The recent announcement by Pfizer of a potentially effective COVID-19 vaccine has led to great excitement, even though some nurses express misgivings about the speed of COVID-19 vaccine development. This vaccine development would not be possible, of course, without the participation of many thousands of volunteers in clinical trials. Unfortunately, minority participation in these COVID-19 trials has lagged.
“As we strive to overcome the social and structural causes of health care disparities, we must recognize the underrepresentation of minority groups in COVID-19 clinical trials,” notes a column in the August 27, 2020 issue of The New England Journal of Medicine.
A major reason for this underrepresentation involves “distrust of researchers, healthcare in general when it comes to communities of color,” notes Ernest J. Grant, PhD, RN, FAAN, president of the American Nurses Association (ANA). That distrust, he notes, harkens back to such appalling experiences as the “Tuskegee Study of Untreated Syphilis in the Negro Male,” where hundreds of Black men were recruited to study syphilis without treatment.
“Trusting Relationship”
Dr. Grant suggests a number of ways to address the underrepresentation of minorities in COVID-19 clinical trials. One is to provide thorough education as people are being recruited into a trial. Another involves the recruiter. “There tends to be more of a trusting relationship if they see that it is a researcher that perhaps resembles them, or is from their culture,” according to Dr. Grant.
Another tactic involves recruiting a “community influencer or someone like a pastor or a community leader or doctor or nurse within the community that people respect.” Those influencers, he notes, can help dispel myths and address uncertainties potential minority participants may have.
Once a vaccine is available, minorities are at special need of receiving the treatment, especially because minorities are at greater risk of not surviving or having a more difficult time with the disease. The virus, notes Dr. Grant, tends to proliferate more when there are comorbidities that tend to be more prominent in black and brown individuals, such as hypertension and diabetes. “When a vaccine does come along, it would prove to be more beneficial and reduce their chances of succumbing to this virus,” he says.
ANA President as Study Participant
Practicing what he preaches, Dr. Grant is currently participating in a COVID-19 vaccine phase III clinical trial at the University of North Carolina. He will be followed for two years.
One reason for his participation, he says, is the knowledge that more minority participants are needed. Another is that as a leader of the nation’s nurses, “it’s my way of trying to give back to them, knowing that they will be some of the first individuals to take the vaccine once it is approved.”
Dr. Grant ask nurses to consider volunteering for a clinical trial, and then once a vaccine has been approved, to “educate themselves so that they can educate the public.” Nurses also need to be at the table, he notes, when decisions are being made about such things as vaccine distribution. Nurses, he says, “obviously play a very critical role in that process.”
COVID-19 is hitting minorities harder than other communities. According to the Centers for Disease Control, as of June 12, 2020, the age-adjusted hospitalization rates were reported highest among non-Hispanic American Indian or Alaska Native and non-Hispanic black persons, followed by Hispanic or Latino persons. The CDC clearly states that such racial and ethnic minority groups are an increased risk of the getting COVID-19 regardless of age due to long-standing systemic health and social inequities. It has been found that non-Hispanic American Indian, Alaska Native, and non-Hispanic black persons are hospitalized for COVID-19 at a rate 5 times that of non-Hispanic white persons. Hispanic or Latino person have a rate approximating 4 times that of non-Hispanic white persons.
Why are minorities at increased risk during the COVID-19 pandemic?
For decades, health differences among racial and ethic groups have arisen due to living, working, health, and social conditions. During this pandemic, such conditions have not disappeared but work against minorities by isolating them from the resources they need to cope with such outbreaks.
Living conditions contribute to an increased risk of COVID-19 for minority groups. Many minorities live in highly populated communities due to institutional racism. Such institutional racism occurs through residential housing segregation. An example of this can be seen in the overcrowding in tribal reservations and Alaska Native villages. As a result of such densely populated areas, it acts as a barrier to social distancing. Racial housing segregation is all linked to several health conditions such as asthma which increases the risk of becoming severely ill or death from the virus. Also, certain communities with higher minority populations also have increased exposure to pollution and environmental hazards. The reservation homes of non-Hispanic Native Americans also have been found insufficient in plumbing when compared to the rest of the U.S. As a result, it proves a challenge for handwashing to occur regularly. Some members of minority groups also rely heavily on public transportation, making it difficult to follow through with social distancing. Minority groups also more commonly have multigenerational and multi-family households, which makes it harder to protect older adult family member or isolate sick household members in such limited space available. Minority groups are also over-represented in congregate environments such as jails, prisons, homeless shelters, and detention centers, which again presents a challenge for social distancing as they engage in activities of daily living in group settings.
Certain work conditions and policies also put workers at an increased risk of being infected with COVID-19. Certain minorities are more likely to work under such conditions. Being an essential worker in essential industries like health care, meat-packing, grocery stores, and factories put minorities at risk. This is because they are required to still work despite outbreaks occurring in their communities and some may need to work such jobs due to economic circumstances. They also may not have sick leave so such workers are more likely to work despite being sick. Income, education levels, and unemployment are other factors that must be considered. When considering the average earning of minorities compared to non-Hispanic whites, minorities earn less, possess less accumulated wealth, have lower levels of education, and higher rates of unemployment. All such factors contribute to the social and physical conditions of minorities which also affect health outcomes.
Lastly, the health circumstances of minorities play a major role in their being at increased risk of COVID-19. The issue of being uninsured is one of the highest concerns. Hispanics are about 3 times more likely to be uninsured than non-Hispanic whites. Whereas, non-Hispanic blacks are about twice as likely to be uninsured when compared to non-Hispanic whites. Minorities report cost as a barrier to seeing a doctor as well as distrust of the health care system, language differences, and losing wages due to missing work. Minorities also suffer from certain health conditions at higher rates than non-Hispanic whites. Black have higher rates of chronic conditions and at earlier ages with higher death rates than non-Hispanic whites. Non-Hispanic American Indian and Alaska Native adults are reportedly experiencing higher rates of obesity hypertension, and smoking then non-Hispanic white adults. Such health conditions put minorities at increased risk of severe illness. Racism, stigma, and systemic inequalities also contribute to health circumstances that increase the risk of COVID-19 in minorities. Such factors undercut prevention and increase the levels of stress in such communities, therefore, continuing health and healthcare disparities.
What can we do as health care providers and organizations?
As health care providers we must first understand this novel virus and how to best prevent, intervene, and treat it. However, in order to combat the health disparities in minorities, health care systems should offer providers training on how to identify their implicit biases. Providers must understand how implicit bias affects the way they communicate with their patients and how their patients will react to such communication. They also should be trained on how bias can affect their decision-making. Medical interpreters should be available in health care systems. Health care systems should work on community outreach projects in an effort to reduce the cultural barriers to care. As providers, we need to connect our patients with community resources that can help them manage underlying conditions. We should encourage our patients of all backgrounds to ask questions and promote a trusting relationship. All of these strategies could combat the distrust minorities may experience of health care in general. The starting point for all these forms of action is to learn more about the socioeconomic conditions that put certain patients at risk for getting sick with COVID-19. It is my hope that this essay is only the starting point for all health care providers and administrators who read it to aggressively protect the lives of racial and ethnic minority groups during this grueling pandemic.
Shifting demographics and other market conditions have created a greater need for minority nurses, particularly in certain roles. With a growing multicultural and aging population in the United States, the need for medical case managers to serve patients of various ethnic and minority groups has significantly increased. Regulatory reform—specifically, the enactment of the Patient Protection and Affordable Care Act, which ushered in new preventable readmission requirements for hospitals, along with new models of care (e.g., patient-centered medical homes and physician-hospital organizations) and more prevalent consumer-driven health care plans—has created new opportunities for minority nurses in case management. For minority nurses whose goals are to help serve these largely underserved patient populations and advance in their careers, it is important to understand the changing health care landscape.
Let’s look first at our nation’s changing demographics. The graying of America has resulted in more Americans living longer with more age-related, chronic medical conditions, ranging from arthritis, hypertension, and heart disease to hearing impairments and cataracts. According to the National Academy on an Aging Society (NAAS), almost 100 million Americans have chronic conditions, with millions more developing chronic conditions as they age. By 2040, the NAAS estimates that the number of people in the United States with chronic conditions will increase by 50%. The cost of medical care for Americans with chronic conditions could approach $864 billion in 2040—almost double what it was in 1995. While the most common chronic conditions are the same for blacks and whites, the conditions are generally more serious among minority populations, particularly individuals with lower incomes.
Another major factor in our changing health care landscape is the higher percentage of racially and ethnically diverse individuals. An AARP Bulletin article titled “Where We Stand: New Realities in Aging” reported that minorities are expected to comprise 42% of the American population by 2030. Currently, the United States has 150 different ethnic cultures represented within its population, with over 300 different languages spoken and a wide range of cultural nuances reflected. For health care providers, this broad spectrum of cultural diversity in its patients introduces higher incidences of certain conditions, while also posing challenges relating to care and communications.
Addressing Cultural Challenges
On the disease front, we know that certain ethnic groups are more prone to certain medical conditions. Many health care providers and insurers are responding with targeted initiatives, such as: the Chinese Community Health Plan’s Diabetes Self Management: A Cultural Approach initiative to enhance diabetes knowledge and management in the Chinese population; Excellus Health Plan’s Healthy Beginnings Prenatal Care program to decrease NICU admission rates for African American teens; and Med One Medical Group’s Adherence to Hypertension Treatment and Measurement project to educate English, Arabic, and Vietnamese-speaking hypertensive patients.
Beyond the obvious language and communication barriers that can prevent quality health care delivery and optimum patient outcomes, there are cultural issues that, if mismanaged, can also interfere with providing quality health care. For example, in Latin culture, religious healing, praying to certain saints, and relying on religious symbols to address health issues are not uncommon. Patients of African descent are inclined to believe in the healing power of nature and their religion. Within Asian groups, achieving balance between yin and yang, using certain herbs and foods, and relying on acupuncture to unblock the free flow of energy (chi) are common practices. Health behaviors also vary among ethnic groups. Armenians are tolerant of county health facilities, whereas the Vietnamese regard them and the related bureaucracy associated with government facilities as degrading. They, therefore, prefer receiving care in a physicians’ office, even if higher costs are incurred.
There also are differences relating to how certain minority and ethnic groups want to hear about their medical conditions. Did you know that the majority of African Americans and European Americans believe patients should be informed of terminal illnesses, while fewer Mexican Americans and Korean Americans agree? Family values relating to health care decisions also differ among minority and ethnic groups. Within the Mexican, Filipino, Chinese, and Iranian cultures, for example, there is the belief that a patient’s family should be first informed about a loved one’s poor prognosis so they can decide whether or not the patient should be informed. Obviously, these variables and many others are important for health care professionals to understand when caring for a patient. This is an area where minority nurses of different backgrounds and cultures can be a tremendous asset to their patients and to the overall health care system. Studies have demonstrated that case managers help strengthen primary care. This is particularly true when patients have complex or multiple medical conditions—as many elderly people do—or chronic conditions such as diabetes or chronic obstructive pulmonary disease.
Combating Disparities in Health Care
It is widely known that disparities exist in the care of minority patients. While this is more pronounced in rural primary care practices, it holds true across the board. An Institute of Medicine report found that “racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as insurance status and income, are controlled.” Other studies also have explored these disparities, including Aetna’s “Breast Health Ethnic Disparity Initiative and Research Study” and Health Alliance Plan’s “Addressing Disparities in Breast Cancer Screening.” Collectively, they further make the case for minority nurse case managers to advocate for minority patients.
Related research supports the fact that, where minority case managers are in place, there is a significant improvement in patient outcomes. This was evident in a study of rural African American patients with diabetes mellitus where it was found that they were able to better control their blood sugar levels with a redesigned care management model, which incorporated nurse-led case management and structured education visits into rural primary care practices.
From Public Sector to Hospitals, Physicians’ Offices, and Entrepreneurial Settings
There is no question that, given today’s health care landscape, minority nurses have a great opportunity to help make a difference in the care of minority groups and enjoy heightened career fulfillment and potential advancement. Among the settings minority nurses can consider are:
• The public sector—serving within the Veterans Health Administration system for our veterans, many of whom are minorities, or the Indian Health System for our nation’s native American populations;
• Hospitals—helping hospitals achieve lower rates of preventable hospital readmissions, caring for minority and ethnic patients, and serving as a patient advocate and liaison with family members;
• Physicians’ offices—facilitating patient-physician communications, assuring appropriate records are communicated between treating physicians, monitoring patients’ adherence to treatment plans, and identifying any family and/or home issues that might affect a patient’s well-being;
• Financial advisors and estate planning attorneys—working with these professionals who are becoming increasingly more involved in the financial aspects of their clients’ health care and the costs associated with their care, as well as protecting their clients’ estates;
• Independent practice—working for a case management firm or establishing your own practice.
Independent practices present an opportunity for minority nurses to shape their own destiny and financial reward. Through one’s own practice, a minority nurse can focus more fully on his or her patients’ well-being without the over-emphasis on cost containment we see in many other practice settings, especially hospitals. These nurses can decide that they want to specifically dedicate their practice to a certain minority and/or ethnic group. They can establish a truly patient-centered care management business model, performing health risk assessments, providing health coaching, disease education and management, assisting with patient transitions of care, coordinating health care resources on behalf of their patients, reviewing hospital bills, helping patients assemble their health records, and providing end-of-life care coordination.
Based on a 2013 survey by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, nurses from minority backgrounds represent 17% of the registered nurse (RN) workforce. Currently, the RN population consists of 83% white/Caucasian, 6% African American, 6% Asian, 3% Hispanic/Latino, 1% American Indian/Alaska Native, 1% Native Hawaiian/Pacific Islander, and 1% other. Given the increasing shortage of nurses, combined with the growing demand based on our shifting demographics, it appears that the time has never been better for minority nurses, while fewer in number, to take center stage in case management.
Catherine M. Mullahy, RN, BS, CRRN, CCM, is president of Mullahy & Associates www.mullahyassociates.com, and author of The Case Manager’s Handbook, Fifth Edition.
It’s been said that lesbian, gay, bisexual, and transgender (LGBT) nurses form one of the largest minorities within the profession, and yet they are hardly recognized as a subgroup. To date, limited data are available to determine just how many nurses identify as LGBT (or some variation of those letters, such as LGBTQ, in which the “Q” stands for questioning or queer). But according to a 2013 Gallup poll, approximately 3.5% of the US general population identifies as LGBT; so whether or not you identify as LGBT, it’s likely that you will have to treat patients who do at some point during your nursing career. As patient advocates first and foremost, nurses must strive to provide culturally competent care for all, regardless of gender or sexual orientation.
LGBT nurses and patients alike face a unique set of challenges in the health care system: hostile personnel, lack of insurance, and higher rates of certain disorders, such as substance abuse. Yet both seek to make the health care system more supportive and equitable through changes in policy, education, and advocacy. Their aim: to raise cultural competence of health care professionals and lower the health disparities and barriers to care affecting LGBT individuals, families, and couples. Here are the profiles of five professionals committed to leading the charge for an open and accepting health care environment.
Austin Nation, RN, PHN, MSN
PhD Student at University of California – San Francisco (UCSF)
Veteran nurse Austin Nation has over 30 years of nursing experience to his credit, including stints in hospital supervision and providing AIDS services, before heading back for a PhD program. His aim is to teach nursing, which he is now undertaking as an adjunct professor at San Francisco State University.
He says he’s faced a “triple-whammy” of discrimination—surprising in a city like San Francisco, where he expected more cultural competency around these issues.
“I thought this was the gay mecca, with open, liberal thinkers, but that hasn’t been the case,” he says. “I’ve experienced racism, sexism, and homophobia. I’m a black male in nursing. I’ve been blatantly subjected to all this stress while embarking on a PhD journey, which is already stressful enough.”
Nation wonders why the UCSF system, which dominates the city and cares for a larger LGBT population than any other, is “so provincial when it comes to addressing issues closest to the heart of that community.”
“We have beautiful diversity banners, photos of different kinds of people together all getting along, but it isn’t like that,” he says. “In an academic setting, change happens so slow—it’s like turning the Titanic.”
Nation takes every opportunity to raise consciousness in class. “I’m trying to provide education in real time as it happens.” For example, if a nurse refers to gay patients in a distant or disrespectful way, he’ll step in: “Hey, that’s us you’re talking about—we’re not those people.” In addition, Nation leads a Men in Nursing group and is spearheading an LGBT Cultural Competency for Healthcare Providers workshop that has generated overwhelming interest.
One part of the problem, Nation suggests, is that “the health care community tends to be conservative. We come from a paradigm of heterosexuality.” It wasn’t too long ago that homosexuality was considered a psychological aberration, he adds.
Nurses are often uncomfortable with the subject of sexuality and reluctant to talk to patients about sexual health, Nation has observed. He suggests that discomfort first crops up during physical assessment class as undergraduates.
“We learn about the human sexual reproduction system. Then, during a head-to-toe assessment of a patient, you pull the covers up and look. But what are you looking for?” What happens if a nurse pulls up the gown of a male and sees female sexual organs, say? “That’s a good opportunity to have a conversation about gender variances,” he says.
“There have been many people that didn’t accept me,” explains Nation. “I’m the kid from the ghetto who made good. For me, the saving grace is that I’ve had women who’ve taken me under their wings. They watched over me and protected me in difficult or sensitive situations. I try to create that same sense of belonging for my students.”
Riikka Salonen, MA
Manager, Workforce Equity and Inclusion, Oregon Health & Science University (OHSU)
A bi-national native of Finland, Riikka Salonen leads diversity and inclusion strategy efforts at OHSU in Portland, Oregon. “Our intention is to provide an environment of care which is welcoming and inclusive,” she says, “as well as protective of patient and employee rights and benefits. For instance, we’ve had same-sex partner benefits since 1998, and offered transgender health-specific benefits for employees for over a year.”
Family inclusion is one topic that OHSU focuses on—and for patients, that means visitation is a given for everyone, including same-sex couples or a child who has two mothers. “Family inclusion also means that if a gay employee wants to put out family photos, they feel they can without there being whispering about it.”
OHSU Pride, an employee resource group for LGBTQ employees and allies, was started in 2007 to ensure an inclusive environment. “OHSU Pride has created a significant difference in our campus, which has become very LGBTQ-affirming,” says Salonen.
LGBTQ education and consciousness-raising at OHSU is an ongoing effort, Salonen notes, starting with new employee orientation. From there, it proceeds on an as-needed basis, depending on a nurse’s specialty. For example, Salonen says, OHSU provides “a specific session for pediatric nurses that focuses on providing care for transgender or gender-nonconforming youth.”
Parents worried about a 5-year-old boy who insists he’s a girl, for example, can be referred to TransActive Gender Center (www.TransActiveOnline.org), a national nonprofit with low-cost services for youth and families. (For those living outside Portland, Skype counseling sessions are an option.)
Mary Bylone, RN, MSM, CNML
Regional Vice President, Patient Care Services, Hartford HealthCare, East Region, and Director, American Association of Critical-Care Nurses National Board of Directors
“I’m 58 and didn’t figure out my lesbian orientation until later in life,” says Mary Bylone. “My brother is gay and so is my son. I didn’t come out at first because of the prejudice and abuse my brother experienced. As a manager, I’m now out; [but] as a staff nurse, I wasn’t.”
Bylone says her sexual orientation doesn’t totally define her: “It’s part of me, not all of me.” She has noticed that fellow employees and patients gravitate toward her to talk about gay issues. Possibly, she suspects, they do it “because I’m an out person in a responsible position. One day, a mother started crying when she told me her son was gay. I was able to comfort her as the mother of a gay son.”
Bylone has experienced situations where patients have discriminated against gay nurses. “I remember a patient who asked to see me when I was a head nurse,” Bylone recalls. “She didn’t want to see her nurse that day. ‘Why? Is it because he’s a man?’ ‘No, that’s just the problem. He’s no man,’ is what she answered. Unfortunately, the nurse was standing outside the door and heard her cruel complaint.”
Bylone adds that managers sometimes treat out nurses differently. “You may be assigned a gay patient when people know you’re gay, misunderstanding that someone’s sexual orientation does not define her or his entire person,” she explains. “I’m a nurse who happens to be lesbian, not a lesbian nurse.”
Emily Pittman Newberry
Trans Woman and Recent Surgical Patient in Portland, Oregon
Emily Pittman Newberry says she lived life for 55 years “pretending to be a man,” before embracing her gender identity as woman and transitioning over a period of five years. “People often ask me, ‘When did you decide you were a woman?’ The question should be: ‘When did you acknowledge it to yourself and choose to live openly?’” Every transgender person Newberry has met or read about says they always knew.
Newberry maintains that health care personnel have been universally professional and even kind to her during this process, though she had trouble with her insurance company. They wouldn’t cover the cost of surgical gender-confirming surgery.
She has some advice for nurses, such as not taking it for granted that you know a patient’s gender. “Ask them to self-identify and tell you what gender pronoun they prefer you use in referring to them,” says Newberry, though she understands that “asking is a tender place for a nurse and a transgender person.”
“Sometimes I see someone who is clearly struggling with it—getting pronouns wrong, getting uptight [such as the time she asked a clerk to change her gender in the clinic patient record system],” says Newberry. “I want to say, ‘This is new for everybody.’ It’s my job to educate people, be kind and humane even when I feel angry. It’s a dance, and we’re all learning the steps.”
Another piece of advice is to not get thrown if a transsexual patient has a health condition that doesn’t match their gender as your records show it. “If you see a prostate problem in a woman, for instance, act like it’s no big deal,” Newberry suggests.
Many health care IT systems only offer “male” or “female” as gender choices, which is limiting and potentially hazardous. Binary options are also being challenged by popular culture. Facebook now allows users to self-select from 56 gender options, such as “transgender” and “intersex” and “Female to Male/FTM.”
There are bound to be many uncertainties and uncomfortable moments for Trans patients and their nurses as we travel this unmarked path. “Do your best to carry on in a professional way,” says Newberry. “Ask yourself: ‘Am I being tender or am I being rational?’ You can be both at all times, of course, but sometimes more on the compassionate side and other times the scientific. Both are a part of every health care professional—you can emphasize one or the other, depending on the situation.”
Desiray Bailey, MD
Hospital Chief of Staff, Central Hospital, Group Health Cooperative, Seattle, WA, and immediate past president of GLMA: Health Professionals Advancing LGBT Equality (formerly known as the Gay and Lesbian Medical Association)
“GLMA was a physician-oriented organization originally, but we decided to be more inclusive and include the whole health care team,” says Desiray Bailey. “We work to provide opportunities to practice openly and more compassionately.”
Nurses are now an active part of the group, as evidenced by GLMA’s annual conference and nursing summit, scheduled for September 10-13, 2014, in Baltimore, Maryland.
One of the aims of GLMA is to improve education and awareness of gay and transgender issues among health care personnel. “It’s a very rare nursing program that provides LGBT education,” says Bailey. “We’d like to see it as part of the curriculum for all health professionals—physicians, nurses, physician assistants, and people in behavioral health training.”
At Group Health, Bailey has been an advocate for equal treatment of LGBT staff and patients for many years, facilitating changes in policy, employee benefits, patient and family visitation, consumer rights, and community outreach.
Additionally, she advocates for equal treatment so that “any professional in a hospital or medical center who is gay, lesbian, bisexual, or transgender won’t experience discrimination as an employee because they can’t be out, or their organization doesn’t provide benefits that are equitable with straight employees.”
In many states where LGBT employees aren’t a protected class, it’s possible to be discriminated against or fired for being gay. Even worse, a few states have “anti-gay laws—where certain sexual acts are illegal—or there aren’t specific protections,” Bailey says. “I’m fortunate to live in Washington State—we’ve had domestic partnerships for a few years and now marriage equality.”
According to Bailey, the Affordable Care Act has benefited the LGBT community. “Insurance plans can’t discriminate based on sexual orientation or gender identity. Legally married couples are still recognized, even if they live in a state that doesn’t recognize their union, and there aren’t lifetime limits for AIDS patients,” she adds.
Among the tools available to improve LGBT equality in a health care setting is the Healthcare Equality Index of the Human Rights Campaign, a civil rights organization. “This is a tool that really changes the atmosphere for employees and patients,” says Bailey. Once a decision has been made to participate, “there’s an organizational will to want to score well. They want to put in place the right policies and training for staff,” she adds.
Seeking out legitimate information about LGBT issues is very important “if you want to take care of all your patients,” Bailey says.
Jebra Turner is a freelance health and business writer based in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at www.jebra.com.
Advanced education and specialty certifications can help minority nurses take their careers—and their ability to improve health outcomes—to a whole new level.
Carmen Paniagua has so many educational and professional credentials after her name that she practically needs an oversized business card to fit them all. In addition to being an RN, she is an ANP (Adult Nurse Practitioner), a board-certified ACNP (Acute Care Nurse Practitioner) and AGACNP (Adult-Gerontology Acute Care Nurse Practitioner), an APNG-BC (Advanced Practice Nurse in Genetics), and a FAANP (Fellow of the American Academy of Nurse Practitioners). She’s also a CPC (Certified Procedural Coder) and a CMI (Certified Medical Interpreter), and she holds MSN and EdD (Doctor of Education) degrees.
“Some people probably look at my CV and think this is just a lot of ‘alphabet soup,’” says Paniagua, a faculty member at the University of Arkansas for Medical Sciences College of Medicine in Little Rock. “But advanced degrees and certifications are more than just a collection of letters. They’re the evidence and recognition of your competence and clinical expertise. They enable nurses to take pride in the accomplishment of advanced practice knowledge and to demonstrate their specialty expertise to both employers and patients.”
Jose Alejandro, president of the National Association of Hispanic Nurses and corporate director of case management at Cornerstone Healthcare Group in Dallas, agrees that it’s what those abbreviations really stand for that counts.
“You can have all the degrees and certifications you want, but it’s the tools you learn from having them that’s the biggest benefit,” says Alejandro, an RN-BC (Registered Nurse-Board Certified), CCM (Certified Case Manager), FACHE (Fellow of the American College of Healthcare Executives), and a MBA who recently earned his PhD. “They give you additional skills and what I call your ‘chops.’ That’s primarily what has enabled me to move up in my career, because I can accomplish things based on more than just having experience.”
Opening Doors
There are many compelling reasons for minority nurses to pursue graduate education and specialty nursing certifications. Acquiring these credentials opens the door to a wide new horizon of rewarding advanced practice careers and leadership roles—from nursing professor and nurse scientist to nurse practitioner, nurse anesthetist, nurse executive, and more. Furthermore, the Institute of Medicine’s (IOM’s) landmark 2010 report The Future of Nursing: Leading Change, Advancing Health calls for all nurses to “achieve higher levels of education and training” and “attain competency in specific content areas” in order to respond more effectively in today’s rapidly evolving health care environment.
But the IOM report also underscores an even more persuasive reason. Advanced degrees and certifications—or more precisely, the specialized knowledge and skills nurses gain from them—are linked to improved patient outcomes and better nurse-led interventions for eliminating minority health disparities.
“This is a wonderful time for all nurses, and particularly nurses of color, to seriously look at graduate education, because of the millions of uninsured and underinsured people who will now be coming into the health care system as a result of the Affordable Care Act,” says Kem Louie, PhD, RN, PMHCNS-BC, APN, CNE, FAAN, professor and director of the graduate nursing program at William Paterson University in Wayne, New Jersey. “Many of these new patients will be members of medically underserved minority populations. The other issue is that there’s a shortage of primary care physicians. So there’s a tremendous need to increase the number of culturally competent advanced practice nurses who can meet these patients’ primary health care needs.”
Of course, it’s also hard to ignore the “what’s in it for me?” benefits. Becoming certified in an in-demand specialty—for example, emergency nursing, perioperative nursing, critical care, or pediatrics—increases your value to employers. Plus, it’s no secret that many advanced practice (APRN) specialties that require a master’s degree and board certification—such as Certified Registered Nurse Anesthetist (CRNA) and Certified Nurse-Midwife (CNM)—pay substantially higher salaries than the typical staff RN position (see sidebar). In fact, according to the most recent (2008) Health Resources and Services Administration (HRSA) National Sample Survey of Registered Nurses, RNs with graduate degrees earn an average of at least $20,000 more per year than nurses with lower education levels.
But it’s not just about the money, argues Henry Talley V, PhD, CRNA, MSN, MS, director of the nurse anesthesia program at Michigan State University College of Nursing in East Lansing and treasurer of the American Association of Nurse Anesthetists. “Advanced degrees and specialty certifications do increase your earning powers,” he says. “But they also increase your ability to make change happen in health care. They make you an expert in your particular field, and they put nurses on an equal footing with other health professionals.”
Breaking Down Barriers
Minority enrollments in graduate nursing programs have nearly doubled over the past decade, according to the American Association of Colleges of Nursing (AACN). Yet racial, ethnic, and gender minority nurses continue to be underrepresented among the ranks of APRNs and certified RNs—primarily because they’re still underrepresented in the nursing population as a whole. Fortunately, numerous nursing organizations, from AACN to the American Board of Nursing Specialties, are recognizing the need to identify and remove barriers that may prevent nurses from diverse backgrounds from earning the advanced credentials they need to succeed.
Traditionally, one of the biggest challenges in going back to school—for majority and minority nurses alike—is finding the funds to pay for it. And thanks to the current economy, with its skyrocketing tuition rates and burgeoning student loan debt, figuring out how to afford graduate school can be a trickier task than ever. Then there’s the cost of certification examinations, which in some cases can range from about $300–$400 to as high as $725 for the CRNA exam. But even though finances can be a formidable obstacle, they’re not an insurmountable one.
“What I have personally observed is that our potential minority nursing students are much more hesitant to take out loans and incur debt than majority students,” says Courtney Lyder, ND, ScD(Hon), GNP, FAAN, dean and professor at UCLA School of Nursing. “And what I tell them is: Nurses make good salaries. Compared with other academic disciplines, the compensation in nursing makes it one of the few professions in which you can actually pay off student debt in a timely manner.”
“One of the benefits of coming to graduate school now is that there are still scholarships and federal financial assistance programs available,” adds Louie, who is also the founding president of the Asian American/Pacific Islander Nurses Association. She cites HRSA programs like the National Health Service Corps, which provides scholarships for nurse practitioner and nurse-midwife students in return for a commitment to practice in a medically underserved area for at least two years after graduation, and the Nurse Faculty Loan Program, which forgives 85% of student loan debt for RNs who complete a graduate degree at a participating school and agree to serve as full-time nursing faculty.
Talley and his wife, a Clinical Nurse Specialist (CNS), recently conducted research examining some of the other factors that impede minority nurses from pursuing advanced degrees in general and nurse anesthesia degrees in particular. Lack of knowledge about APRN and specialty nursing career paths is another big barrier, he says.
“There are still people of color out there who have just not had the exposure to these career options,” Talley explains. “Nursing specialties have to get the message out to them about these opportunities and what the requirements are. Nurses need to know early on that they will want an advanced degree, because the key to opening that door will be how well they do in their undergraduate studies. Otherwise, they’ll find out about advanced practice specialties later in their BSN programs and decide ‘I want to do that’ when their GPAs will not support it.”
But Alejandro believes that perhaps the hardest hurdle for minority nurses to clear is the surprisingly common “fear factor.”
“It’s the fear of failure, fear of the unknown, fear of whatever,” he says. “I tell all the students I mentor: ‘The very first barrier you have to overcome in pursuing any advanced education or any certification is removing that fear.’ In my case, once I was over that fear, I was able to ask questions. If I didn’t understand something in a particular class, I went ahead and asked classmates who understood it a little better.”
Starting the Journey
So you’ve decided it’s the right time to return to school, earn an advanced degree, and chart your course toward a fulfilling specialty nursing career. Congratulations! But where do you start? How do you choose which graduate program to apply to? And what type of degree should you go after? Is a terminal master’s enough or will you need a doctorate?
Lyder, who made history by becoming the first male minority dean of a school of nursing in the United States, as well as the first African American dean at UCLA, says it all boils down to answering one basic question: What do you want to do?
“Find your bliss,” he advises. “Is it pediatrics, geriatrics, psych/mental health, administration, nurse-midwifery, nurse anesthesia? Once you’ve figured that out, the next step is to identify schools in your community that may have those programs. Then, contact those schools and schedule a time to talk with the admissions counselors—and I don’t mean an e-mail—to see if this is something you really want to pursue. Also, try to find an opportunity to shadow someone who’s in that role. Identify that CRNA or that psychiatric nurse practitioner and say, ‘Can I shadow you for a day to get a sense of whether this is what I want to do?’”
Getting over the fear of speaking directly with admissions officers or the graduate program director to get the facts you need to make well-informed decisions about a school is key, Louie emphasizes.
“You have to tell yourself, ‘Just pick up the phone,’” she says. “Graduate programs in nursing are competitive and some of them can be very daunting. But I find that I have to invite students to talk to me, to ask me, ‘What support services are available? Tell me about the admission requirements. Help me through the application process.’”
As for what kind of advanced degree to get, once again it all depends on your goals.
“Some nurses are confused about advancing their education. They think they all have to be PhDs,” says Paniagua. “Well, if you’d like to be a nurse researcher, then a PhD is fine, because it’s primarily a research-focused doctorate. But then there are other avenues. You can get a doctorate in nursing practice (DNP), which is a professional practice degree, or you can get an EdD, which is an education-focused doctorate. So if you’re planning to have a career in academia, you should pursue either an EdD or a PhD. If you’re planning to practice or to work in the clinical setting, you should get your DNP. Or you can just get a master’s degree [in your specialty area of interest, such as an MBA or an MSN in nursing informatics].”
Above all, the most important thing to consider when shopping around for a graduate program is finding one that’s the right fit for your specific needs—both academic and personal.
“You need to make sure that your value system is in sync with the mission and vision of the institution,” Lyder says. “For example, here at UCLA we are a research-intensive school of nursing. Our professors infuse research and evidence-based practice into every course, every lecture, everything they do. If that’s not the type of learning environment you want, then this isn’t going to be a good match for you.”
Louie recommends investigating different program formats to find options that will accommodate what she calls “your life needs.” For instance, if you have to keep working at your job while going to school, or you have young children or other family obligations, the traditional full-time, brick-and-mortar campus model may not work for you. “You need to know that there are online programs, there are blended online/on-campus programs, there are part-time and weekend programs,” she says.
Another alternative worth exploring is the accelerated (fast track) format. These programs include RN-to-MSN—also known as a Master’s Entry Program in Nursing (MEPN)—which bypasses the traditional BSN degree, and BSN-to-PhD, which bypasses the master’s. Their greatest advantage is that they enable nurses to earn graduate degrees more quickly and earlier in their careers. However, because the accelerated time frame makes the academic workload extremely intensive, these programs aren’t for everybody.
Taking the Plunge
Achieving the advanced degrees and certifications that will boost your career to a higher level can be an arduous process. But all the nurse leaders interviewed for this article agree that the rewards are worth it. In fact, with the right preparation, the right program, and strong support networks (family, friends, faith, colleagues, mentors, and minority nursing associations), it might just be easier than you think.
Talley offers this advice: “Don’t be afraid to take the plunge. I think sometimes we [minority nurses] doubt ourselves, and there’s no reason to. Believe in yourself, have faith in yourself, and don’t let anyone interfere with your dreams.”
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