap of assuming that some poorer patients check into medical facilities to access prescription drugs, three square meals, or a warm bed, she says. “I’ve heard people say ‘the patients are looking for three hots and a cot,'” Stevens says.
These biases are often reinforced when patients have high rates of repeat visits, she says. But despite the challenges, many minority patients who do receive appropriate care become better and are able to function in society, she says. Minority nurses must provide the best service possible by making a sincere effort to view each patient as deserving of quality medical attention, Stevens says. “Nurses have to fight to eliminate negative stereotypes they see, even if they may have had those same stereotypes themselves,” Stevens says.
Translating policy into practice can be difficult because of how pervasive some biases are, but it can be fought the way any ethnic or cultural stereotype is fought, says Stevens. “It starts with education and awareness.”
Some patients will be difficult, Stevens concedes. But if mental health care is your specialty, you should remain confident that you are helping your patients. Standards of care have to be the same, regardless of who the patient is or where he or she comes from, Stevens says.
Minority nurses are specially suited to help break down barriers and stigmas, build trust among their communities, and help their patients live the best lives possible.
For most people, going to nursing school, passing the boards and working as an RN in today’s often stressful health care arena is difficult enough. But for people who have physical disabilities, pursuing the dream of becoming a nurse can be even more of a challenge.
But that didn’t stop Ernesto Fagundo, Susan Nordemo and Steve Berlan. Each has overcome significant odds to build successful careers in the nursing profession.
“I always wanted to be a nurse,” says Fagundo, who was born with multiple mobility issues. “All I needed was a chance so I could help other people.”
All three agree that for nurses and nursing students with disabilities, the keys to success are determination and an optimistic outlook. “You’ve absolutely got to have a positive attitude,” says Nordemo, who lost most of her eyesight three years ago. “You have to be willing to ask for help and you have to be willing to accept help.”
“A Sixth Sense”
Steve Berlan, BSN, RN, has never let his hearing disability get in the way of achieving his goals in life. Exposed to German measles before birth, he was born with a cleft lip and profound hearing loss.
Berlan, who is 46, was among the first wave of deaf students to go to school in mainstreamed classrooms. Whereas most deaf children used to be sent to special schools where they learned American Sign Language, Berlan learned how to speak and lip-read. He has 80% hearing loss in his left ear, 75% hearing loss in his right and wears hearing aids in both ears.
His route to nursing was a roundabout one. He worked at an iron works company for 15 years, starting out as a pipe fitter apprentice and working his way up to engineering planner. But business became slow and he was laid off in August 2001.
By then, the economy was struggling and it was not a good time to look for a job. Unsure of what he wanted to do, Berlan decided to go to trucking school–an interest he’d had for many years–and graduated near the top of his class. He soon learned, however, that the long hours of sitting required for the job aggravated his back. He needed a profession that would let him stand.
That’s when nursing came to mind. Berlan’s wife is a nurse, and though she often spoke of the challenges inherent in the job, he knew there was a shortage of registered nurses and that nursing graduates were in high demand.
So Berlan, who lives in Maine, enrolled in nursing school. In December 2005, he graduated magna cum laude from the University of Southern Maine with a BSN degree and was inducted into Sigma Theta Tau International, the Honor Society of Nursing. Before graduation, he had been hired by St. Mary’s Regional Medical Center in Lewiston, Maine, as a graduate nurse because he had not yet taken the NCLEX-RN®.
When he failed the boards, he was “devastated.” He was demoted to a certified nursing assistant. In retrospect, he says, speaking over an amplified phone, “it probably was a good thing, because now I can appreciate what a CNA does.”
Berlan passed the boards when he took them again in March. He now works as a floor nurse in a nursing home, where most of the patients are hard of hearing. They are drawn to him, Berlan says, knowing he shares their hearing loss.
A combination of special equipment, task workarounds and new health care industry regulations all help make it easier for Berlan to communicate with patients and coworkers. He uses an amplified stethoscope, which has cables that connect to the back of his hearing aids. Most of the time this works quite well, elevating the sound of a patient’s heartbeat to a level his hearing aids can detect. But if the patient is obese or machinery is running in the background, it can be hard to hear. Adjustments to his hearing aids and the stethoscope continue to make the process work better.
When Berlan first started working at the nursing home, reports between shifts were tape-recorded. “That was a nightmare for me,” he says. “I can hear a person talking on a tape recorder, but I can’t [make out] what they’re saying.”
Fortunately, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nation’s leading standards-setting and accrediting body, recently issued a new rule that works in Berlan’s favor: Shift-change reports must now be made face to face. This is because JCAHO recognized a potential for some degree of hearing loss in the aging nurse population. (The average age of RNs is now in the mid 40s.)
The new rule means Berlan can lip-read reports. “I’m entering the nursing profession at a good time,” he says.
In addition, JCAHO now requires nurses to read back instructions phoned in by attending physicians–another policy improvement that Berlan finds very helpful. To him, people speaking through a traditional phone sound “like they’ve got the ocean mixed in with their voice.” Speakers with heavy accents are particularly difficult for him to understand, he adds.
Berlan, who has a fascination with technology, says he eventually wants to become a critical care nurse. In an ICU environment, the slightest blink of an eye or body movement may be the only way a patient can communicate. Berlan feels he could bring a higher level of care to ICU patients because he compensates for his hearing loss by observing human behavior.
“I have a ‘sixth sense’ and can tell if something is wrong,” he explains. “I can respond faster to a potential crisis than a hearing nurse, who relies on bells and whistles and other sounds.”
Discovering where his talents are best used required a fair amount of trial and error, Berlan adds. “It really requires a lot of initiative on the part of the hard-of-hearing person. Nobody’s going to roll out the red carpet for you.”
Taking the First Step
Susan Nordemo, RN, has been a nurse for more than 40 years. But it wasn’t until she lost most of her eyesight that she knew how badly she wanted to remain in the profession.
Several years ago, cataracts started robbing her of her sight. (A former heavy smoker, Nordemo is convinced that the habit made her more prone to cataracts.) As her eyesight worsened, she had to stop working as a hospital nurse. Her Reiki and hypnosis business began to suffer.
Nordemo says she was depressed, though she didn’t realize it at the time. She would go for days without talking to friends or family. She had no passion for her business. Then one morning, she woke up and knew she could no longer ignore the source of her malaise.
She called the New Hampshire Department of Education’s Division of Adult Learning and Rehabilitation Services for Blind and Visually Impaired and asked for help in finding a job. It was a crucial step, she says.
Her call brought a state employee to her house the next day to install ZoomText, software that magnified the text on her home business computer screen to a size she could see. In the next day’s mail, she received a flier seeking nurses to work for Alicare Medical Management, a health care cost management company whose services include providing telephone triage to patients around the country. Nordemo could no longer do traditional bedside nursing, but a job fielding medical questions would be a perfect way to still utilize her decades of nursing experience.
The same day, an acquaintance who helps people with disabilities find jobs came over to help her revamp her resume.
Nordemo’s considerable experience and a fair amount of moxie got her the triage job. She didn’t say anything about her low vision until she was offered the position the day after the interview. Surprised at first, the company still hired her, and Nordemo went through training to learn the job’s juggling act: simultaneously talking on the phone to patients, typing in their questions, following medical guidelines and recommending appropriate care.
Three years later, the company has loaded ZoomText on four computers and has also hired two other people with different disabilities. Nordemo is very happy with her job. “It’s using all my nursing skills and I don’t need to have perfect vision,” she says. “They’ve accommodated me every step of the way. They’ve been very good to me. But I had to take that first step, and that was a challenge.”
Her Reiki and hypnosis business, Healing Crossways Hypnosis Center in Nashua, N.H., is thriving as well. In fact, Nordemo believes her vision loss has helped make her more aware with her other senses–an approach that benefits the healing therapies she provides.
“I’ve always been blessed,” she concludes. “Things have always worked out.”
Finding a Way
Ernesto Fagundo, RN, has a lot of empathy for his patients: He knows what it’s like to live with pain.
Born in Cuba in 1970 with completely malformed legs, he endured a long process of casting and multiple surgeries. As a youngster, he used crutches, a walker and a wheelchair (from which he worked as a shoeshine boy). Yet he refused to think of himself as permanently disabled.
At the age of 10, Fagundo learned to balance his body and walk on his own. He came to the U.S. with his father when he was 15, picking strawberries on the West Coast during the day and studying at night. After graduating from high school, he moved to Miami, where he got a job doing billing posting at a clinic. He slept on the clinic floor at night.
For all of his early struggles, Fagundo believes his biggest challenges came while he was a nursing student at Broward Community College. He had a full scholarship and says he endured discrimination by fellow students who resented his success. But despite these obstacles, Fagundo did well in his courses and clinical evaluations. He graduated from the program in December 2005.
“When there is a will, there’s a way,” says Fagundo, who shares his inspirational story on request with Miami-area groups. “I just needed to find a way, because I already had the will.”
Nursing students with disabilities should know what accommodations the law requires colleges and employers to make for them, Fagundo emphasizes. He also advises having a doctor evaluate your condition and make recommendations for accommodations. To give Fagundo relief from chronic pain when he was a graduate nurse, a doctor recommended that he sit down (rather than stand) at the nurses’ station while writing his reports during clinical–a simple thing, but it required a shift in staff attitude. At the facility where he was working, only full nurses were afforded the luxury of being able to sit.
Today Fagundo, who passed the NCLEX-RN in May, works at Nursing Education Center, Inc., a Florida Board of Nursing-approved continuing education provider. He is also an American Heart Association community training instructor and operates his own AHA training site. He eventually wants to become a home health nurse “to help the elderly. Nobody listens to them.”
Living with chronic pain since birth, Fagundo says, gives him a special empathy for patients who are suffering. He understands the need to be treated with dignity and respect and he gives his patients room to grieve and come to terms with their conditions.
“There is something that nurses with disabilities can bring to the profession, and that is heart,” adds Fagundo, who continues to deal with pain as well as fibromyalgia. “Let’s not forget: we’re not disabled people. We’re people with disabilities.” He also offers this advice for nurses and students with disabilities: “Get all the help you can, because there’s a lot of help out there.”
Some people who dream of nursing careers are told they will never make it through nursing school. Some nurses who hear about a potential dream job are told they won’t even be considered a candidate for the position. Some are even told they have no business pursuing or continuing a career in health care altogether.
Although many of these nurses are not members of racial or ethnic minority groups, they are still a minority within the nursing profession. They are nurses with disabilities.
“[Nursing schools and employers] see a person with a disability and consider us to be damaged goods. They think: ‘What could this person possibly be able to contribute?’” says Karen McCann, RN, MSN, CPNP, APN-C, a pediatric nurse practitioner in New Jersey.
In reality, McCann and other nurses with disabilities are indeed contributing to their profession and enjoying successful careers. But for many of them, there were major barriers to be overcome along the way.
“The biggest obstacle is attitude,” explains Martha Smith, coordinator of the Health Sciences Faculty Education Project at the Oregon Health & Science University in Portland. The federally funded project’s goal is to increase the retention of students with disabilities in health sciences programs by educating and training faculty to better understand these students’ needs.
“Historically, the medical model concerning disability implies that the person needs to be fixed,” Smith continues. “Particularly if the disability is visible, the immediate thought is that this person needs to be taken care of or needs an intervention, rather than this is a healthy person who also has a disability and who can be a competent health care professional.”
Because of the long-standing myth that health care providers must be “physically perfect,” the question on everyone’s mind, whether verbalized or not, about a nurse with a disability is: “Is it safe to have you caring for patients?” Nurses interviewed for this article agree that doubts about whether a nurse with a disability will be able to provide safe, competent care are common across the board—from nursing faculty and students to physicians, nursing peers and even patients.
As one nurse comments, “If I make a mistake, [people assume] it’s because of my disability and suddenly I’m no longer safe. I don’t get a second chance, because the safety issue automatically kicks in.”
An Educational Irony
Nurses with disabilities often encounter these prejudicial attitudes well before they enter the workplace. It begins in nursing schools—which some experts believe are actually harder for nurses with disabilities to get into since the passage of the Americans with Disabilities Act (ADA) of 1990.
Designed to prohibit discrimination against individuals with disabilities seeking admission into educational institutions, the Act allows colleges and universities to develop a list of “technical standards”—abilities that a potential student must possess to succeed in the program. (Similarly, the ADA’s employment provisions let employers create lists of “essential functions” that a job applicant must be able to perform in order to be hired for a particular position.)
Many nurse educators say these lists allow potential students to know what is expected of them in the program, explains Candy Moore, RN, MSN, associate professor in Health Professions in the Nursing Department at Elgin Community College in Illinois. But, she argues, when academia uses a cumulative “wish list” of functional abilities as a guideline for formulating technical standards, it limits entry into the profession—the exact opposite of what the Act had intended.
Furthermore, because these technical standards can vary from program to program, nursing students who sit for the same licensing examination are potentially subject to different standards.
Another defense of technical standards commonly put forth by nurse educators is that they will assure safety in the workplace. But Moore doesn’t buy this argument either. In work settings, she points out, essential functions should be specific to the actual job that a nurse has or is seeking.
For example, a critical care nurse may need to be able to see the EKG monitor, perform two tasks with two hands at the same time and run to a patient’s bed, she says. “But should a nurse in nursing informatics be required to do all these things? No, they would not be essential functions for that job description. Yet both of these people are nurses and we need both in the profession.”
Still another rationale used to support technical standards is that in order to teach a student or patient, a nurse needs to be able to do everything that could potentially be taught, explains Beth Marks, RN, PhD, assistant director of the Rehabilitation, Research and Training Center on Aging with Developmental Disabilities at the University of Illinois in Chicago. “But if you extend that line of thinking to a logical conclusion, then how can a nurse who doesn’t have a disability teach a person with a disability?” asks Marks, who is a nurse with a disability.
Marks believes that discrimination against individuals with disabilities—or “ablism”—is so pervasive and systemic in nursing schools that students are often forced into choosing not to disclose their disability status. This again is ironic, because it effectively denies them access to accommodations, which they have a legal right to obtain under the ADA.
“There is a risk and consequences to disclosure,” agrees Donna Maheady, ARNP, EdD, a pediatric nurse practitioner in Palm Beach Gardens, Fla., and adjunct assistant professor in the College of Nursing at Florida Atlantic University in Boca Raton. She is also the founder of ExceptionalNurse.com, a Web site for people with disabilities in the nursing profession.
For example, Maheady says, “If an education program has precise measurable guidelines for physical attributes that are necessary for admission, such as the ability to hear a patient call for help, and you put down on the application that you have a 50% hearing loss, the program may not accept you.”
Pam Rathbone, RN, MSN, WHCP, a woman’s health care nurse practitioner in Portland, Ore., didn’t disclose that she had attention deficit and hyperactivity disorder (ADHD) when she was seeking her BSN degree in 1980. “I didn’t want to tell anybody. I was afraid I would be kicked out because there’s a stigma attached to having a disability,” she remembers.
Instead, Rathbone quickly learned special studying skills that enabled her to block out her hyperattentiveness to activities going on around her. Upon her return to graduate school in 1990, she revealed her ADHD to the faculty. Although her advisor told her she probably wouldn’t make it through the program, Rathbone graduated magna cum laude.
Similarly, when McCann went back to school for her master’s degree one year after a work-related injury left her with permanent nerve damage in her legs, arms and face, she was told by faculty at one state university that she wouldn’t be able to finish the program and therefore wouldn’t even be considered for admission. Even worse, the faculty at another state school informed her that nurses with disabilities have no business returning to work. Faculty at a third school told McCann that she would be a liability; however, they agreed to review her credentials and she was admitted to the program.
“Once I became a student there, the faculty was very supportive,” relates McCann, who as a part-time student graduated at the top of her class in 2000. “If I needed more time to do clinicals because I wasn’t able to keep up with the other students, or I needed to take breaks and sit, they were more than happy to make those accommodations.” Although such special arrangements can sometimes bring resentment from the rest of the class, McCann never ran into any problems with fellow students.
Breaking Down the Barriers
Once they graduate from nursing school and enter the “real world,” nurses with disabilities face a whole new set of challenges. While the ADA’s requirement that employers make “reasonable accommodations” to eliminate any barriers that would prevent an employee with a disability from performing his or her job has been criticized as vague and confusing, many health care employers are making a concerted effort to accommodate nurses with disabilities.
However, such efforts still have a ways to go, advocates for nurses with disabilities maintain. For example, says Smith, while hospitals and clinics are required by the ADA to have wheelchair-accessible bathrooms for the general public, nursing stations are notorious for not being accessible.
In some instances, this can be resolved by moving charts, which are typically placed high up, down to lower shelves, or to lower hooks if they hang by the patient’s door. Audio pagers can be replaced with vibrating pagers to alert nurses with hearing loss that they are needed. Additionally, new technologies, such as amplified stethoscopes, automatic blood pressure cuffs and digital thermometers, have helped level the playing field for nurses with disabilities.
Kristi Reuille, RN, BSN, a graduate student at Indiana University School of Nursing who has a 35% hearing loss, recalls getting her first amplified stethoscope while in nursing school. “I was concerned about whether I would be able to hear using a regular stethoscope because my hearing loss is in the low tones,” she remembers. “Getting an amplified stethoscope helped build my confidence that I wasn’t going to harm a patient by not hearing something. If I ever had a question about what I heard, I would ask a colleague to make sure I wasn’t missing anything.”
The pager system used at the hospital where she worked was helpful, Reuille adds, because it decreased the background noise level on the unit, making it easier to hear her patients. “It was done mostly for patient comfort,” she says, “but it worked well for me because the background noise, especially when you’re trying to talk one-on-one, is very distracting.”
McCann, who is currently the clinical educator for Pediatrics at Monmouth Medical Center in Long Branch, N.J., says it took her a full year to find a job that would accommodate her. For starters, the facility was willing to hire her an assistant. This enabled McCann to work part-time, which was necessary because she can’t physically work a full-time job. She also has the autonomy to set her own hours. “If one day I’m not feeling well,” she explains, “I can shorten that work day and work longer the next day.”
Her office is located next to the pediatric floor so she doesn’t have far to walk, continues McCann, who uses a cane. She has a special chair that provides extra lumbar support and a computer keyboard with ergonomic padding. She is still trying to scout out the best stethoscope for her needs, since the amplified ones can’t be used with hearing aids.
In addition to benefiting from special technology and equipment, nurses with disabilities often develop their own creative strategies for circumventing workplace barriers, notes Maheady. For example, a nurse with a hearing loss who has difficulty hearing a monitor that beeps can position the device so that he or she can see the monitor’s flashing light. The nurse may also check more frequently on patients and stay in close proximity when speaking to them.
Rathbone’s biggest on-the-job obstacle is not a physical one. “It’s organizing my paperwork,” she says. “Patient charts are a nightmare.” She solves the problem by using templates for charting notes and doing flowsheets, and by generally surrounding herself with people who are meticulous about doing paperwork.
Whether Reuille consults with a peer about what she heard through the stethoscope or Rathbone asks for assistance with patient charts, it’s all part of the teamwork that is essential for any nurse’s survival in a busy, fast-paced workplace. “You have strengths and weaknesses, and your floor- and clinic-mates also have strengths and weaknesses,” says Smith. “If you’re doing something in an area that you’re weak in, whether or not you have a disability, you’re probably going to ask a colleague to double check it.”
Many nurses with disabilities work in professional areas that capitalize on their strengths. For example, they have become nurse educators like McCann, or have moved into administrative roles. They do telephone triage, conduct in-service educational programs, perform case management, teach at nursing schools, work as consultants for insurance companies, work for poison control programs, do home health visits and more.
“There are a million ways to use your nursing knowledge,” says Moore. “You can work in different settings all over the world, with different age groups, or with specific patient populations, both ill and well. The goal in the nursing profession has always been to match the strengths of each individual nurse to a specific role.”
One unique strength that many nurses with disabilities can bring to the table is personal insight into what it’s like to be ill and hospitalized. As McCann notes, “I’m not only a nurse and nurse practitioner, I’ve also been a patient who has been put through the wringer. I’ve lived through the nightmare of fighting insurance companies and dealing with doctors who really don’t care.” As a result, when McCann hears a doctor say that he or she doesn’t have time to explain something to a patient, she urges them to make the time, reminding them that the patient is their number one priority.
Nurses with disabilities can also offer special skills, such as lip-reading and sign language. Reuille says that because she is able to read lips, she can understand patients who talk very softly or can’t speak because they have a tracheotomy tube in their windpipe—unlike some of her co-workers. Another nurse with a hearing disability who reads lips says her patients often comment that they know they are getting the best care from her because she is always looking at them and paying attention to what they’re saying.
Contrary to popular belief, most patients seem to connect well to a health care provider who is not physically perfect, adds Smith. “The patients have an immediate sense that the nurse with a disability will understand them because they’ve been through it, too.”
She cites the example of a nurse acquaintance who works in rehabilitation. This nurse, who has paraplegia, is the most sought-after nurse in the unit because patients know she has first-hand knowledge of what it’s like to receive rehab treatments. “The patients can ask their physician, but they figure ‘why not talk to someone who really knows?’ The patients really tune into that,” Smith explains.
Go For It
In its fall 2000 issue, Minority Nurse published a letter from Victoria Christensen, who at that time was a nursing student in the BSN program at Washington State University. “As a cultural minority, I have never felt represented by Minority Nurse,” she wrote.“I have paraplegia and use a wheelchair for mobility. As I read the articles in your magazine, I often substitute the word ‘disability’ whenever any word denoting minority is used—and it is noteworthy that it fits the context of the article perfectly in about 99% of the cases.”
While not every reader would agree with that statement, nurses of color and nurses with disabilities do have many things in common. Both groups are discriminated against and judged on factors that are irrelevant to their ability to provide quality patient care. And they both share the challenge of having to overcome prejudice in nursing schools and the workplace by “proving their worth” based on others’ preconceived notions.
In addition, both ethnic minority nurses and nurses with disabilities can be powerful role models to show other people like themselves that they, too, can achieve success in the nursing profession. “People with disabilities have virtually no opportunity to see role models,” says Marks. “Only in the past several years have we begun to see individuals with disabilities in the media and the work environment.”
Karen McCann encourages anybody with a disability who wants to pursue a nursing career to “go for it” and not let themselves get discouraged by the ignorant or prejudiced attitudes they may encounter.
“My experience has been that people tend to put more limitations on you than you already have,” she cautions. “They think that just because you have a disability, you can’t do anything. But don’t let someone else make that decision for you. Even if you have difficulty ambulating, there isn’t any acceptable reason why accommodations to the work environment cannot be made to make it disability-friendly so that you can do the job.”
Rueille agrees. “I can envision someone in my situation thinking it is not possible to be a nurse,” she says. “But it is possible. There may be some practical issues that need to be worked out, but you can do it.”