Top 5 Tips for Graduate school
So, you are thinking about completing your Master’s degree. You may be just graduating with your bachelor’s, established in your career, seeking career advancement, or an overall career change. You should commend yourself wherever you currently are in your professional journey. Graduate school is essential for career progression and as daunting as the challenge may be it is feasible and worthwhile. However, there are certain things that I wish I had known previously to enrolling in my first graduate courses that would have saved me a ton of grief on this grad school journey.
Learn the APA Manual
Do you briefly remember being introduced to this in your undergraduate English and Research classes? You know, the blue book that you couldn’t wait to toss as soon as you completed those courses! Well, don’t get too excited and toss that manual out just yet. The APA manual will be your bible at the graduate level. It is best to not only familiarize yourself with it but read it cover to cover. In all seriousness, there will be no mercy for APA formatting issues at the graduate level, and failure to comply will hinder your ability to graduate. Let’s be honest; graduate school is very expensive so do not lose points over APA errors and get your bang for your bucks when it’s time to cash in on that top G.P.A.
Grad school will push your writing capabilities to the maximum. When I first started, I went in under the false pretenses that I was a decent writer. After all, my highest scores were always in English and Language Arts. However, never underestimate the power of proofreading your document, or having someone else review it. It is important to remember that you are not supposed to be writing as if you are talking in scholarly writing. Read every single thing you submit out loud at least two times before turning it in. You will be surprised at some errors you will find in your documents once you hear it out loud. I swear by Owlet Purdue, Grammarly, and PERRLA to assist with the completion of my papers.
One of the biggest mistakes that I made during my Grad school journey was “taking a break”. Apparently, life happens to everybody, but if you can help it, you should stay on the course to graduate on time. While taking a leave of absence is certainly an option, there are some universities have a time limit on the amount of time you can spend on the completion of your master’s degree. Taking a leave of absence sounds a nice break until you return and you are under even more pressure to complete your degree. Stay on track and graduate on time. Put yourself out of grad school misery. Try not to prolong it.
My zodiac sign of a Libra makes finding balance very high on my priority list. Regardless of your sign, it is essential to find a way to balance everything you have going on in life. Many of us are career focused, have spouses or partners, children, and community obligations. There are going to be some times that you will simply have to say no to others as well as avoid taking on too many additional duties. You have to be able to take care of yourself before you can take care of others. Do not feel guilty about taking a step back or going on a much need hiatus to keep everything together. Remember that this is temporary, and there will always be opportunities to restock your plate once you have graduated.
Cost vs. Reputation
This has been an ongoing debate for such a long time. I will give you my honest opinion and say that it is best to go for value in regards to selecting a school to attend. There is absolutely nothing wrong with investing yourself, but please do not break the bank along the way. Try your very best to avoid debt, save up, and develop a reasonable budget that you can use to finance your educational goals. If you are shelling out a ton of money, ensure that the institution has a reputation that fits your tuition bill. Student loan debt is a serious problem. Remember that you will need to pay that money back, and if this degree does not make a high paying job seem promising to you it may be necessary to scale back. Remember, grad school isn’t cheap!
Wrapping it All Up
I hope that you avoid the pitfalls that I incurred during my grad school journey and that these tips will help ease you in your transition and prepare you for entry into grad school. A graduate degree is totally obtainable; it’s just a different academic dynamic. I’ll see you on the other side!
Happy Independence Day, Nurses, on this fabulous fourth of July!
The character of our nation and that of the nursing profession are so similar that through out our history they’ve been intertwined. Try these traits on for size and see if you agree: Nurturing, caring, patriotic, independence-loving, tolerant, and humanitarian.
I was reminded of the patriotic role of the nurse by Melodie Chenevert, herself a nurse for 50 years and a collector of nursing memorabilia, and also founder-owner of the Lost Art of Nursing Museum in Cannon Beach, Oregon.
Melodie displays some sensational artwork that show just how elevated nurses became during the first World War, when Red Cross nurses were romanticized as the heroic feminine ideal of American womanhood.
That trend continued during World War II, when the US government swung into full gear to recruit young woman into the nursing corps. The need for nurses was great and the supply short, so recruitment posters marketed military service as a way to aid the war effort. The fact that service in the Army, Navy, or Nurse Cadet Corp. served as a bold call to adventure and offered a free vocational education didn’t hurt, either.
Leading artists and illustrators, songwriters and poets all heralded the noble nurse who fulfilled her duty to country through military service. Some famous artists who received commissions to depict the nurturing nurse in battle: Norman Rockwell, Dana Gibson (creator the lauded Gibson Girl) and N.C. Wyeth.
Before the age of celebrity and before the Kardashians, nurses captured the public’s imagination. They served as magazine cover girls and advice columnists and product endorsers and pitch women. Just as today, nurses were trustworthy figures and so their “seal of approval” actually meant something to consumers.
So, as we mark our nation’s birthday, light up the candles…or fireworks…and let’s celebrate!
Outside a dining room in the Longworth House Office Building on Capitol Hill, I asked Congresswoman Karen Bass of California how nursing prepared her for service in Congress. Her response was quick: “Good bedside manner.” But she has had only three terms to hone those skills to propose, advocate, or deliver legislation that impacts the field of her choosing. Not so for Congresswoman Eddie Bernice Johnson of Texas. She is an accomplished nurse, administrator, and legislator covering 23 years in Congress and 60 years as a nurse. I recently visited with them both and gained a fresh perspective on their experiences as nurses in Congress, as well as a candid reflection on the issues currently afflicting our country.
Congresswoman Johnson set her mind on becoming a nurse as a teenager, but in 1952 no nursing program in Texas would accept her, so she applied and was admitted to St. Mary’s College in Notre Dame, Indiana, graduating in 1955. She holds the BS degree in nursing from Texas Christian University, and in 1976, she was awarded the MPA degree from Southern Methodist University. Ten years into her nursing career at Veterans Affairs (VA), she was appointed chief psychiatric nurse at the VA Hospital in Dallas. In 1977, she was appointed regional director of the U.S. Department of Health, Education, and Welfare.
Before her election to Congress, Johnson served as a member of the Texas State House of Representatives from 1972-1977 and a member of the Texas State Senate from 1986-1992. She was elected as a Democrat in 1992 to the 103rd Congress and is in her 12th term representing the 30th Congressional District. In December 2010, she was elected as the first African American and first female ranking member of the House Committee on Science, Space, and Technology, a standing committee of the U.S. House of Representatives. Additionally, she was the first African American female to serve as chairwoman of the Subcommittee on Water Resources and Environment during the 110th and 111th sessions of Congress. Her name is attached to several pieces of legislation. Her office in the Rayburn House Office Building impresses visitors who can clearly see what seniority provides.
James Daniels: Mrs. Johnson, your accomplishments are impressive and even astonishing. Your firsts set you apart as a genuine trailblazer. You are the first woman ever elected to represent Dallas in the U.S. Congress. You are the very first chief psychiatric nurse of Dallas; first African American elected to the Texas House of Representatives from Dallas; first woman in Texas history to lead a major committee of the Texas House of Representatives; first African American appointed regional director of U.S. Department of Health, Education, and Welfare; and the first female African American elected from the Dallas area as a Texas senator since Reconstruction. Your crowning accomplishment, however, is as the first nurse elected to the United States House of Representatives.
Congresswoman Johnson: And I hope I won’t be the last!
Daniels: You are clearly regarded as a pioneer because of all the firsts you have accomplished. What does this mean to you? How do you handle that?
Johnson: I never think about it until someone brings it up. I don’t see it as extraordinary. I see it as opportunities that appeared, and I took advantage of them and was fortunate enough to get elected. It has not been easy because I was the first. As a matter of fact, it has probably been more difficult because of that.
Daniels: What motivated you to enter politics coming from a stellar career in nursing?
Johnson: When I was first approached about running for office, I thought it was a joke. All of the women I spent most of my volunteer time working with were mostly white at that time. The judge that gave Lyndon Johnson the oath of office, Sarah T. Hughes, was the one who pushed it, and along with others, encouraged me. It was the white community that persuaded Stanley Marcus [Chairman of Neiman Marcus] to give me a job because I was working for the government at that time. My African American community had to be brought along because they thought what I was doing was a man’s job.
Daniels: So, you were a pioneer.
Johnson: I guess so! My campaign was run out of my garage and my dining room. Not until I went into a run-off against my opponent did my African American women bring their support. After I won, everyone became my friend.
Daniels: You could not get into any university in Texas to obtain your nursing degree.
Johnson: There was no nursing degree program in Texas [in 1952] with national recognition that I could attend. This was before the University of Texas opened [its doors to black students]. It was before Baylor or Texas Christian opened, so that’s why I went out of state. The colleges [in Texas] were not integrated at that time.
Daniels: Growing up, did your parents influence you to achieve? What role did your parents play?
Johnson: My parents played a very key role, because education was number one for them. They thought it was very important. My grandmother was a teacher and went to Prairie View College. My father finished high school but did not want to go to college. He wanted to be a businessman. I watched them as examples.
Daniels: You’ve been here since 1993. What do you isolate as high points during your tenure?
Johnson: My high point was my first two years. Bill Clinton was president and we [Democrats] had a majority, and I had a chance to work very closely with the president in an environment where we were in the majority and with others who thought just the way we did. It lasted two years. This is my 23rd year and I’ve been in the majority six of those years. What I’ve learned during that time is to keep focused on my work and set the goals of what I was trying to achieve and just keep my attention on that. I have been able to get monies for research, and monies for transportation projects of all kinds. I always saw this as an opportunity to make things better at home. When I look back over my achievements, it feels pretty good.
Daniels: There are six members of the House of Representatives who are nurses. Do you ever find common ground on any legislative issue?
Johnson: Well, some. Four of us are Democrats. Unless I look on the roster, it is hard to tell who are nurses from the Republican side, primarily because they are governed from the top. Many things that we try to do—if they do not get permission to do it they will disappear on you.
Daniels: Some of your nursing background includes time with the VA. What do you think of the state of affairs in the VA?
Johnson: Most of my nursing career was at the VA. It needs great improvement. I didn’t blame the secretary [of VA]. It is that layer of management right under the secretary who has gotten their buddies in these hospitals, and it is fueled by retaliation if anyone complains. Until that is broken we will never get to solve the problems of the VA. People are so afraid if they report something because there is going to be retaliation. It’s a very bad situation.
Daniels: Do you think the president is on top of it?
Johnson: The president is trying. We appropriate enough money for every veteran to get first-class care. Care is not being given to the veterans as this point.
Daniels: Do you think Hillary Clinton is going to be the Democratic Party’s standard bearer?
Johnson: I don’t know, but if Hillary runs I will support her and will give it all I’ve got to see that she becomes president. I’ve known Hillary before she married Bill Clinton, so I know her very well.
Daniels: What’s the whisper regarding who is the likely Republican candidate?
Johnson: I have not seen too many Republican candidates that I liked—and I never thought I’d say this—the one that I liked, compared to the rest of them, was [George W. Bush] I never ever thought I’d say this. He was fun to work with, easy to talk with, he was accessible. He was more accessible than Obama is. Listen, when he called me and told me he would run for governor [of Texas], I said, “You what?” I asked him, “What made you decide to run for office?” He loved to have fun. He loved people. He still loves people. When he was in office he was a people person. I remember I called him to tell him I needed his support on the Water Resources Development bill I sponsored [in 2007]. I told him it’s to make sure there is no flooding of the Trinity River. I said, “Are you going to move back to Dallas when you leave the White House?” He said, “If I can find a house I can afford.” I said, “I just need your address because I want a trench from the Trinity to your front door so you’ll be the first to know when it floods.” But that’s the kind of relationship we had. We have the same relationship now.
About this time in our conversation, Johnson’s director of communications, Yinka Robinson, signaled that Johnson had another engagement. I thanked her for her time and invited her to take some photos with me. As she did, she leaned towards me and said, “I wish I had time to tell you what it was like to be the only black student at St. Mary’s. Perhaps we could do that at some later time.”
Congresswoman Karen Bass grew up with three brothers in the Venice/Fairfax area of Los Angeles and is the only daughter of DeWitt and Wilhelmina Bass. In 1990, she graduated from California State University, Dominguez Hills, with a BS in health sciences and certification as a licensed vocational nurse. She completed the University of Southern California’s Keck School of Medicine Physician Assistant Program, and for nearly a decade, worked as a physician assistant (PA). She also served as a clinical instructor.
Prior to serving in Congress, Bass made history when the California Assembly elected her to be its 67th Speaker, the first African American woman in U.S. history to serve in this powerful state legislative role. Bass serves on the House Committee on Foreign Affairs where she is the ranking member of the Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations. As a member of the House Judiciary Committee, she is also working to craft sound criminal justice reforms as well as protect intellectual property right infringements that threaten the economic health of the 37th Congressional District she represents.
Bass’s office is in the Cannon House Office Building, but she is on her way to a luncheon with the Congressional Black Caucus and pauses to chat with me.
Daniels: You are the first PA ever elected to the Congress, and the first African American and woman elected as Speaker of any legislature in the United States. Does that give you a sense of pioneering?
Congresswoman Bass: No, it gives me a sense of enormous responsibility. I am happy to step up to that responsibility, but it definitely is a big responsibility.
Daniels: You leaped past nursing to obtain credentials as a PA. Why did you do that, and what drew you to the role of the PA?
Bass: When I was a nurse, the pathway to be a nurse practitioner was very, very long. I was a licensed vocational nurse. The pathway to be a PA was much more direct. And in those years I had originally started out to be a PA. But the PA profession was very new, [so] you had to be another profession first.
Daniels: Looking at your nursing and PA careers, how do they inform you to be an effective legislator?
Bass: Well, you know bedside manner can apply in a lot of different places. [Uproarious laughter.] And bedside manner in the political context is called diplomacy. As a PA, I worked in the emergency room, and when I was a nurse, I worked in acute care—both life and death areas—and that type of responsibility and pressure make this pressure seem a lot easier. It gives me a level of calmness in the midst of crisis that other people might not share.
Daniels: Now there are six nurses in Congress. Do you ever collaborate or find common ground with those on the other side of the isle?
Bass: Yes, as a matter of fact, Diane Black [Tennessee Republican Representative] and I are working on child welfare issues. We are both co-chairs of the Child Welfare Caucus. We know each other! It might not be nursing issues per se that we are working on, but it certainly is human service issues.
Daniels: I like what you just said about equipping you with good bedside manner. Does that say you use a lot of touchy, feely ways to persuade support for legislation you are advocating?
Daniels: Tell us about your work on behalf of the foster care issue in the country.
Bass: It’s one of those issues that bring Republicans and Democrats together. The basic premise is that for kids who do not have families, who don’t have parents, it becomes the responsibility of government to take care of those kids. And we should take care of those kids as we would take care of our own. Those are the values that underlie the work that I do on child welfare.
Daniels: Do you run up against Republicans who believe this is just another government overreach?
Bass: No, no, I don’t at all. Diane Black is a Republican and she is the co-chair of the committee. This is an area where members of Congress come together because most of the members of Congress are parents. When it comes to juvenile dependency, kids who are without parents, people are a lot more open.
Daniels: About your work on behalf of Africa, do you see a movement towards democracy and the establishment of democratic institutions?
Bass: Absolutely. The big issue in Africa right now from the perspective of minority nurses is the reason why the Ebola crisis happened. The health infrastructure in those particular countries was so weak that it got out of control. In countries like Nigeria, where they had a few cases, they were able to bring it under control. I think one of the biggest issues for the continent of Africa right now is making sure its health infrastructure is strong enough so that when an epidemic happens it is not catastrophic.
Daniels: And your hot button issue that you are pursuing in this Congress?
Bass: My hot button issue regarding Africa is trade. There is a trade agreement that we need to have happen, the African Growth and Opportunity Act. In terms of health care, it is to ensure that our health care reforms stay strong.
James Z. Daniels is a consultant and writer who lives in Durham, North Carolina, and frequently contributes to Minority Nurse.
Do you know the symptoms of post-traumatic stress disorder [PTSD]? Do you know who is at risk? Are men and women at equal risk of developing it?
If you find yourself struggling to answer these questions, consider checking The PTSD Toolkit for Nurses, www.nurseptsdtoolkit.org, a new interactive resource designed by the University of Pennsylvania School of Nursing.
The American Nurses Foundation (ANF) recently announced the launch of the toolkit to help civilian registered nurses better assess and treat PTSD in veterans and military service members.
An estimated half million veterans and military service members suffer from this mental health condition that is triggered by a traumatic event, such as exposure to combat, violence, natural disasters, terrorism and accidents.
According to the U.S. Department of Veterans Affairs website, experts think PTSD occurs:
- In about 11-20 percent of Veterans of the Iraq and Afghanistan wars (Operations Iraqi and Enduring Freedom).
- In as many as 10 percent of Gulf War (Desert Storm) Veterans.
- In about 30 percent of Vietnam Veterans.
PTSD symptoms include angry outburts, trouble sleeping, and other negative changes in thinking and mood, or changes in emotional reactions.
PTSF can affect anyone, and women are at greater risk. Sometimes symptoms are hard to identify. The website provides an e-learning module to build assessment and intervention skills, so nurses can treat and refer military members and veterans for help. It also includes videos and an interactive game to practice your assessment and referral skills.
Nurses are often the first point of contact when veterans and military personnel seek medical help. PTSD can be treated and cured. This toolkit can help you immediately recognizie symptoms, and intervene to help veterans make a successful transition to civilian life.
Robin Farmer is a freelance journalist with a focus on health, business and eduucation. Visit her at www.RobinFarmerWrites.com.
It’s the experience of a lifetime. After you’ve cleared security to enter Fort Bragg in North Carolina and your vehicle has been searched, you are instantaneously awed by the enormity of this army military post. I am on my way to engage two ranking officers—nurses—in conversation regarding health care in the military. The drive takes you on the four-lane All American Expressway with vehicles whizzing by between 55 and 60 miles per hour. As I slow down to take in this sprawling city, I am reminded that I am no longer in the city of Fayetteville that abuts the post.
But the pièce de résistance was the emotional tremor I felt when the Womack Army Medical Center loomed up at the end of a long entrance way to affirm that this was iconic America. This complex, 1.1-million-square-foot (this is not an error) care facility is not just impressive by its bricks and mortar, but is a care facility providing world-class health care across a compendium of general and specialized medical disciplines to our service men and women, veterans, and the families of those who serve on active military duty. To visually take it all in requires a significant swivel of my head.
The purpose of my visit is to gain some measure of understanding and appreciation of this reputable institution and to tell the story to those who will not have the opportunity I had to visit and see for myself. My host is Lieutenant Colonel Angelo D. Moore, Deputy Chief, Center for Nursing Science and Clinical Inquiry, a native of Queens, New York, and graduate of Goldsboro High School in Goldsboro, North Carolina. Moore holds a PhD from UNC Chapel Hill and was the university’s first African American male awarded a doctorate from the School of Nursing. A scholar, clinician, and practitioner with a passion for attacking health care disparities, Moore knows his way around scholarly journals but is just as comfortable applying a Band-Aid to a 5-year-old with a splinter in his thumb. He leads the effort at Fort Bragg to integrate evidence-based practice (EBP) into all aspects of nursing care.
Moore chose Winston-Salem State University for his undergraduate degree because of the seven-to-one ratio of women to men among the student body—a decision he candidly admits worked out for him because that was where he met his wife, Lee Antoinette, a civilian nurse now on the faculty at Fayetteville Technical Community College. He was posted to Fort Bragg last July from Honolulu, where he had been stationed for six months having initiated and led the EBP process.
For the better part of a day, Moore allowed me to engage him in an in-depth conversation on what happens within the walls of this facility that necessitates a tour by a skilled guide to truly appreciate the delivery of military health care services. I was taken through the “miles” of passageways and corridors, to the service malls and the various departments, as well as the skilled nurses training center to witness the nurses being tested on their competencies on a variety of medical and dispensing procedures; the cafeteria to sample military fare; and, eventually, one of the deputy commanders of the medical center, Colonel Kendra Whyatt, who on this day was in charge.
Too often there is a perception that connects questionable treatment of our military service personnel to the assumption that the health care delivered is similarly questionable. Nothing could be further from the truth. In my conversation with Colonel Whyatt, she very carefully called my attention to the signature difference between a military nurse and a civilian nurse that is invaluable in understanding the dynamism of military health care.
“Military nurses,” Whyatt says, “wear inseparably and simultaneously the role of the soldier and the role of the nurse, and they are expected to provide care for their fellow soldiers and protection for them if necessary, and certainly for themselves at the same level of competence.”
It is this dichotomy—the syringe and the gun—that guides my desire to understand how care is delivered by our nurse soldiers to a military population of 57,000 at Fort Bragg, of which 45,000 are active duty members.
What we know today as Fort Bragg came into effect in September 1922, but its history is attached to a Confederate general, Braxton Bragg, a native of North Carolina. The post occupies 127,000 acres; its population makes it the largest US Army base; and it is the home of the Airborne—the 82nd Airborne Division, referred to as “All-American” because its members represent 48 states. It is also the home of the distinguished Special Operations Force. Among its many amenities are its schools—preschool through high school for nearly 5,000 students, the children of soldiers on active duty.
Womack Army Medical Center opened its doors on March 9, 2000. The center is named for Private First Class Bryant H. Womack, a North Carolina native who was posthumously awarded the Medal of Honor for conspicuous gallantry during the Korean conflict. The center’s mission is succinctly stated: Provide the highest quality care, maximize the medical deployability of the force, ensure the readiness of Womack personnel, and sustain exceptional education and training programs.
The center is 1,020,359 square feet, encompassing six-floor towers and other buildings. It sits on a 163-acre site, has a 153-bed inpatient capacity, and serves the more than 225,000 eligible beneficiaries in the region. It is the largest beneficiary population in the Army.
The building has a state-of-the-art design: The inpatient tower floors have an interstitial space between each floor that allows computers, as well as other technical components, to be repaired without interrupting patient care. The complex is designed to transform many of the administrative areas into service areas providing care if necessary, which would double their inpatient treatment capacity.
Four patient-centered medical homes are located on Fort Bragg, and two community center medical homes are located in the surrounding military community where their beneficiaries live and work. The Womack Army Medical Center was among the first health care providers in the country to seize on the benefits, design, and purpose of the medical home in 2004. The military’s ability to make the medical home work for their patients rests on their enormous electronic records capacity, making it easier for them to implement the benefits from the Electronic Health Records (EHR) system that gives providers worldwide access to comprehensive and timely patient histories. The $1.2 billion medical records system began deployment that year across the entire force and was fully operational by 2007, just as the benefits and necessity of the EHR were dawning on the civilian medical community.
The medical home is best described as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the simplest to the most complex medical conditions.
But there is also the Soldier Centered Medical Home (SCMH). This is a care process with an exclusive and unique focus: the soldier. It includes behavioral health, physical health, and nutrition services; these are significant to soldiers who may be displaying the symptoms of Post-Traumatic Stress Disorder (PTSD). Everyone is screened using a predetermined questionnaire and an initial evaluation that determines whether the soldier is a prime candidate for treatment or follow-up. The Army’s official position is that “80% of all soldier complaints at sick-call are muscular-skeletal,” according to physician Colonel Dallas Homas, the former commander of the Madigan Army Medical Center in Tacoma, Washington, and the originator of the SCMH that became operational in November 2011. The concept grew out of an incident where an exceptional noncommissioned officer lost his knee unnecessarily, according to Homas.
Diagnosis and treatment of PTSD, however, continues to be a contentious issue within the military sector and might have led to Homas’s reassignment from Madigan Army Medical Center. Colonel Ramona Fiorey, a nurse, assumed command of Madigan on August 9, 2013. The Department of Veterans Affairs (VA) has reported that for the last two years PTSD diagnoses are just shy of 30% of the 800,000-plus Iraq and Afghanistan War veterans treated at VA hospitals and clinics.
It is during my conversation with Moore that a picture emerges of how the soldier-nurse threads her way through the system to attain the highest heights of a nursing career. One thing they do have is the role models to motivate them to succeed. You see, the Surgeon General of the US Army is also the Commanding General of the US Army Medical Command. Currently, that person is Lieutenant General Patricia Horoho. She is a nurse. Whyatt, one of Womack’s deputy commanders, is also a nurse. Nurses provide the leadership at the highest level and at base level. This is without precedent, and the profession does take notice.
Horoho has already made significant changes regarding military health care by her emphasis on what she calls, “life space.” She wants providers to address those periods when military personnel are away from a care facility with emphasis on ensuring they are engaged in healthy behavior.
Horoho’s leadership centers around the Army Nurse Corps’ five-point strategy, known as the Patient CaringTouch System or—with the military’s characteristic use of acronyms—PCTS. It has five components: enhanced communication, capability building, evidence-based practices, healthy work environments, and patient advocacy. The PCTS is a patient-centered model for nursing care that was developed to reduce clinical quality variance by adopting a set of internally and externally validated best practices. Additionally, it is an enabler of Army medicine’s culture of trust initiative and the transition from a health care system to a system of health. The plan is elaborately laid out in a campaign document intended to guide the care leadership through 2020, with emphasis on evidence-based decisions, metrics, and best practices that cannot be overemphasized.
As you might expect, the Army takes the issue of leadership very seriously. Army nursing is guided by an Army Nursing Leader Capabilities Map that encompasses a thirty-year journey, and Moore is a good example of how the process has guided his own career. A nurse’s development has three segments, and the progression is tied to seven performance criteria. The three segments are tactical skills, operational and organizational skills, and strategic thinking and execution. The nurse can move along a career path in what is called “duty positions,” beginning as a staff or charge nurse and rising in rank to a section or department chief and then deputy commander for nursing.
During this progression, the Army nurse develops competency in such areas as change and people management, succession planning, and foundation thinking, where he or she is expected to demonstrate unit-level, evidence-based decision making. At this level, “the PhD or the DNP enables and equips a nurse to engage in visionary and strategic thinking,” explains Moore. “After ten years in the military, nurses overwhelmingly have acquired the master’s degree, and this is a distinguishing factor in military nursing culture.”
Lieutenant Colonel Moore (never addressed as “Dr. Moore” but exclusively by his rank, as is the pattern within the military regardless of credentials) actually wanted to be a dentist, but financing that career seemed to be out of reach. He heard about the Army College Fund, so he enlisted in 1989. He was placed in the communications section, but had a strong desire to transfer to the medical field. He was working to complete his associate’s degree at night and heard from a friend about the Army’s Green to Gold program in which, if selected, he could progress over time from an enlistee to an officer. He completed the degree and applied, was accepted, and enrolled in the nursing degree program at Winston-Salem State University, graduating with the BSN in 1995.
As an active duty nurse, Moore’s assignment took him to the Eisenhower Army Medical Center in Georgia as a medical/surgical nurse; later, he chose to be certified as a critical care nurse upon completion of a four-month training program. Moore tells me that this is the normal developmental pattern allowing nurses to be associated with a particular specialty of their choosing.
As a male nurse in the 1990s, Moore was not an oddity because the requirements of war had always allowed the Army to attract males to the military nursing profession. Medics were trained to provide treatment to fellow soldiers on the battlefield, so the transition to formal training to administer generalized or specialized care was natural for many. Today, males’ 30% representation in Army nursing is six times higher than in the civilian nursing population.
“Male nurses,” Moore says, “are usually more prevalent in the areas that are ‘action-packed,’ such as trauma, or the highly technical areas where elaborate technical components are integrated into the patient’s care and in emergency room nursing.”
After several years of praying “Please, Lord, do not let any of my ICU patients die on my shift,” Moore wanted a change out of critical care and chose to work in primary care to reduce the prospect of patients needing critical care in the first place. He applied to the Army’s long-term education and training program and was accepted into the master’s program to become a nurse practitioner.
His next assignment was his appointment in 2007 as a recruiting commander stationed in Brooklyn, New York, with centers in Albany, New York, and New Jersey. Moore and his team of recruiters focused on enticing doctors, dentists, and nurses into the Army as officers by being visible at medical conferences and health forums where these professionals were present. The recruiters championed the experience, benefits, and research engagements that a recent MD graduate, for example, would never get in a hospital or private practice in his or her civilian role. They also targeted students considering careers in the medical profession.
Moore responds to my question regarding minority recruitment within the Army by explaining that there is no program designed to recruit minorities into the health care ranks as a targeted group.
“To the best of my knowledge, we do not look at race in our recruiting efforts,” says Moore. “We make appealing what the Army has to offer and allow the prospect to decide. Because of the culture of the Army, we encourage the prospective recruit to consider carefully the choice of military service.”
There is a well-known, generalized concern, however, about the low minority representation among the officer ranks in the military, which has attracted the attention of the top brass. So it came as no surprise when in March 2011 the Military Leadership Diversity Commission issued a report that included the state of diversity among the leadership ranks of the military.
“The disparity between the numbers of racial and ethnic minorities in the military and their leaders will become starkly obvious without the successful recruitment, promotion, and retention of racial/ethnic minorities among the enlisted force,” the report states. “Without sustained attention, this problem will only become more acute as the … makeup of the United States continues to change.” It’s similar to the state of private sector organizations.
Whether the Army does or does not have a minority recruitment strategy, the fact is that officer and leader representation will not improve unless there is a deliberate pipeline strategy leading from enlistee to officer. However, as I walked the hallways and visited the patient treatment locations at Womack, those at work and those receiving care looked very much like America.
With Moore accompanying me as I toured the facility past the many labs, the enormous back-office function, work stations, administrative functions, physical therapy service areas, and clinical specialties of every description along the long and seemingly interminable walkways, he added to my attempt to grasp the magnitude of what takes place at Womack as a matter of routine, by citing some impressive statistics. While doing so, he emphasized that the active military and the Veterans Healthcare Services are decidedly not affected by the provisions of the Affordable Care Act (ACA).
“There is one provision, however, where we see eye-to-eye with the ACA, and that is in the aspect of prevention as opposed to curative or disease care, because a healthy lifestyle is central to mission readiness,” explains Moore. “The three streams that drive mission readiness within the healthy life space triad are activity, nutrition, and sleep—and we are confident there will be a pay-off down the road.”
In fiscal year 2013, the Womack Army Medical Center had over 12,000 admissions with a 62% average daily bed occupancy rate and average length of stay of 2.6 days, over 3,000 live births, and over one million outpatient appointments. On a daily average, the associated clinics provided over 3,400 outpatient visits, approximately 6,000 outpatient prescriptions, almost 1,000 radiological exams, over 4,000 pathological tests, almost 200 Emergency Department visits, almost 40 surgeries, and at least eight live births. There are two medical residencies (family practice and obstetrics), and 14 other physician or Allied Health educational and training programs. Moore points out that no prosthetic service is provided to the injured soldiers at this facility. He reminds me that the health care staff consists of active duty members, Department of Defense civilians, and contractors who include civilian physicians and nurses. It is easy to identify the civilian medical staff because they are listed on appointment boards by their medical credentials; whereas, the active duty medical staff are listed by their rank, often on the same appointment boards.
Moore guides me along a walkway with photographs of distinguished service members and towards the skilled nursing center where competency tests are taking place. This is a biannual event where nurses are tested and certified to perform certain medical procedures. Womack nurses are required to expose themselves to this process if they are to be allowed to perform certain procedures. It is proctored by senior nurses and other technical staff. My visit to the center as this event was taking place was purely coincidental.
In a room deep inside the complex, nurses were examined on performing catheterizations on a mannequin (part of the infusion therapy procedure) and on their ability to know the difference when it is a pediatric patient compared to an adult; reading and interpreting the ECG tape—a necessary step before referring it to a cardiologist; identifying mental health behavioral issues such as PTSD; and using newly introduced, technologically sophisticated equipment. There are charts and poster boards everywhere. The atmosphere is intensely business-like, presided over by a nurse with the rank of major and dressed in fatigues. Even the test mannequin appears to be aware of the buzz over the event’s significance.
Next, Moore takes me to the pharmacy services mall, which is where the patients have their prescriptions filled. Every aspect of this procedure is very clearly understood as between 25 and 30 patients wait for either a consultation with a pharmacist or watch to see that their prescription is ready. The first served are those requiring immediate and preferential attention: the active duty soldiers. He or she registers as they all do, and the patient’s name lights up on a marquee pallet as an indication that the prescription is ready. The active duty member’s name will supersede all others.
Finally, our walk heads towards the command center where Moore has arranged for me to visit with Colonel Whyatt, Deputy Commander for Nursing and Patient Services, who is acting commander today because Commander Colonel Steven J. Brewster is off the post. This is Whyatt’s first assignment to Fort Bragg. After being cleared to enter the command center, I am seated in what is quite easily comparable to an executive suite in any corporate headquarters. The offices are bright and cheerfully wood-paneled, with each executive officer’s support staff seated within earshot of their work stations. One is dressed in fatigues, as is Colonel Whyatt. She is tall, relaxed, and with a distinctive military bearing that suggests a calm, in-control demeanor. She is a native of Greenwood, Mississippi, and was previously stationed at a military facility in Germany.
With my discussion about minority recruiting still turning over in my mind, I wanted to know her opinion regarding mentoring and coaching. But first she has to be reassured by Moore that I have been cleared to have this conversation with her.
I first want to know what makes for a successful and responsive military health system. “It’s the combination of the military, civilians, and contractors working together,” Whyatt responds.
“What are the two top concerns that occupy your attention?”
Whyatt responds succinctly: “[To stay in mission readiness], I have to recruit staff, retain and train staff, and we are facing challenges in this area; in particular, in the recruiting and retention of staff. Most everyone knows that certain funding is at a standstill.”
“Do you mean the sequester?”
But a majority of hospital executives believe there is a shortage of physicians and nurses in the US, according to a new survey from American Mobile Nurses Healthcare, a staffing company that recently published its 2013 Clinical Workforce Survey. It found that 78% of hospital execs think there is a shortage of physicians; 66% say there is a shortage of nurses; and 50% report there is a shortage of advanced practitioners. The survey also found that the vacancy rate for physicians in hospitals is nearly 18%, compared to 10.7% in 2009, and nearly 17% for nurses, up from only 5.5% in 2009. The vacancy rate also rose for allied professions, from 4.6% in 2009 to 13.3% in 2013. But Womack is currently under a staff freeze, and the civilian workforce is expected to be reduced sometime during 2014.
Colonel Whyatt owes her military career to her mother. At the end of Whyatt’s sophomore year at Prairie View A & M University, her mother strongly suggested that instead of coming home and looking for a summer job, she visit with the ROTC office on campus and see what they could do for her. Whyatt visited the office, enlisted, and went on to complete her undergraduate degree in nursing with a scholarship from the Army. Her career has taken her to three tours of duty to Germany and several Army posts within the US.
“Are you mentoring and coaching any on active duty at this time?” I ask.
“That is an expectation of this position. Yes, I am,” she responds.
“And is LTC Moore one of your mentees?”
“Absolutely, he is my newest.”
According to the U.S. Department of Veterans Affairs (VA), approximately 20% of our nation’s 23.5 million veterans are people of color. Like other racial and ethnic minority populations, minority veterans face a variety of unique health care challenges, ranging from chronic disease disparities and high levels of post-traumatic stress disorder (PTSD) to difficulties in accessing medical treatment.
Testifying before the House Committee on Veterans Affairs in July 2007, Lucretia McClenney, MSN, RN, director of the VA’s Center for Minority Veterans (CMV), noted that “in many instances, any challenges that minority veterans encounter as they seek services from VA are magnified by the adverse conditions in their local communities. These challenges may include [lack of] access to VA medical facilities (especially for American Indians, Alaska Natives, Pacific Islanders and other veterans residing in rural, remote or urban areas), disparities in health care centered on diseases and illnesses that disproportionately affect minorities, homelessness, unemployment, lack of clear understanding of VA claims processing and benefit programs, limited medical research and limited statistical data relating to minority veterans.”
The CMV’s mission is to identify barriers to service and health care access, increase local awareness of minority veteran-related issues and improve minority participation in existing VA benefit programs. As a result, VA medical facilities throughout the country are implementing strategies to provide veterans of color with more accessible, culturally sensitive care. Each VA health care facility has a Minority Veterans Program Coordinator (MVPC) who serves as a liaison and advocate for minority patients. And VA health care professionals are taking the lead in developing innovative solutions for closing the gap of health disparities, from outreach programs designed to increase minority veterans’ use of services to diversity training programs aimed at increasing staff members’ understanding of patients’ cultural needs.
Not surprisingly, nurses are playing key roles in these efforts. Here’s a look at how individual nurses are working to improve health outcomes for minority veterans, one program at a time.
Native American Outreach
Bruce Kafer, MSN, RN, is a member of the Oglala Sioux (Lakota) Tribe that resides on the Pine Ridge Indian Reservation in South Dakota. Adopted as an infant by white parents, he grew up with virtually no knowledge of his tribal culture. After tracking down his birth mother in 2000, he began to learn about his lost Indian heritage from his Tiospaye (Lakota extended family) and tribal elders. Now, as American Indian/Latino Outreach Coordinator at the Louis Stokes Cleveland (Ohio) Department of Veterans Affairs Medical Center, Kafer is drawing on his rediscovered heritage to provide culturally sensitive healing to Indian vets.
Kafer, who works with Native veterans both in Cleveland and in Arizona, is also a PhD student at Case Western Reserve University in Cleveland, where he is conducting research with Indian vets to add to the limited body of knowledge available about this population. Through his research, he has discovered some compelling statistics about Native Americans who have fought for their country. During World War II, for example, 40% of the Cheyenne Nation volunteered service to the U.S. military. During the Vietnam War, 90% of eligible Cheyenne volunteered for duty, with the overwhelming majority serving in combat areas. Yet despite this long-standing history of service, Native Americans have historically underutilized VA services, Kafer says.
“Part of my role,” he adds, “is to help bridge that gap and make services more accessible.” To accomplish this, Kafer does outreach to the American Indian community, participating in powwows and other cultural events, visiting reservations in remote locations and working with Native veterans and elders from a variety of tribes to develop culturally appropriate programs.
There are about 562 federally recognized Indian tribes in this country and 365 state-recognized tribes, each with their own unique cultural traditions and, in many cases, their own indigenous languages. Therefore, VA nurses who work with Native veterans often find themselves treating a patient population that is not homogeneous but highly diverse—a concept Kafer calls “diversity within diversity.” Still, he says, while culture and language may differ from tribe to tribe, there are some basic beliefs about health, illness, healing and spirituality that are common to all Native people.
“In traditional Native American culture, health and healing begin first in the spirit, then the mind, then in the body,” he explains. “In the Western model of health care, it’s an opposite paradigm—health and disease begin first in the body, then in the mind, last in the spirit.”
Kafer won an award from the Society of American Indian Government Employees (SAIGE) for a VA diversity training video he helped produce, called “Native America: Diversity Within Diversity.” Created as part of the VA’s R.E.A.C.H. for Diversity program, the video has been distributed to all VA medical centers nationwide to increase employees’ understanding of the unique challenges Indian veterans face.
“Native America resonates with me and my history,” Kafer says. “I’m in a unique position to contribute to improving health care for Native American veterans because I understand about bureaucracy, government and the various phenomena that can impact tribal access to health care.”
Kafer is also involved in another innovative diversity training project, the Gathering of Healers program at the Southern Arizona VA Health Care System in Tucson. The program brings the facility’s staff together with Native veterans and elders to learn more about American Indian culture and how to provide culturally competent care.
“Staff come back from the Gathering of Healers and are more aware of the special needs of this [population],” says Yvonne Garcia, BSN, RN, the facility’s American Indian Nursing Case Manager. “They learn to treat people with cultural humility. They want to know more about them instead of making assumptions.”
Garcia, who is part Mandan Indian, also works with the Indian Health Service to complement services delivered to Native veterans.
Researching Health Disparities
Carol Baldwin, PhD, RN, CHTP, CT, AHN-BC, associate professor and director of the Office of International Health, Scientific and Educational Affairs at Arizona State University College of Nursing and Healthcare Innovation in Phoenix, is a nurse researcher who has focused some of her recent work on studying chronic disease disparities in Mexican American veterans, a population about whom very little health information is available. She led one study which found that, compared to non-Hispanic white veterans, Mexican American veterans were significantly more likely to have diagnosed type 2 diabetes and that having a high body mass index (BMI) put them at greater risk of developing the disease.
More recently, Baldwin published a study in the September 2007 issue of the Journal of Nursing Scholarship that compared homocysteine levels and other stroke risk factors between Mexican American and Caucasian male veterans. High homocysteine levels in the blood have been associated with increased risk of cardiovascular diseases, such as coronary heart disease and stroke.
Baldwin conducted her research in Tucson at the Southern Arizona VA Health Care System’s Minority Vascular Center. She found that Mexican Americans have higher homocysteine levels regardless of whether they scored a high or low risk for stroke. She also determined that the Framingham Stroke Profile, a commonly used stroke risk assessment tool, was derived for a predominantly Caucasian population and does not necessarily provide relevant stroke risk factors for people of other races and ethnicities.
Baldwin says her findings suggest that Mexican American veterans, like other minority populations, face barriers to stroke prevention and therapy, including lower income and education, as well as dietary, genetic and environmental factors.
There has also been very little research conducted on the health care needs of Puerto Rican veterans, says Constance Uphold, PhD, ARNP-BC, FAAN, a research health scientist with the Rehabilitation Outcomes Research Center at the North Florida/South Georgia Veterans Health System in Gainesville. Her current work focuses primarily on the health challenges experienced by Puerto Rico veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).
In one study, Uphold—who has a master’s degree in transcultural nursing and a doctoral degree in family health nursing—examined mental health issues affecting Hispanic veterans and their caregivers and families. She documented stressors from each group’s perspective, as well as successful coping models. Based on her findings, Uphold and her colleagues developed 12 culturally competent fact sheets for veterans, family members and clinicians. These educational materials are tailored to Puerto Rican veterans, complete with colors and symbols from the Puerto Rican flag. She’s now working to secure funding to reproduce and disseminate the fact sheets.
This past February, Uphold became a co-investigator of a grant that will research stroke interventions and family caregiving for Hispanic veterans, as well as how to disseminate stroke prevention information to this population. The Spanish-language information will be posted on MyHealtheVet.com, an interactive Web site that encourages veterans to take charge of their own health.
Promoting Health Literacy
Teaching minority veterans with chronic diseases how to self-manage their conditions is also a priority for Jawel Lemons, RN, MS, FNP-C, associate director of Patient Nursing Services at the Charlie Norwood VA Medical Center in Augusta, Georgia. Lemons remembers watching her own father struggle with his health. The man who raised her had a third-grade education and couldn’t read the directions printed on his medicine bottles.
“I thought, ‘If he wasn’t living with me, what would he do?’” she says. “That’s when I came up with the idea for the labels.”
The “labels” in question were part of a highly successful health literacy program Lemons created and implemented at the Dallas VA Medical Center in Texas before transferring to her current position in Augusta last year. As a cardiology nurse practitioner in the medical center’s congestive heart failure clinic, she often received referrals from primary care providers for patients who appeared to be noncompliant with their medications. Assessing the situation, Lemons discovered that the real reason why the veterans weren’t taking their medicine was that they had low literacy levels and couldn’t understand the instructions printed on their prescription labels.
So she designed a protocol for teaching her low-literacy patients how to take their medications correctly, using pictures instead of words. She found colorful, easy-to-understand computer clip art symbols, copied them onto adhesive labels and stuck them on the patients’ medicine bottles. For example, a rooster pictured with a sunrise symbolized a morning medication, while a bed indicated a nighttime medication. Lemons also transferred the same symbols to the patients’ pill boxes. As a result, the patients’ health improved dramatically.
VA Travel Nurse Corps
Her current goal is to establish special needs clinics across the VA system, with physician consults on site and nurses who are trained to make sure medications are properly labeled. She also hopes the concept of using picture labels will catch on with pharmacies.
Another way Lemons is empowering minority veterans to take control of their health is by providing them with culturally relevant dietary guidelines. “A lot of our [patient education] information is geared toward the average [majority] American, but there’s not much on the different cultures,” she notes.
Suggested menus for a low-salt diet, for example, are usually designed with Caucasian patients in mind and don’t always address the foods that African American or Hispanic patients may include in their regular diets. Lemons provides her patients with the general list of approved foods, but she also offers additional food lists that take into account a patient’s particular culture.
This is another example of how minority patients can be labeled as “noncompliant” when the real problem is that they simply could not overcome cultural barriers to their care, Lemons emphasizes. “If they don’t understand how to eat and take their medicine, they’re not in control of their ailment,” she says. “It really impacts the cost of health care when you have people who end up in the hospital over and over because they just don’t understand what they’re supposed to do.”
One of the Department of Veterans Affairs’ newest initiatives for increasing minority veterans’ access to culturally sensitive nursing care is the VA Travel Nurse Corps (TNC). Designed for RNs who prefer the flexibility and adventure of travel nursing, this program will establish an internal pool of nurses who can be available for temporary, short-term assignments at VA medical centers throughout the country. The TNC deployed its first nurse in December 2007.
Jacqueline E. Jackson, RN, MS, MBA, director of the TNC, says the new program is actively recruiting nurses from culturally diverse backgrounds. “[Minority] VA nurses bring not only cultural competence but respect and acceptance to the many culturally diverse patients under VA care,” she explains. “Nurses in the VA Travel Nurse Corps have an opportunity to travel the country working with a diverse VA patient population and a diverse VA workforce.”
For more information about the VA Travel Nurse Corps, visit www.travelnurse.va.gov.
Who Are Today’s Veterans?
Estimated U.S. Veterans Population: 23,532,000
Number of Total Enrollees in VA Health Care System (FY 2006): 7,900,000
Veteran Population by Race:
- White Non-Hispanic 80%
- Black Non-Hispanic 11%
- Hispanic 6%
- Other 3%
Veteran Population by Gender:
Percentage of Veteran Population Age 65 or Older: 39%
Source: Department of Veterans Affairs, October 25, 2007