With 40% of the U.S. population currently consisting of either immigrants or first-generation Americans, and with people of color actually outnumbering Caucasians in some parts of the country, it’s imperative that health care facilities provide cultural competence training for their nurses, to ensure that all patients receive quality care. After all, nurses are on the front lines of patient care and are often the first professionals that patients encounter when they enter the health care system. Fortunately, there are a variety of training options your organization can choose from to help your nursing staff develop these essential cross-cultural skills.
What should a cultural competence training program include? It should discuss overall organizational cultural competence as well as focus on the specific population groups and/or health issues that are relevant to the community your facility serves. It also should address the linguistic access needs of patients with limited English proficiency, as outlined in the National Standards on Culturally and Linguistically Appropriate Services (CLAS) in health care, developed by the Office of Minority Health (OMH) in 2000.
“It’s important to [start with] a broad overview,” says Valera Hascup, MSN, RNC, CTN, CCES, director of the Transcultural Nursing Institute in the Department of Nursing at Kean University in Union, N.J. “If the organization primarily serves a specific population, such as Latinos, then it can target that group or subgroups to discuss more specific care.”
According to Josepha Campinha-Bacote, PhD, MAR, APRN, BC, CNS, CTN, FAAN, president and founder of Transcultural C.A.R.E. Associates in Cincinnati, an effective training program should address the three themes of the CLAS standards: organizational, clinical and linguistic competence. Prior to the development of the CLAS guidelines, most cultural competency training focused on organizational issues of cultural diversity. But a well-rounded program also should help clinicians with diagnostic issues, such as identifying health conditions specific to certain ethnic patient populations or conducting skin assessments for patients with skin of color.
Cultural Competency ResourcesThe Provider’s Guide to Quality & Culture (a joint project of Management Sciences for Health, the U.S. Department of Health and Human Services, the Health Resources and Services Administration, the Bureau of Primary Health Care and the Office of Minority Health), www.msh.org/programs/providers_guide.html#topNational Center for Cultural Competence, Georgetown University Center for Child and Human Development, www11.georgetown.edu/research/gucchd/ncccOffice of Minority Health, www.omhrc.govUniversity of Medicine and Dentistry of New Jersey (UMDNJ) Center for Cultural Competency, http://njms.umdnj.edu/culweb
Cora Muñoz, PhD, RN, professor of nursing at Capital University in Columbus, Ohio, and co-author of the book Transcultural Communication in Nursing, begins her presentations with a frank discussion about organizational racism. “We have to look at ourselves because we have biases,” she says. “Sometimes we aren’t even aware of them, but they impact the way we provide care.”
Muñoz backs up such statements by citing the Institute of Medicine’s 2003 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which found that bias, prejudice and stereotyping on the part of health care providers may contribute to minority patients receiving lower quality care than Caucasians. “A good training program needs to have such knowledge passed on,” she emphasizes.
Options for providing cultural competence training include using an existing training program that can be adapted to your organization, hiring a consultant to develop a program specifically for the institution, creating your own in-house training program, or a combination of all three. Here’s a look at the pros and cons of each approach.
Using an Existing Program
Why reinvent the wheel when there are so many effective cultural competency training programs that have already been developed by experts? Some of the more widely used programs include those offered by the Cross Cultural Health Care Program, Management Sciences for Health, and the Center for Cross-Cultural Health, to name just a few (see “Resources” sidebar). A new and particularly exciting option is the soon-to-be-released Culturally Competent Nursing Modules (CCNMs), which will be launched in February.
Respected cultural competency models that can be found in the nursing literature include those developed by Andrews and Boyle, Campinha-Bacote, Giger and Davidhizar, Leininger, Purnell and Spector.
Train-the-trainer programs, such as the Cultural Competence Leadership Fellowship sponsored by the Health Research & Educational Trust and others, are considered one of the most effective formats for providing cultural competence education. The main reason is that this type of program enables an organization to reach many individuals.
The primary benefit of using an established program is that it has been proven effective. Additionally, many of these programs provide a consultant as part of the package to explain the program and how to implement it.
Campinha-Bacote recommends sticking with existing programs, such as the aforementioned ones, that have a strong track record of effectiveness. It is also important to spend the necessary time needed to research the various programs to determine which one best fits your organization’s needs. For instance, some programs may emphasize cross-cultural communication skills while others may center on building community partnerships or addressing clinical issues.
Muñoz focuses on racial and ethnic health disparities when she gives presentations on cultural competence and transcultural nursing to health professionals. “I train physicians and nurses, so I look at the impact of cultural competence on direct patient care,” she explains. Muñoz also recommends making sure that the program you use contains information that is sound and evidence-based.
The main disadvantage of using an existing program is that it will have to be modified to fit your organization. But as Muñoz points out, many of these programs were designed to be adapted. Plus, the consultant can work with you to help make the necessary adjustments.
Hiring a Consultant
A cultural competence consultant/trainer offers an objective perspective, something that is difficult to obtain from within your organization. An outside consultant can direct your organization in assessing its needs, design a program that incorporates those needs and help guide its implementation, says Hascup. This is a particularly good option for organizations that lack an in-house individual with expertise in cultural competency issues.
While a national consultant can be very knowledgeable, a local consultant knows the community and the populations your facility serves.
In either case, the trainer should have expertise in both clinical and organizational issues, with credentials from a reputable national or international credentialing body. A history of research and/or publications in the area of cultural competency is important. The individual should demonstrate a history of continuing growth in this field, because it continues to evolve, says Campinha-Bacote. Outstanding interpersonal skills, a genuine passion for the subject and an ethics/values and personality fit with your institution round out the qualifications, she adds.
Because of her academic perspective, Muñoz prefers trainers who are doctorally prepared. When seeking a consultant, she advises, find out the number of training sessions the person has conducted on a local, state and national level. Also, ask if he/she has been involved in developing curriculum on a national level. More importantly, ask if the trainer has firsthand experience working with minority communities. The trainer does not necessarily have to be a racial or ethnic minority, Muñoz explains, but should have extensive experience working with minority populations.
Norma Martinez Rogers, PhD, RN, FAAN, associate professor in the School of Nursing at the University of Texas Health Science Center at San Antonio, suggests asking the consultant for client references that you can contact.
Doing It Yourself
The benefit of developing your own cultural competency training program from scratch is that your training department knows your organization’s culture best and therefore has a good grasp of what approaches will be most effective. The disadvantage is that the individual responsible for this task may lack experience and/or expertise in cross-cultural health issues. That’s why the experts we talked to recommend using a cultural competence consultant to guide and direct the process even when creating an in-house program.
Conducting an organizational cultural assessment is a critical first step. As Campinha-Bacote puts it, “Some organizations don’t know what they don’t know.”
Doing an assessment helps determine the strengths and weaknesses of staff in regard to cultural competency, and this information can be used to help design an effective training program, says Hascup. Other experts recommend conducting an assessment both before and after implementing the formal training, to determine how much the nurses have learned. It can also serve as a benchmark down the line.
Additionally, Martinez Rogers, who is president-elect of the National Association of Hispanic Nurses, recommends conducting periodic evaluations and an assessment as part of the orientation process for nursing staff. She also emphasizes the importance of including patients in the assessment process. Several good cultural assessment tools are readily available, including some created for or used by the training programs on our resources list.
Making It Work
Cultural Competency ResourcesWhile this brief list of organizations and programs is by no means exhaustive, it’s a good starting point for learning more about cultural and linguistic competency in health care, including training programs, assessment tools and the latest research.Transcultural C.A.R.E Associates, www.transculturalcare.netThe Center for Cross-Cultural Health, www.crosshealth.comThe Cross Cultural Health Care Program, www.xculture.orgDiversity Rx (sponsored by the National Conference of State Legislatures, Resources for Cross Cultural Health Care and the Henry J. Kaiser Family Foundation), www.diversityrx.org
No matter which training option a health care facility chooses, experts agree that buy-in from administration is essential for the program to be effective. “The top players need to be committed to the concept of cultural competency, because it is their attitude that will filter down to the staff,” says Hascup.
A hospital with committed leaders armed with a cultural assessment and an arsenal of proven-successful training tools is well on its way to being able to provide effective cultural competency training for its nursing staff.
And what is the final word of advice? “If you do not have a program, start one. If you have one, enhance it, because cultural issues are alive and well and constantly changing,” says Campinha-Bacote, who notes that she has tweaked her training model four times in the 15 years since she created it.
She points to new developments that have emerged in recent years, such as a greater emphasis on linguistic issues because of the CLAS standards and changes in the way hospitals use interpreter services. Therefore, a training program developed in the 1990s may be inadequate to address today’s cultural competency issues. “Most importantly,” Campinha-Bacote concludes, “cultural competence is a journey, not a destination.”
The term cultural competence is finally starting to become common parlance in the nursing profession. Although various definitions of cultural competence exist, when minority health experts talk about “culturally sensitive care” most nurses pretty much understand what this means. But how do patients–especially patients of color–define cultural competence? What exactly does culturally competent health care mean to them, and how do they want clinicians to provide it?
To answer these questions, a research team funded in part by the Agency for Healthcare Research and Quality (AHRQ) conducted a series of 19 community focus groups with racially and ethnically diverse health care consumers. The groups included 61 black participants, 45 Latinos and 55 non-Latino whites. As reported in the Healthcare Intelligence Network’s online newsletter Healthcare Daily Data Byte, some of the study’s key findings were:
• Definitions of culture common to all three ethnic groups include value systems (25% of focus group comments), customs (17%), self-identified ethnicity (15%), nationality (11%) and–surprisingly–stereotypes (4%).
• All three groups cited the following as cultural factors that either positively or negatively influenced the quality of health care encounters: clinicians’ sensitivity to complementary/alternative medicine (17%), health insurance-based discrimination (12%), discrimination based on social class (9%), ethnic concordance of clinician and patient (8%) and age-based discrimination (4%).
• Differences between the minority and the white participants’ responses emerged in several areas. Only the black and Latino participants cited the following as important cultural factors: ethnicity-based discrimination (11%), clinicians’ acceptance of the role of spirituality (2%) and of family (2%). Additional factors specific to Latino respondents were language issues (21%) and immigration status (5%).
Charlotte Thomas-Hawkins, PhD, RN, CNN, assistant professor at Rutgers, The State University of Jersey, College of Nursing, and winner of the American Nephrology Nurses’ Association (ANNA)’s 2005 Nurse Researcher of the Year award.
According to the dictionary, nephrology is “a branch of medicine concerned with the kidneys.” To nurses who work within this specialty, however, it is a great deal more.
“Nephrology nursing offers a lot of career choices,” says Adrian Priester-Coary, MSN, RN, CNN, a nurse educator at the University of Chicago Hospitals. “A nephrology nurse in a hospital can go into an acute/critical care, home training, in-center or clinic setting. You can choose many different paths as you grow in this field.”
Those career paths may include such options as:
direct care of patients with end-stage renal disease (ESRD) who receive dialysis or who undergo renal transplants;
education of patients, communities or health professionals about risk factors that can lead to chronic kidney disease (CKD);
research into the effectiveness of treatment modalities and the impact of nursing practice on patient outcomes;
advocacy, such as working with government agencies to develop health policies that will improve the care of kidney disease patients.
No matter what their area of expertise may be, nephrology nurses in all of these career settings are working toward the same goal: to help patients who have or are at risk for kidney disease lead the healthiest lives possible.
According to recent statistics, 10 to 20 million Americans have kidney disease, although many are unaware of their condition. The primary risk factors include diabetes (the leading cause of ESRD), hypertension and a family history of kidney problems. People who have at least one of these risk factors are almost five times more likely to develop kidney disease than those who have none.
With both diabetes and hypertension on the rise, especially among African Americans, Hispanics, American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders, it is small wonder that the risk for kidney disease is also much higher in these populations. African Americans, for example, are four times more likely to develop ESRD than Caucasians.
These disparities mean that nurses of color have the opportunity to make significant contributions to the care, education and overall well-being of minority patients with kidney disease. “[Being a minority nurse] gives you insight into the patient’s culture, some of the things that have happened in their lives and why they may have postponed their treatment,” explains Janie Martinez, BSN, RN, CCRN, CNN, a nephrology nurse clinician at Alamo Kidney Health at Bexar County Dialysis Unit in San Antonio. “For a lot of the men, it’s the macho instinct. For women, it’s the nurturing belief that their family comes first, so the little money they have is spent on the family and not on their medication.”
Charlotte Thomas-Hawkins, PhD, RN, CNN, assistant professor at Rutgers, The State University of New Jersey, College of Nursing, and winner of the American Nephrology Nurses’ Association (ANNA)’s 2005 Nurse Researcher of the Year award, agrees that having first-hand knowledge of a minority kidney patient’s culture can be helpful. “Because [minority nurses] have many life experiences similar to those of our patients, we share an understanding,” she says. “When patients respond to health care professionals with cultural cues—for example, particular facial expressions or hand movements that may be unique to a certain culture—minority nurses pick up on those cues more easily because we understand them. And we can help nonminority nurses understand the background, experiences and responses to illness that are grounded in minority patients’ cultures.”
Caring Across the Continuum
Nephrology nursing encompasses total patient care, because the kidneys affect every other major system in the body—cardiovascular, pulmonary, gastrointestinal, etc. Comorbidities, especially diabetes and high blood pressure, are usually causative factors in CKD and must be addressed concurrently. And because treatment for kidney disease is costly, patients also face numerous psychosocial and financial issues.
For More Information About Kidney Disease and Nephrology NursingAmerican Nephrology Nurses’ Association
www.annanurse.orgNational Kidney Foundation, Council of Nephrology Nurses and Technicians
www.kidney.org/professionals/CNNT/index.cfmNational Institute of Diabetes & Digestive & Kidney Diseases
www.niddk.nih.govNational Kidney Disease Education Program
www.nkdep.nih.govNational Kidney Disease Education Program
www.nkdep.nih.gov National Institute of Diabetes and Digestive and Kidney Diseases, 2002. National Kidney Foundation, March 2005. U.S. Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, 2004.
“Many of [our ESRD patients] are indigent. Most are already on Medicare, so getting medication becomes a problem,” says Martinez. “For young people who now have to have dialysis three times a week, it changes their lifestyle completely.” Even patients who are not on dialysis must face many lifestyle changes, such as alterations to diet and exercise and possible side effects from medications.
Nephrology nurses may work with patients at any point along the continuum of care: people who have one or more risk factors but have not yet been diagnosed with CKD, patients who have been diagnosed with abnormal kidney function but do not yet require dialysis, ESRD patients on dialysis and kidney transplant patients.
Although renal failure cannot be reversed, early diagnosis and intervention can slow the disease’s progression. According to Gwen Bryant, BSN, RN, CNN, facility administrator for two DaVita dialysis centers in Detroit, “Seventy percent of renal failure is related to either diabetes or hypertension. So if [nurses] can get out and talk to the population about risk factors, get people to look at the warning signs and know what they are, they can start intervention and slow down the disease.”
Dialysis treatment is so time-consuming that for many patients it can feel like a part-time job: They must come in three days a week for three to four hours at a time. To promote continuity of care, charge nurses work the same days (Monday/Wednesday/Friday or Tuesday/Thursday/Saturday) and the same shifts (sometimes 10 to 12 hours) so patients always have the same caregiver. Working alongside specially trained technicians who actually operate the dialysis machines, nurses keep track of patients’ responses to treatment, monitor their overall health and provide education.
“You spend time with your patient and you learn from each other,” says Bryant. “You can share information that’s going to make their lives—and their families’ lives—better.”
Dialysis centers and hospital dialysis units aren’t the only practice settings where nephrology nurses help ease the burden on ESRD patients and families. Many dialysis patients also require home health care and personal care because they’re too weak to perform some of their common daily activities, plan their diets or accurately monitor their medications. Plus, in today’s increasingly cost-conscious health care industry, in-home dialysis is a growing trend.
“Unfortunately, many of these patients don’t have family support,” says Wanda Chukwu, RN, MA, owner of Assertive Health Services, a home care agency in Detroit that specializes in dialysis patients. “One of my goals is to help promote their needed lifestyle [regimen] when they’re home. If you can increase a patient’s compliance, you’re going to decrease hospitalization.” Home care nurses are also in an excellent position to educate patients and families about risk factors and preventive measures before kidney disease enters the picture.
Moving to Management
Some clinical nephrology nurses find that they have an interest in and aptitude for working with the bigger picture. “I knew I wanted to be a manager,” recalls Sue Jones, RN, CNN, regional director for Gambro Healthcare in Philadelphia. “But I didn’t want to just lead or just manage; I wanted to educate my staff and share knowledge.”
Jones oversees seven dialysis centers with an average daily patient census of 600. Her responsibilities include touring the clinics and communicating with clinical directors about patient problems, adequate staffing and survey readiness. She also makes a point of greeting patients and observing the care being delivered.
Bryant is another manager who shares this interest in maintaining contact with the patients her facility serves. “Because I’m a nurse and I love hands-on work, I come in and make rounds at least twice a day to see all my patients,” she says.
In addition to reviewing clinical outcomes, profit/loss statements and budgetary targets, she also participates in community and corporate education programs, visiting worksites and other community locations to talk to people about kidney disease prevention. For example, in DaVita’s Kidney Education and You (KEY) program, nurses hold seminars, talk to community members about renal failure and risk factors, take blood pressure readings and give out information from the National Kidney Foundation (NKF) and the National Kidney Disease Education Program (NKDEP).
Educating the Masses—and the Nurses
Nephrology nurses agree that this type of educational outreach is critical to stemming the kidney disease epidemic. Many nurses get involved in outreach efforts because they have firsthand experience of how devastating the disease can be.
“I have friends with renal disease who are currently on dialysis and one who is awaiting a kidney transplant,” explains Diana Brown-Brumfield, MSN, RN, CNS, a clinical nurse specialist for surgical services at the Cleveland Clinic Foundation. “I became involved with NKDEP two years ago as a pilot project to educate the Cleveland community about renal disease and how it disproportionately affects minorities. I started doing some education in our local churches about the disease and the effect it has on the minority population. Although I’m not a nephrology nurse, working in surgery affords me the opportunity to get the word out on prevention, because this is a preventable disease if we really focus on it.”
Early education is a goal for many organizations involved in kidney disease prevention, including NKF, the National Institutes of Health (NIH) and state and local support groups for chronic diseases such as diabetes. For example, the goal of NKDEP, an initiative of the NIH’s National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), is to increase awareness of kidney disease, its risk factors and the importance of early diagnosis and treatment. The program offers extensive informational resources for both patients and health professionals, including “You Have the Power to Prevent Kidney Disease,” a national public awareness campaign targeted to African Americans.
Indeed, patients and the public are not the only ones who need information about kidney disease. Nurses who can provide specialized nephrology education to other health care professionals are needed in hospitals, dialysis centers, universities and colleges.
Priester-Coary works as the nurse educator for three chronic units, one acute unit and one home training unit. “My responsibilities are usually project-driven and based on findings from the CQI [continuous quality improvement] group or other hospital initiatives,” she says. “I review the literature, update policies and procedures, develop the necessary teaching tools and then go on the road to educate the staff.”
Shaping the Future
The sharing of nephrology knowledge is not restricted to the education arena. By making their expertise available to government agencies and other influential health organizations, minority nurses have excellent opportunities to help shape the development of policies, best practices, treatments and products that can improve care for renal patients of color.
For example, NKF has a Council of Nephrology Nurses and Technicians (CNNT) that helps develop health policies that impact professional practice and the delivery of patient care. The council also recommends speakers for NKF’s annual clinical meeting and helps moderate sessions. In addition, council members participate in national activities such as the Kidney Early Evaluation Program (KEEP), in which volunteers provide free screening for CKD in community settings such as churches and in dialysis centers.
Participation in professional associations such as ANNA is another important way for minority nurses to make sure their voices are heard. “One of our goals is to actively recruit minority nurses as elected leaders, committee chairs and members,” says Suzann VanBuskirk, BSN, RN, CNN, president of ANNA.
Association involvement can offer various ways for nephrology nurses to share their “real world” experience with health care policymakers. For example, “ESRD networks are contracted with the federal Centers for Medicare & Medicaid Services (CMS),” VanBuskirk explains. “The individuals who work for those networks—many of whom are nurses with previous experience in dialysis and transplantation—work as quality managers and data analysts. They are involved in quality initiatives and educational offerings and they have wonderful opportunities to work as contracted government employees to make a difference in the outcomes and quality of care that is delivered.”
Nurses’ front-line experience and knowledge is also in demand by manufacturers of dialysis equipment and related products, as well as pharmaceutical companies. These firms hire nephrology nurses as quality/outcomes consultants, clinical educators and/or marketing representatives.
Doing the Research
With the emphasis on evidence-based practice throughout the health care field, the development of policies and best practices depends on the results of careful research. And who better to conduct research on nephrology nursing best practices than nurse scientists?
“As an advanced practice nurse in the dialysis unit, I became interested in what nurses did and how they affect patient outcomes,” remembers Thomas-Hawkins. “I realized I needed to get into a doctoral program to learn how to measure patient outcomes and try to figure out, in a measurable way, what nurses can do to have a positive impact.”
The term measurement may cause some confusion about how researchers actually work. Most nurses in clinical practice are familiar with quality improvement projects in which they collect, analyze and present data on outcomes such as patient falls and nosocomial infections. These projects are good starting points because they help staff understand a problem and try to correct it. Researchers, however, apply far more precise tools and scientific methods when measuring rates of comorbidities, effects of treatment modalities and so forth. This ensures that data gathered from different organizations and demographic areas are comparable; if they are not comparable, they are not useful.
“The importance of having more minority nurse researchers [in nephrology] is probably our interest in addressing issues that are important to the minority community,” says Thomas-Hawkins. “We’re able to tap into issues that are important to our respective [ethnic] groups because these are problems we or our families have actually experienced.”
Diversifying the Ranks
Although no demographic information about the percentage of racial and ethnic minority nurses in the nephrology nursing workforce is currently available, nurses in the field seem to agree that minority representation is low. The numbers obviously vary by geographic region and setting (urban, suburban, rural), but the fact is that many patients of color aren’t receiving care from nurses they feel truly understand them and their needs.
How can you find out if a career in nephrology nursing is right for you? Talking to nurses who are already working in the field may help. And it’s worth noting that nephrology nurses tend to remain in the specialty for a long time.
“I’ve been in nephrology for almost 20 years,” says Janie Martinez. “To me, it’s not a profession, it’s a vocation. There are a lot of rewards when you see younger people and they get to go back into the world.”
Gwen Bryant agrees that the patients make the difference. “Chronic renal failure affects every aspect of a patient’s life—their diet, their family life, their work. If you ask me why I’ve been in nephrology for 25 years plus, I’d say it’s because these patients are the most courageous in the world.”
Learning What You Need to Know
Undergraduate nursing curricula are notoriously lax about including more than a passing mention of nephrology, and even the offerings at the graduate level are meager. Therefore, nephrology nursing education often occurs on the job, whether in an acute care setting or a dialysis clinic/unit.
Most training programs run eight to ten weeks and include classes in anatomy, physiology, the disease process and the principles of hemodialysis, peritoneal dialysis and transplantation. Nurses who will be working with dialysis patients are partnered with a nephrology technician to learn how the artificial kidney works and the impact it has on patients while they are dialyzing. The nephrology nurse-in-training also works with a mentor to learn about the pharmaceuticals used in the specific setting (medications differ between outpatient and acute care settings). If the facility handles specific patient populations, such as pediatrics, nurses also must develop age-specific competencies.
Certification for qualified registered nurses can be obtained through the Nephrology Nursing Certification Commission, which offers two options. The certifiednephrology nurse (CNN) examination is designed to test proficiency in nephrology nursing practice. The certified dialysis nurse (CDN) exam is a competency-level test for nephrology nurses working in a dialysis setting. More information is available at the commission’s Web site, www.nncc-exam.org.
Most employers looking to hire nephrology nurses want RNs with at least one year of work experience rather than recent graduates. A background in medical-surgical and/or critical care nursing is highly recommended. “In med-surg, you learn the general basics of patient care and disease processes,” explains Sue Jones, RN, CNN, of Gambro Healthcare. “Then with critical care you go on to the sicker patients and see the impact of what a chronic disease can do. It really helps the nurse to see that continuum from diagnosis of another chronic disease like diabetes to a patient with the need to start on dialysis.”
The various career paths open to nephrology nurses have their own requirements for education, experience and skills. For example, nurses wishing to make the move into management of a dialysis center or unit will require a working knowledge of how that facility operates, usually by working as a charge nurse first. Managers also need excellent communication skills (both oral and written), computer savvy, organizational and time management skills and the ability to deal with conflict among both patients and staff. An understanding of financials, such as budgets and profit/loss statements, is strongly recommended; this can be acquired on the job or through an advanced degree. In addition, managers must be familiar with federal and state regulations to ensure their facilities are in compliance.
If you are interested in starting your own home dialysis, renal care or home health care business, an advanced degree in a related subject is probably helpful. “I’m working on a PhD in organizational management,” says Wanda Chukwu, RN, MA, owner of Assertive Health Services. “I think it helps immensely with the kind of services I offer.”
Nurse researchers require doctoral degrees to learn the rigorous scientific methodologies necessary to conduct accurate studies. “To do a research project, you need to make sure that the instruments you use are valid and reliable and that you’re getting the information you need,” explains researcher Charlotte Thomas-Hawkins, PhD, RN, CNN, assistant professor at Rutgers, The State University of New Jersey. “Certainly nurses with master’s degrees can also conduct research, but they really need to do it with a doctorally prepared researcher. Because there are so few doctorally prepared nurses in any specialty setting, the model for research is for those researchers to do collaborative projects with nurses in clinical practice.”
Nurses interested in becoming nephrology educators may or may not need an advanced degree, depending on the setting. But certification is always a plus, as is a mastery of public speaking. “If you have the desire to learn, plus motivation, patience and compassion for your students, you can teach,” asserts Adrian Priester-Coary, MSN, RN, CNN, a nurse educator at the University of Chicago Hospitals. Nurses who wish to focus on patient education, either at a health care facility or in the community, need to understand the fundamentals of teaching and learning. This knowledge and expertise can be gained as part of degree preparation and nursing practice. To teach at a college or university, however, a master’s or doctoral degree is usually the minimum requirement.
Welcome to the world of occupational therapy (OT). You are about to learn about a profession that can truly make a difference in a person’s life.
As a practitioner in OT you can improve the lives of people, from newborns to the elderly, by providing them with the knowledge, skills and abilities to achieve independence and enjoy life to its fullest.
“I truly enjoy my profession because of its uniqueness,” says Kashala Erby, OTR/L, who works for Sundance Rehabilitation’s Montgomery Village Health Care Center in Gaithersberg, M.D.
“I think the fundamental knowledge that we learn, coupled with clinical reasoning and creativity, makes us a distinct profession,” Erby continues. “I value occupational therapy as a means to influence, restore and rehabilitate.”
A Career in OT: Challenging, Rewarding
Occupational therapy, or “OT” as it is often referred, is a health care profession that uses occupational, or “purposeful,” activity to help those individuals whose tasks of daily living are impaired by developmental delay, physical injury, medical or psychiatric illness, a behavior problem, or a psychological disability. Practitioners in OT evaluate function through an analysis of human performance, relationships and situations. They also engage clients in experiential learning and problem solving activities. Specialties within the field include, but are not limited to: gerontology, pediatrics, developmental disabilities, mental health, prosthetics training, spinal cord rehabilitation, school-based practice and hand therapy.
OTs need to be both people-focused and science-oriented. They must be creative, innovative and well trained in the functions of the mind and body.
Good communication skills are also a hot commodity in the OT field. Brushing up on such skills will greatly benefit all prospective or current OT employees. Emily Groth, who is in the process of completing her master’s degree in OT and serves as the South Carolina representative to the American Occupational Therapy Association (AOTA) Representative Assembly, agrees that communication skills come in handy in occupation therapy, especially for OTs working with children.
“I greatly enjoy interacting with the families and teachers [of my young patients] in order to determine the best placement for them in the school system,” Groth says.
There is no question that occupational therapy is challenging work, however, there are plenty of rewards that come from making a dramatic impact in patient’s lives.
“I really enjoy finding the modification to an environment or activity that will allow a child to be as successful as possible,” Groth adds.
If occupational therapy is an area of allied health that you’re interested in pursuing, you’ll be please to know that this is a great time to enter the field. As the number of middle-aged and elderly individuals increases, the demand for therapeutic services, including occupational therapy, also multiplies. Currently, job growth within nearly all health care disciplines are projected to increase at a much faster rate than other field, but the job outlook for practitioners in OT in particular is expected to increase by 21-35%, according to the U. S. Department of Labor, Bureau of Labor Statistics.
Salaries for practitioners in OT are also on the rise; according to the ADVANCE 2003 Salary Survey, full-time practitioners in OT salaries show an average increase of $9,000 in the past four years. The new national annual average salary for OTs is $51,352, which takes into account professionals in all work settings and with all degrees of experience and education. Occupational therapy assistants, based on all settings and levels of experience, show an average annual salary of $35,635 in the past year $8,000 higher than the average in 1999.
An OT Overview
Occupational therapy is a career for individuals who care about people and have a desire to learn, achieve, and contribute their best to society and the profession. OT’s ultimate goal is to help their clients lead independent, productive and satisfying lives.
“Occupational therapy allows me to interact on a deeply personal level with people from every walk of life and with all levels of ability,” Groth says. “I am able to assist them regain independence in activities of daily life that are easy to take for granted, such as dressing, bathing, eating, and participating in play and leisure activities.”
Practitioners in OT may implement physical exercises to increase the strength and dexterity of their patients, or paper-and-pencil exercises may be chosen to improve visual acuity and the ability to discern patterns. A client with short-term memory loss, for instance, might be encouraged to make lists to aid in recall. One with coordination problems might be assigned exercises to improve hand-eye coordination. Practitioners in OT also use computer programs to help clients improve decision-making, abstract reasoning, problem-solving and perceptual skills, as well as memory, sequencing and coordination, all of which are important for independent living.
For those with permanent functional disability, such as a spinal cord injury, cerebral palsy or muscular dystrophy, therapists instruct in the use of adaptive equipment, such as wheelchairs, splints, and aids for eating and dressing. They also design or make special equipment needed at home or at work. Therapists develop and teach clients with severe limitations to operate computer aided adaptive equipment that helps them to communicate and control other aspects of their environment.
Some occupational therapists, called industrial therapists, treat individuals whose ability to function in a work environment has been impaired. They arrange employment, plan work activities and evaluate the client’s progress.
Practitioners in OT may work exclusively with individuals in a particular age group or with particular disabilities. In schools, for example, OTs evaluate children’s abilities, recommend and provide therapy, modify classroom equipment, and in general, help children participate as fully as possible in school programs and activities.
Groth, who works with children aged three to 18 with various levels of ability ranging from severe autism and orthopedic handicaps to mild coordination disorders and difficulty with handwriting, says, “Educating the child, the family and the educational team on how to improve fine and visual motor skills, self-care and sensory processing skills is the biggest component of my job.
“The children I work with bring me incredible joy and often teach me things about life that I’ve never considered before,” she adds. “The first time they can form their name independently or fasten the button on their pants or play with a special toy all by themselves is a very cherished moment.”
Practitioners in OT in mental health settings treat individuals who are mentally ill, mentally retarded or emotionally disturbed. To treat these problems, therapists choose activities that help people learn to cope with daily life. Activities include time-management skills, budgeting, shopping, homemaking and use of public transportation. They may also work with individuals who are dealing with alcoholism, drug abuse, depression, eating disorders or stress-related disorders.
Recording a client’s activities and progress is an important part of any practitioner’s job. Accurate records are essential for evaluating clients billing and reporting to physicians and others.
Practitioners in OT are employed in a wide range of workplaces hospitals, schools, nursing homes and home health care programs and they serve as employees of public or private institutions or as private practitioners.
Groth has worked in acute, sub-acute and outpatient hospital settings, as well as in an assisted living facility for the elderly. “The diversity of practice areas insures that one will never be bored or lose interest [in the field],” she asserts. “No matter what the setting is, the goal of the therapist is to help restore [their patients] to their highest level of independence.”
Choose Your Role
Along with registered occupational therapists, OT assistants and aides are in increasing demand to assist a ever-growing elderly population. Insurance carriers are also encouraging more occupation therapy to be delegated to OT assistants and aides because it helps reduce the cost of therapy.
In the field of OT, education determines at what level one will work. Those who complete an associate’s degree or certificate program work under the direction of a registered occupational therapist as occupational therapist assistants. Occupational therapist aides however, receive most of their training on the job. Since aides are not licensed, they have more limitations on what they can do in comparison to the range of tasks an occupational therapist assistant is required to do.
However, both OT assistants and aides generally provide rehabilitative services to persons with mental, physical, emotional or developmental impairments. Their ultimate goal is to improve clients’ quality of life by helping them compensate for limitations. For example, a therapist assistant will help an injured worker reenter the workforce through improved motor skill development or may assist a client with learning disabilities increase his or her independence.
Occupational therapist assistants record their client’s progress with rehabilitative activities and exercises outlined in a treatment plan and report back to a registered OT. They make sure clients are performing the exercises and activities properly and provide encouragement. The aide prepares materials, assembles equipment used during treatment, and is responsible for a range of clerical tasks. Duties can include scheduling appointments, answering the telephone, restocking or ordering depleted supplies, and filling out insurance forms.
Those entering at the assistant or aide level of OT should also be aware of the physical endurance that is necessary on the job. Assistants and aides will need some strength in order to lift patients, and they may be required to kneel, stoop or stand for long periods of time. For most, however, this is a minor concern and is overshadowed by the thrill of watching patients succeed and improve through proper care and encouragement.
Occupational therapist assistant candidates interested in improving their admission chances should make sure they have mastered high school algebra, chemistry, biology, English, computer skills and have completed volunteer hours in the field. Training to be an OT assistant includes an introduction to health care, basic medical terminology, anatomy and physiology. During the second year of school, course work will involve mental health, gerontology and pediatrics. Students will also complete 16 weeks of supervised fieldwork. Upon successful completion of academic coursework, assistants must pass a national certification examination in order to receive the title of certified occupational therapist assistant.
Becoming an OTR
Presently a bachelor’s degree is sufficient as a minimum education requirement for entry into the OT profession as an occupational therapist registered (OTR). Starting in January 2007, however, all new occupational therapists registered will be required to complete a master’s degree. In both cases, however, candidates must also pass a national certification examination in order to become an OTR and then receive licensure in the state where they will practice.
Occupational therapy course work includes physical, biological and behavioral sciences and the application of occupational therapy theory and skills. Completion of six months of supervised fieldwork is also required.
Volunteering in a variety of OT areas during one’s education is a critical step in deciding where one would like to work in the field. When students understand what role they want as a therapist, it can make their OT education experience more focused and enjoyable. Kashala Erby, who was a grad student intern and practice associate at the American Occupational Therapy Association, advises practitioners in OT to find a mentor in the field, volunteer in various practice areas, and get involved with the AOTA as a student member.
Erby also brings up the issue of lack of diversity in the occupational therapy field. She believes that the profession needs to embrace and encourage more minorities to enter OT. “While this is a female dominated profession,” Erby says, “as a minority woman in [OT], I face some of the same challenges I would have to face in any other profession.”
The ADVANCE 2003 Salary Survey shows that women greatly outnumber men in the profession. However, men report higher average salaries. The male survey respondents reported average salaries of $55,216 for occupational therapy and $37,425 for occupational therapy assistants; women reported an average salary of $48,763 for OTs and $32,927 for OT assistants.
Paving the Way to a Career in OT
Of course not everyone who ends up in OT initially starts out pursuing the field. When Emily Groth graduated from high school, she aspired to become a pediatric physical therapist. “I went to the University of Central Florida and enrolled in the appropriate prerequisites, however, I soon realized that it wasn’t a perfect fit for me,” she explains.
“My school guidance counselor gave me a test [to determine a more appropriate field]. Occupational therapy was in my top ten fields, and after I job-shadowed an occupational therapist at work, I knew it was for me.
“Engaged with people on such a personal level, the ability to truly help them regain independence, and the diversity of the practice areas drew me into this field,” Groth says.
As she asserts, the diversity of work environments is a plus for many in the OT field. According to the ADVANCE 2003 Salary Survey, most OTs reported that they are employed in schools or in skilled nursing facilities, but therapists can work in hospitals, offices, clinics, home health agencies, nursing homes, community mental health centers, adult daycare programs, job training services and residential care facilities. As an occupation therapist, your career options are truly never-ending.
Those who will succeed in OT are individuals who have patience and strong interpersonal skills to inspire trust and respect in their clients. Practitioners in OT have ingenuity and imagination in adapting activities to individual needs, a strong commitment to serve people, and an interest in social and biological sciences. And, according to Groth, no matter what area you choose, a career in occupational therapy is “so valuable to society.”
“In any job interview, you should prove that in your life you’ve achieved the goals that you set out to accomplish,” says Mark Morales. “Let your greatest accomplishments speak for themselves, and be sure to express that you truly want the job.”
Morales’ advice to allied health job seekers comes from extensive experience. He is currently the vice president of planning and placement at Dallas-based Texas Health Resources (THR). Recent recipient of the Momentum Award for job creation from the Greater Dallas Chamber of Commerce THR is one of the nation’s largest faith-based health care providers in the country, employing 16,800 workers.
“Even though there is a strong demand for individuals in allied health fields such as radiology, imaging and pharmacy, there is still aggressive competition for positions,” Morales warns. “Each facility is looking for the very best and brightest.
“THR is looking for candidates of both genders and all ethnic backgrounds,” he continues. “We’re looking for the best-qualified candidates, and we acknowledge and leverage the differences that out diverse employees bring to [THR].
“Your educational background may be what gets you the interview, but it is your experiences, personal style and communication skills that distinguish you from the others applicants,” Morales adds.
Every workplace calls for a different mix of qualities and skills; the attributes that make you a unique individual are exactly what will make you the perfect fit for the employer that’s right for you.
What Employers Want
Darrell Pratt is the leader of the Health Professions Support Team of Washington, D.C.-based Indian Health Service (IHS). Federally funded IHS serves 1.6 million American Indian and Alaska Native patients and employs 15,000 workers and 9,000 contract providers.
“The job applicant who comes to us is generally motivated to help people and to make a difference in the lives of individuals and communities,” comments Pratt. “We look for people who are interested in other cultures.
We would like to have as many Indian health care providers as we can, and the number has increased substantially over the past several years. The reality is, however, that there aren’t enough to fill all of our positions, so we look for employees who are sensitive and compassionate but not condescending someone who cares about what happens to other people and is able to demonstrate that.”
Thomas A. Pascuzzi, MD is president and CEO of Santa Fe-based Northern New Mexico Emergency Services, PC, which provides emergency-room services to area hospitals. “Our community is very multicultural; we interact with a diverse population in the emergency room (ER), so it helps to have someone who can speak the different languages that we encounter,” he observes.
“I look for employees who are willing to work really hard. ER medical technicians, ER radiology techs, ER ultrasonographers and others have to thrive in a high-pressure environment.
“To work in ER, you have to be energetic. Even though you will be tired at the end of a shift, you will get the fulfillment of making an impression on a lot of people’s lives, and even saving lives,” says Pascuzzi.
Pratt reminds applicants to “read the announcement for the job!” Pay attention to what the qualifications are and what is being asked for in terms of abilities, knowledge, skills and experience,” he adds. “Carefully plan how you will answer the question that underlies all interviews: ‘How do your qualifications fit our needs?'”
If you have only the basic qualifications and presently lack some of the skills asked for in the job description, can you still land the job? During the interview, be truthful. The employer may not be able to find one person with all the ideal qualities and skills. If you’re willing to learn, you may turn out to be the best candidate for the job.
“Maybe the most important thing I look for,” Pascuzzi muses, “is a person who’s looking to grow. Those people do a good job in any position because they have an openness and a desire to learn new things and take on new challenges.”
Be Prepared
All career experts stress the importance of researching an organization before the interview. After all, thanks to your resume and cover letter, your interviewer has background information on you; shouldn’t you be armed with ample information about the organization?
Check recent newspapers and business magazines for reports about the organization and industry trends that may affect its prospects, and take some time to explore the organization’s Web site. Ask yourself some basic questions: Does their stated mission fit your values? Do you see women’s faces and faces of color among the photos of senior managers? Is it a large organization, offering varied opportunities for advancement, or a small one, where you won’t be boxed into a narrow specialty? And which do you prefer?
It’s also important to take time for personal introspection. Figure out exactly what you need and want from a job. And consider the pay range. Darrell Pratt notes that the IHS salaries are “livable, but if money is what drives you, then this isn’t the place for you.”
Location is also an important consideration. Many IHS facilities are located in small settlements near some of America’s wildest, loveliest and emptiest areas paradise for some, but not for all. “Sit down with a map and see exactly where the organization is located,”
Pratt advises. “Call the facility and speak with someone about lifestyle and professional concerns.
“People really need to be upfront about their concerns and needs,” Pratt emphasizes. Other experts agree: “If we can’t meet the potential employee’s needs, then everyone has to move on.
“For us, the bottom line is our patients,” Morales says. “We’re not doing our patients any service if we supply them with health care providers who don’t really want to be there.”
An onsite visit is also recommended. “You don’t really get a sense of an organization until you walk through the waiting room or lobby,” Morales remarks. “Visiting [the organization] gives you a clear understanding of the facility, the location and the community.”
Ready, Set, Go!
When it comes to words of advice for the actual day of the interview, the most important advice is to “be on time!” Morales admonishes. “Allow yourself extra time by arriving 10 to 15 minutes before the interview.”
When you step through the door for your professional interview, you have to look presentable. “If you are dressed appropriately, others will respond appropriately,” Morales declares. Be extra-clean and neat fingernails scrubbed; hair freshly washed and combed; beard or moustache, if any, trimmed; and shoes shined. “The patients we’re serving expect a level of professionalism,” Pascuzzi explains. “Your clothing doesn’t have to be expensive, but it should look nice and neat. Things like flip-flops or un-tucked shirts aren’t really the best way to present yourself.”
Also, remember to bring extra copies of your resume and references, and bring a pad of paper and pen to take notes. And if women are wearing nylons, they should bring an extra pair in case of an unexpected run.
When you meet the interviewer for the first time, look him or her in the eye and give a “good, firm handshake. Avoid nervous mannerisms, fiddling with things and giggling,” Morales advises. “Stay away from slang and don’t speak in a monotone. Speak with some inflection, smile, look interested, demonstrate good body posture and maintain great eye contact!” he continues.
Be prepared with specific examples of how you have achieved your accomplishments. Pick out several key stories that demonstrate your abilites, Morales suggests. Each story should illustrate a point that you want to highlight during the interview. “One specific example is worth half a dozen vague references,” he says.
For example, when asked, “How do you keep organized?” You might reply, “During my internship, I liked to come in a few minutes early. I would prioritize my tasks so that I would be ready to begin work with the most urgent task.”
If it’s hard for you to “brag” about yourself, imagine that you are describing a good friend whose work you respect. The only way that the interviewer can learn about this person is through what you say, so present the best image that you can. Don’t let the interviewer miss out on learning about such a great job candidate!
“Listen carefully to exactly what the interview is asking,” Morales urges, “and clearly answer that question. If you don’t understand what’s being asked, get further clarification, then respond to that question and don’t ramble.”
Trick Questions?
“Interviewers are not going to purposely try to trip you up,” Morales explains. “They want accurate, succinctly information; they are not going to ask a trick question.”
Interviewers have some favorite questions, however, that are not meant to be deceptive but are especially complex for minority and immigrant applicants. For example, an interviewer may ask, “What made you decide on a career in this field?” The interviewer assumes that the decision was yours alone and is curious what basic talents and life-long interests make you well suited to the profession. Some applicants, however, went into a particular field because their family decided it would be best. Stating that your chosen profession was your family’s idea may lead the interview to believe you cannot think for yourself. Downplay this part of your reasoning, and instead list some of the other reasons underlying your decision. A radiologic technologist might answer, “I’ve always been interested in technology. Even as a child, I tinkered with electronics. I also have a deep desire to be of service to others. So this field seemed like a good fit for me.”
Another “trick” question is, “What do you like to do in your spare time?” The interviewer hopes to put you at ease and to get a more accurate understanding of you as a person. This is an opportunity to relax for a minute. Do smile as you answer and allow yourself to calm down a bit, but don’t go on and on about sports, hobbies, family and travel. Interviews typically last only 30 to 60 minutes, so there isn’t much time to chat. Simply mention one or two things you like to do, and then turn the conversation back to the interviewer’s interests or to the work at hand.
A busy mother might answer, “We like to spend a lot of time together as a family. That must be your family photo on your desk cute kids!” Or she might say, “We like to spend a lot of time together as a family, and I’m glad that everyone helps out with the children. It allows me to give my undivided attention to my work while I’m on the job.”
During an interview you should never discuss salary or benefits before an actual job offer is made, even if the interviewer brings it up. Make some general comment, such as “I’m sure the pay will be fair in terms of my qualifications and the responsibilities of the job,” and then go back to showing how your qualifications fit the responsibilities of the job.
The interviewer will probably invite you to ask some questions of your own. Be ready with some questions about the work, the equipment, the organization’s growth plans anything except pay and benefits. Your questions should show your interest in contributing to the team’s success. After you are offered the job, there will be plenty of time to discuss vacation time, sick days and bonuses.
Honesty Is Best
“Be honest about what you put on your application and what you say during an interview,” Pascuzzi says. “Be straightforward about what you’ve done and what you haven’t done yet. Don’t try to go in there and be someone you’re not,” he recommends. “By the time you’ve applying for jobs in the health care profession, you’ve already achieved a lot. You’ve shown that you’re willing to work hard and do what it takes.
“When you go into the interview, be confident. Describe the type of person you are, the type of work you like to do, and the type of job you do,” he concludes.
After the interview, send a quick thank-you note right away. Re-emphasize what makes you the right person for the job, and say you enjoyed meeting with the interviewer and discussing the job. If the employer doesn’t call you back within the timeframe indicated at the end of the interview, follow up with a telephone call.
