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.”
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.”
Last summer, The Joint Commission’s culturally and linguistically competent patient-centered communication standards became part of the hospital accreditation process. One year later, what difference are they making?
In 2009, Minority Nurse published a Vital Signs story that asked: “Have you ever wished that hospitals had more of an incentive to provide culturally and linguistically competent patient care?” What prompted that question was The Joint Commission’s announcement that it was developing a set of standards that would incorporate the provision of culturally competent patient-centered care into the national requirements for hospital accreditation.
They’ve been a long time coming, but on July 1, 2012, these new and revised standards for patient-centered communication officially became part of the overall accreditation decision. The standards—which are published in a free downloadable implementation guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals—require health care organizations to, among other things:
- Identify and effectively meet the oral and written communication needs of all patients, including those with limited English proficiency, hearing or visual impairments, and low health literacy;
- Use highly qualified interpreters and translators, rather than untrained individuals, family members, or bilingual staff;
- Document patients’ language and communication needs in their medical records.
Plus, the standards include two provisions designed to create a more equitable environment for lesbian, gay, bisexual, and transgender (LGBT) patients and their loved ones. One requires hospitals to prohibit discrimination based on sexual orientation and expression of gender identity. The other provides equal hospital visitation rights for same-sex domestic partners by allowing “a family member, friend, or other individual to be present with the patient for emotional support during the course of stay.”
As all nurses know, Joint Commission accreditation reviews are something hospitals take seriously. One year later (or two years in the case of the LGBT standards, which took effect in July 2011 to align with the Centers for Medicare & Medicaid Services’ 2011 visitation rights regulations1), what effect have the patient-centered communication standards had? Are they helping hospitals do a better job of serving culturally diverse patients’ needs? And more importantly, are they starting to make any difference in improving minority health outcomes?
Too Soon to Know
The answer is: It’s still too early to tell.
“We’ve been trying to do some analysis of the scoring data and the requirements for improvement that we’ve seen since last July,” says Christina Cordero, PhD, MPH, associate project director, Department of Standards and Survey Methods, at The Joint Commission. “These data have been somewhat limited because of the time frame. But we’re planning to [look at] that information to see how frequently these issues are being scored, what kinds of situations and comments are coming up on survey, and what our surveyors are seeing on-site.”
In the meantime, anecdotal evidence suggests that most hospitals are at least trying to make sure they’re implementing the standards correctly. For instance, says Cordero, who helped develop the patient-centered communication standards and the Roadmap for Hospitals, The Joint Commission has been fielding many questions about how to implement standard RC.02.01.01, EP 28, which requires hospitals to include patients’ race and ethnicity in their medical records.
“Most of these inquiries have focused on what categories and question formats hospitals should use to collect that information from patients,” she explains. “For example, should they ask about race and ethnicity together in one question or in two separate questions? We responded by publishing FAQ documents on our website to help hospitals implement a data collection system that works for them.”
As for identifying areas where improvement may be needed, The Joint Commission’s initial analysis of data from surveyor site visits seems to indicate that hospitals are finding some of the standards harder to comply with than others.
“The one standard that has been coming up most frequently on-site over the last few months is PC.02.01.21, identification of patients’ language and communication needs during the provision of care, treatment, and services,” Cordero reports. “This may mean that hospitals are struggling more with that issue. Our surveyors are looking at not just the documentation of communication needs but what hospitals are doing to identify and address those needs.”
Is It Enough?
Minority health advocates are also keeping an eye on what The Joint Commission’s evaluation of the standards’ early years will reveal.
“I hope there will be a systematic examination of the outcomes and the impact on the quality of patient care,” says Cora Muñoz, PhD, RN, co-author of the book Transcultural Communication in Nursing. “But the fact that there are now two external bodies that require this—the Office of Minority Health [which developed the Culturally and Linguistically Appropriate Services (CLAS) standards in 20002] and now The Joint Commission—is a step in the right direction.”
Hector Vargas, JD, Executive Director of GLMA: Health Professionals Advancing LGBT Equality (formerly the Gay & Lesbian Medical Association) feels that the patient-centered communication standards are “just one piece of a larger picture of progress we’ve seen over the last few years. These standards, the CMS hospital visitation rules, the  Institute of Medicine report [The Health of LGBT People: Building a Foundation for Better Understanding], Healthy People 2020—which for the first time includes specific LGBT health goals—and the Affordable Care Act have all made a difference in how hospitals are addressing the needs of LGBT patients.”
But some transcultural nursing leaders, such as Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CNS, CTN-A, FAAN, President and Founder of Transcultural C.A.R.E. Associates in Cincinnati, argue that simply having culturally sensitive accreditation standards—or even federal government mandates—in place is not enough. Unless these requirements are vigorously enforced, she believes, there’s no guarantee that hospitals will act on them.
Vargas agrees. “The policies are there at the macro level,” he says, “but we really have to rely on the professionals in the hospitals—nurses in particular, but all members of the health care team—to make sure those policies are enforced.”
Nurses as Communication Champions
What can nurses do to help ensure that their institutions are complying with the standards on an ongoing basis—not just when Joint Commission surveyors show up? Muñoz, who is professor emeritus and an adjunct professor at Capital University School of Nursing, asserts that nurses must be leaders in a constant dialogue about the crucial role culturally competent communication plays in planning and delivering the best possible care for every patient.
“When nurses have a patient who needs language assistance, they must demand that the patient gets those [interpretation] services,” Muñoz adds. “As patient advocates, they should not settle for just getting by, or using family members [as interpreters] when it is convenient. That is not acceptable.”
Laura Hein, PhD, RN, an assistant professor at the University of South Carolina College of Nursing and a member of GLMA’s board of directors, gives two reasons why it’s important for nurses to be involved in championing the standards’ LGBT-inclusive provisions. “One is patient protection and advocacy. The other is to protect the rights of their [LGBT] colleagues, whether they themselves are LGBT-identified or not.” However, she cautions, “If they’re working in a state, or a hospital, that is not accepting of LGBT people, it’s a little trickier for them to be an advocate without endangering their own employment.”
Even though the impact of the patient-centered communication standards is still a work in progress, Muñoz emphasizes that progress is the key word. “At least we have the standards now; we didn’t have them before,” she says. “We’re moving forward. I wish we could move faster. But we’re moving.”
- U.S. Department of Health and Human Services, “Medicare Finalizes New Rules to Require Equal Visitation Rights for All Hospital Patients,” November 17, 2010, www.hhs.gov/news/press/2010pres/11/20101117a.html, accessed March 26, 2013.
- U.S. Department of Health and Human Services, Office of Minority Health, “National Standards on Culturally and Linguistically Appropriate Services (CLAS),” http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15, accessed March 25, 2013.
Minority children have higher rates of food allergy than their white counterparts, yet they’re less likely to receive the treatment they need to manage their condition and avoid potentially life-threatening allergic reactions. Nurses can play a key role in serving up interventions that will help take food allergy disparities off the menu.
“Food allergy doesn’t discriminate,” proclaims a poster from the national nonprofit organization FARE (Food Allergy Research and Education). But even though allergies to foods such as peanuts, milk, fish, eggs, wheat, soy, shellfish, and tree nuts affect some 15 million Americans of all ages, races, and ethnicities, a growing body of scientific evidence shows that food allergy does affect some populations disproportionately—and children of color are at particularly high risk.
According to a recent study published in the Journal of Allergy and Clinical Immunology, minority children and children from low-income families are more likely to have undiagnosed and untreated food allergies than their majority and/or more affluent peers.1
“What’s interesting about food allergy is that we tend to see it more in mid- to high-income Caucasian kids,” says the study’s lead author, Ruchi Gupta, MD, MPH, associate professor of pediatrics at Northwestern University’s Feinberg School of Medicine in Chicago. “So one big question I had was: Is food allergy really less prevalent in minority and low-income kids or are we just not diagnosing it in them?”
Other recent studies reveal similarly troubling findings:
- Black and Asian children have significantly higher odds of having a food allergy than Caucasian youngsters.2
- Between 1997 and 2007, Hispanic children had the greatest increase in parent-reported food allergies, compared with kids from other ethnic groups.3
- Black children are twice as likely as white children to have peanut and milk allergies and four times as likely to be allergic to shellfish. Unlike some other food allergies, which children tend to outgrow, shellfish and peanut allergies are more likely to continue into adulthood, creating a lifelong risk.3-4
FARE calls food allergy “a growing public health concern” that currently affects one in 13 children and adolescents in the United States. Symptoms of an allergic reaction to food may include itching, coughing, sneezing, swelling of the mouth and throat, vomiting, stomach cramps, skin rash, diarrhea, trouble breathing, and loss of consciousness. The severity of reactions can range from mild to life-threatening. In its most dangerous form, a food allergy attack can result in anaphylaxis, a rapid-onset whole-body reaction that can be fatal if the child is not immediately treated with the drug epinephrine.
Why the Disparities?
If food allergies are more common in racial and ethnic minority children, why do these kids have a lower chance of being diagnosed? Is it simply because there’s a need for more awareness about these allergies in communities of color? Or are the usual socioeconomic suspects that so often contribute to health disparities—such as cultural and linguistic barriers, limited financial resources, and unequal access to quality medical care—also a factor?
“It could be a little of both,” says Gupta, who is also a pediatrician at Ann & Robert H. Lurie Children’s Hospital of Chicago. “If the family doesn’t have access to a primary care provider, they may take it into their own hands and just try to make sure their child avoids the food. But there are also many parents who just don’t discuss their child’s food allergy with their clinician, because they’re unaware that there is any kind of treatment or plan that would help the child.”
Cynthia Samuel, RN, MS, PhD-C, a school nurse at Grove Street Elementary School in Irvington, New Jersey, believes one of the biggest culprits is “just not being educated about food allergies—not knowing what signs to look for and what to do should symptoms occur. In some instances, the family may think the child will outgrow the allergy, so they don’t do anything until it becomes more complex to treat or so severe that they have no other option but to take the child to the emergency room.”
Still, another reason for the underdiagnosis is that health care professionals don’t always know what to look for either, says Karen Rance, DNP, RN, CPNP, AE-C, a pediatric nurse practitioner at Allergy, Asthma, & Clinical Immunology Associates in Indianapolis. “Overall, there’s room for improvement in helping health care providers recognize the symptoms of food allergy,” she explains. “There are so many moving parts with that diagnosis that often the symptoms can be very subtle.”
What Nurses Can Do
Nurses—including pediatric nurses, allergy nurses, school nurses, camp nurses, public health nurses, and nurse practitioners—can make a tremendous difference in helping to level the playing field for minority children with food allergies. Because nurses are the professionals who are most often responsible for health teaching, says Gupta, they can play a crucial part in educating patients, families, caregivers, and even entire communities about everything from understanding the risks to handling anaphylaxis emergencies.
“It’s critical that parents and kids get educated about things like how to choose safe foods and how to read food [ingredient] labels in stores,” she emphasizes. “Nurses also need to make sure families know that food allergy is serious and that it will have a major impact on their lives.”
But before they can teach others, nurses must become knowledgeable about this health issue themselves. “We need to encourage nurses and nurse practitioners, especially those who care for children at high risk for food allergies, to seek [those] educational opportunities,” says Rance. Fortunately, there’s no shortage of information available to bring you up to speed, from NIH clinical guidelines and professional association websites (see “Resources” sidebar) to books like The Health Professional’s Guide to Food Allergies and Intolerances, published by the Academy of Nutrition and Dietetics.
Kids and families must also learn how to administer the epinephrine that could potentially save the child’s life if he or she were to have a severe reaction, Gupta continues. “Nurses should all know how to use an epinephrine auto-injector, and they should have a practice device available to teach with,” she says. “You can show [parents] a video demonstration, but that’s not going to help in an emergency situation. Unless they have practiced holding the auto-injector, popping the top off, and sticking [the needle] in, they’re not going to feel comfortable trying to inject their child.”
For community education, nurses can tap into national outreach programs such as Food Allergy Awareness Week (sponsored by FARE) and Anaphylaxis Community Experts (ACEs). The award-winning ACEs program, developed by Allergy & Asthma Network Mothers of Asthmatics in partnership with the American College of Allergy, Asthma & Immunology, sends teams of health professionals into communities to increase awareness of anaphylaxis and conduct free seminars on treating and preventing anaphylaxis episodes.
At South Bay Allergy & Asthma Associates in Torrance, California, staff nurses Ruena Mantes, BSN, RN, PHN, Lisa Lin, BSN, RN, and Anna Chocholek, BSN, RN, PHN, are actively involved in their local ACE team. They host workshops for parents, schools, employees of area businesses, and other community groups about how to recognize and respond to food allergy emergencies. This past summer, the nurses visited a nearby preschool where they trained 20 teachers to use epinephrine auto-injectors.
The School Nurse’s Role
In its most recent position statement on allergy and anaphylaxis management in the school setting, the National Association of School Nurses states that “the registered professional school nurse [must be] the leader in a comprehensive approach [that] includes planning and coordination of care, educating staff, providing a safe environment, and ensuring prompt emergency response should exposure to a life-threatening allergen occur.”
Gupta couldn’t agree more. “School nurses are going to become more and more critical in caring for children with food allergies,” she says. “The students are in school all day and food is a part of everything they do. Between breakfast, lunch, snacks, holiday treats, etc., there’s a ton of exposure to foods at school.”
Samuel points out that in economically disadvantaged communities of color, school nurses can play a unique role in closing the gap of food allergy disparities by serving as an entry point into the health care system. “Many of these families don’t have the time, money, or transportation resources to easily reach doctors,” she explains. “By having the school nurse there, at least the student and the family have someone they can turn to who understands them and is familiar with their cultural background.”
If a student with an undiagnosed food allergy suddenly has an allergic reaction at school, “the school nurse can bring the family in and use that as a teachable moment for initiating a health care plan for that child,” Samuel says. “And in the case of a severe reaction, the school nurse may be able to administer emergency epinephrine or at least call an ambulance to get the child to an emergency room.”
Providing referrals for allergy testing is another way school nurses can make it easier for minority students to get the diagnosis and treatment they need. “I had a case involving a student who would eat lunch at school and get a stomachache every day,” says Beverly Horne, RN, BSN, MPH, a lead school nurse for Chicago Public Schools’ South Cluster magnet schools. “I was able to contact the girl’s mother to find out if this was also happening at home. I referred the student to a pediatrician who did the workup on her and found that she was having [allergy] problems with some of the foods that were being served at school.”
In addition, school nurses can take the lead in helping their institutions develop food allergy policies and action plans.
“One of the things I did at my school was that I color-coded the lunch cards for all of the kids with food allergies,” says Samuel. “A green smiley face indicates an allergy to milk and dairy products; a yellow smiley face means ‘allergic to peanuts,’ and so on. When the student gives his or her card to the lunch aides, they know right away that this is what this child is allergic to. I also faxed this information to the food service company that supplies our school. We implemented this safety measure in 2011 and it’s had an extremely high success rate.”
Food Allergy Advocacy
One of the most empowering contributions nurses and nurse practitioners can make to the fight against food allergy disparities is helping minority and low-income families find resources and support systems. For instance, families who live in impoverished, food desert communities may have difficulty locating and affording allergen-free or low-allergen foods, which are often expensive.
“We just did a study on the economics of food allergy,” reports Gupta, who is the author of the book The Food Allergy Experience (www.foodallergyexperience.com), a guide for families, caregivers, and teachers of food-allergic kids. “It found that ‘special foods for your child’ was one of the biggest out-of-pocket costs for these families.”
Nurses can bridge this gap by letting families know that financial assistance options are available. “For those parents who are on a limited income and yet their child presents with a challenging and complex food allergy diagnosis, [I] will refer them to the children’s hospital in our area, which has a nutrition department,” says Rance. “The parents’ Medicaid insurance will pay for a nutrition consult.”
She also informs her patients who have access to the federally funded Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)—which serves low-income mothers and children up to age five who are at nutritional risk—that WIC will cover the cost of certain specialty foods, such as soy-based milk and amino acid-based infant formulas for children who are allergic to milk products.
Nurses can also be advocates by urging their federal, state, and local lawmakers to support legislation that could provide greater protection for all children with food allergies. One example is the federal School Access to Emergency Epinephrine Act (S. 1884/H.R. 3627), which was introduced into Congress in late 2011. If passed, this legislation would give states incentives to adopt laws allowing schools to maintain a supply of stock epinephrine auto-injectors that could be administered to any student in the event of an anaphylaxis emergency. For more information, visit www.foodallergy.org/page/school-access-to-emergency-epinephrine-act1.
In underfunded school districts that have cut back on staff to reduce costs, nurses must work together to make the case that hiring a full-time nurse at every school is not a luxury but a lifesaving necessity, says Samuel.
“If a district has only one or two school nurses, those nurses need to come together and get on the same page,” she stresses. “They have to pool their documentation so they can say, ‘On a given day, I see this many kids with food allergy problems,’ or ‘I had four occurrences this month in which students had an allergic reaction or went into anaphylactic shock.’ [Then they can] pull all this data together and come up with a report [that summarizes the need]. You really have to present the evidence, because that’s what’s going to support the potential hiring of another school nurse. If people don’t recognize food allergy as a problem or a challenge, it’s not going to be treated as such.”
- Gupta RS, Springston EE, Smith B, Pongracic J, Holl JL, Warrier MR. Parent report of physician diagnosis in pediatric food allergy. J Allergy Clin Immunol. 2013 Jan;131(1):150-6.
- Gupta RS, Springston EE, Warrier MR, et al. The Prevalence, Severity, and Distribution of Childhood Food Allergy in the United States. Pediatrics. 2011;128(1):e9-e17.
- Liu AH, Jaramillo R, Sicherer SH, et al. National Prevalence and Risk Factors for Food Allergy and Relationship to Asthma: Results from the National Health and Nutrition Examination Survey 2005-2006. J Allergy Clin Immunol. 2010 Oct;126(4):798-806.e14.
- Food Allergy & Anaphylaxis Network. Food Allergy Facts and Statistics for the U.S. http://www.foodallergy.org/page/facts-and-stats. Accessed October 29, 2012.
On a warm spring night in Miami, one of the nation’s foremost African-American oncology nursing scholars and researchers, Sandra Millon Underwood, RN, PhD, FAAN, is delivering an impassioned speech to a group of about 30 cancer nursing educators and clinicians about how it’s time to stop talking about minority health disparities and start doing something about them.
“I am appalled by the lack of information in nursing textbooks about health disparities that we know exist. [The Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care] shows there are disparities not just in occurrence [of cancer and other serious diseases] but in treatment. How many more reports do we need to write?” she demands.
“This is a time for commitment, for active involvement,” continues Underwood, who is the American Cancer Society Oncology Nursing Professor and Northwestern Mutual Life Research Scholar at the University of Wisconsin-Milwaukee School of Nursing. “If we are to be real nurses, we can’t sit here any longer and do nothing. Our efforts must be directed toward cancer prevention, early detection and cancer control throughout the community. We need to go out into our own communities and deliver information about cancer prevention where we live, where we shop, where we worship.”
Fortunately, the nurses in the audience, most of whom are African American, have no intention whatsoever of sitting and doing nothing. In fact, they’ve just spent much of the past year doing exactly what Underwood is talking about: creating and implementing successful education, prevention and screening programs designed specifically to close the gap of unequal cancer outcomes in America’s communities of color. And now they’ve come together at this Dissemination Colloquium to present their projects, share ideas and learn from one another.
The two-day colloquium, held last May, was part of an ongoing series of Cancer Prevention and Early Detection Programs for nurses involved with historically black colleges and universities (HBCUs) and minority-serving institutions (MSIs), sponsored by the Oncology Nursing Society and funded by a grant from the National Cancer Institute. Many of the participants had previously attended a prevention programs workshop taught by Underwood in August 2001, had found it incredibly motivating and had returned in 2002 eager to report on the activities they had developed as “homework assignments.”
Ending the Silence, Challenging the Myths
As the name implies, the purpose of the dissemination colloquium was to give the nurses an informal opportunity to network and exchange experiences about what strategies are working in the battle to bring effective, culturally appropriate cancer prevention programs to minority communities. There was even a presentation by a panel of nursing editors (including Minority Nurse) to encourage the attendees to share their success stories with the wider nursing community by writing and publishing articles about their projects.
But a more urgent undercurrent running beneath this focus on getting the word out was the need for nurses to not just share information with other health professionals but to bring the message directly to those who will benefit from it the most–at-risk minority individuals whose lives could be saved if they were better informed about cancer prevention and the importance of detecting the disease in its early stages when it is easier to treat.
During one networking session, the nurses spoke frankly about the problem of “silence barriers”–i.e., reluctance to talk about experiences with cancer–that have become a cultural legacy in many minority communities. This silence can result in a deadly lack of information that can prevent people from seeking screening or treatment until it’s too late. For example, some African Americans may never have been told by their parents that they have a family history of cancer. “Minority populations can’t afford to be silent about cancer,” one participant declared. “We need to start talking about it and get all the information out in the open. We have to end the secrecy.”
Added Underwood, “It’s more than just a question of getting the information out there. We also need to dispel the myths and challenge the incorrect information.” She cited the example of a widely circulated Internet hoax that scared many women into believing certain types of deodorants and underwire bras cause breast cancer. “If you receive one of these hoax emails, don’t just delete it,” she urged. “Respond to it and set the record straight. Send an email to each person whose name is on the list and give them the facts.”
Other participants–many of whom had lost friends and relatives to breast cancer or had suffered from the disease themselves–shared their own experiences with cultural beliefs and misperceptions that can create barriers to early detection and treatment in African-American communities. These included the reluctance of some black women to perform breast self-examinations because of cultural taboos against touching one’s own body, and the surprisingly common belief that cancer surgery does more harm than good because cancer spreads when it’s exposed to the air.
Yvonne Ford, RN, MSN, oncology patient resource manager at Duke University Medical Center in Durham, N.C., spoke eloquently about the nurse’s role in replacing cancer myths with facts as she presented her project, a colorectal cancer education and screening program targeted to African Americans in the Durham area. “Once the myths are dispelled, people want more information,” she said. “Information is power and it can save lives.”
Although colorectal cancer is very curable early on, it is usually not diagnosed until the disease is in an advanced stage. “Screening and early detection are critical–by the time you have symptoms, it’s too late,” Ford emphasized. “Our program was a targeted educational intervention, because I believed very strongly that the reason why people didn’t get screened was that they didn’t know about colon cancer, what the risks are and what the screening methodology was.”
To break down these barriers, Ford and her team of nurses held several community education events that featured quizzes to assess people’s knowledge of the disease, informative discussions about risk factors and symptoms, and–most importantly–free colorectal screenings. There were also demonstrations of colon-friendly, high-fiber cooking–“people will always come to a program if you feed them,” Ford pointed out–and distribution of informational materials Ford obtained from the American Cancer Society at little or no cost.
When you’re trying to arm people with empowering information about cancer, it’s important to allow plenty of time for questions, Ford advised. “These people have questions they probably wanted to discuss with their doctors, but they didn’t, for whatever reason. This is where you as a nurse have the opportunity to find out what their concerns are–whether you need to refer them on for further care, or if you need to calm their fears, or whatever. That was the piece of the project I actually liked the best.”
An Army of Educators
While nurses can play an extremely active role in bringing cancer prevention information and screening into underserved minority communities, they can’t do the whole job by themselves. That’s why many of the projects presented at the colloquium featured a strength-in-numbers strategy of nurses teaching people other than RNs to become community cancer educators. These “partners in prevention” included student nurses, high school teachers, community leaders and even minority medical students.
After attending Underwood’s 2001 workshop, a group of nine Chicago nurse educators, most of whom teach at the inner-city Dawson Technical Institute, teamed up to launch a project designed to increase their LPN students’ awareness of minority cancer disparities and encourage them to become involved in helping to address these issues. Calling themselves the Coalition of African-American Nurses (CAAN), the group’s members include Carol Alexander, RN, BSN, Alma Boykin, RN, BSN, Donna Calvin, RN, MSN, FNP, Rubie Elkins, RN, MSN, Rose Murray, RN, BSN, Muriel Reed, RN, BSN, Velita Sanders, RN, BSN and Alicia Theodore, RN, BSN.
Their project is particularly innovative because LPNs have been largely overlooked as a resource for fighting the war against unequal health outcomes. “Why shouldn’t we educate the LPN nursing student [about health disparities]?” argued Alexander, the coalition’s director. “LPNs are nurses who primarily function in direct patient care and they are also positioned to serve as positive role models for their patients and families. If they are equipped with the knowledge to appropriately counsel their patients, we will be able to increase the number of health care educators in the African-American community, where many LPNs currently serve.”
Other nurse educators showcased projects that enabled BSN students to gain hands-on experience in delivering cancer prevention education in minority communities. What was striking about these programs is that the outreach activities are incorporated directly into the school’s nursing curriculum.
For example, Linda Byrd, RN, MSN, CRNP, an instructor at Auburn University School of Nursing in Auburn, Ala., described her institution’s community-based curriculum, designed to serve an area where 23% of the residents are African Americans, many of them at poverty level. As part of the school’s community clinic program, students serve at two clinic sites to work on various health promotion projects–e.g., smoking cessation, healthy eating and drug abuse prevention.
Byrd asked the student nurses to introduce cancer prevention activities into this already established program. They eagerly accepted the assignment, going out into the community to distribute information and performing presentations and skits at the clinic sites. The new focus on cancer awareness was a huge success, Byrd said. The number of patients visiting the clinics increased and the students were well received by the community residents.
At the University of the U.S. Virgin Islands in St. Thomas, where student involvement in public service projects is an integral part of the BSN experience, students in two junior-level med/surg nursing courses taught by Edith Ramsay-Johnson are required to independently develop and implement health promotion projects for increasing awareness of cancer prevention in the local black community. “The students’ ingenuity and motivation has resulted in a number of dynamic, creative programs that reached a significant number of persons in our community,” Ramsay-Johnson reported proudly.
Working in teams, the students present preventive education and early detection programs at churches and senior citizen centers. In addition, said Ramsay-Johnson, “an optional aspect of the health promotion projects involves wider dissemination of the information.” Students have chosen a variety of avenues for getting the word out to a larger audience, including poster presentations at a shopping mall and appearances on local radio talk shows.
Most of the colloquium participants who were actively enlisting their nursing students into the fight to eliminate unequal cancer outcomes came from HBCUs or schools with large minority student populations. But the information exchange also included the perspectives of educators at predominantly white schools, whose projects focused on building their students’ awareness of minority cancer disparities and preparing them to provide culturally sensitive care to patients from a diversity of backgrounds.
For instance, Sheila Fredette, RN, EdD, who teaches the clinical component of a community health nursing course at Fitchburg State College in Fitchburg, Mass.–a public college where the student population is 82% Caucasian, 15% Hispanic and 3.6% African American–is developing a program that would require students to create a series of poster sessions on five major cancer types that disproportionately strike African Americans. The students will then present this information to audiences such as the school’s black student union, community service agencies and members of local African-American churches.
Turning Awareness Into Action
Knowledge may be power, but when it comes to fighting cancer in minority communities, spreading the word about the importance of prevention and early detection is only half the battle. Another recurring theme uniting many of the presentations was the challenges nurses face in getting people to translate cancer prevention knowledge into action–such as going in for screening or making lifestyle changes that can help decrease their risk.
Early on in the colloquium, Barbara Buchanan, RN, EdD, FNP, and Quentin Newhouse, Jr., PhD, from Tennessee State University presented their study, “Cancer Knowledge and Health Beliefs Among Select Groups of African-American Women.” The researchers surveyed a sample of 126 black women between the ages of 23 and 79 with no prior experience with cancer, asking them to respond to true-or-false statements such as “cancer is curable,” “all cancer drugs have the same effect” and “keeping cancer secret will make everyone less afraid.”
The results, Buchanan reported, showed that the women’s knowledge base was high and their beliefs about cancer were sound and realistic. “The respondents strongly believed that taking charge of one’s health is important and necessary,” she concluded. “But do they really do that? We’ll have to go back and see.”
This concern was echoed by other attendees, who related their experiences with patients who know preventive screening can save lives but don’t take the next step and follow up on that knowledge. Why, the nurses asked with obvious frustration, do so many African-American women make appointments to get mammograms and then not show up? Why is it, as research studies have revealed, that more than 95% of all women report knowledge of breast self-exams (BSEs), yet less than 50% actually perform them on a monthly basis? Clearly, in cases like these, lack of information is not the problem.
One presenter who directly addressed this situation was Linda Forté, RN, DSN, of the Mississippi University for Women in Columbus, Mississippi. “The discrepancy between knowledge of BSE and practice of BSE is still an unsolved clinical problem,” she emphasized. “[Nurses], as health educators, could play a big part in being able to resolve that issue.”
Forté’s project, “Circling the Issues,” involved teaching African-American 11th and 12th grade students how to perform BSEs on themselves and then share what they’ve learned with other important people in their lives, such as mothers, sisters, peers, and even fathers and brothers. “These people would be receiving the information from someone in their own group, someone they trust, and therefore they would be more willing to learn it and to do it,” she explained.
Eight of Forté’s BSN students worked with teachers at a local high school to conduct a one-day education session that included a BSE video and a 30-minute presentation on breast cancer facts. Next, the teens practiced performing BSEs on a model before examining themselves.
“For Sisters Only,” a project developed by Glenda Sims, RN, PhD, to increase the use of mammography by African-American women in medically underserved communities, took a different but equally innovative approach to the problem: making mammograms impossible to avoid. “We bring the mobile mammography unit directly into their communities for free screenings,” explained Sims, who teaches at the University of South Carolina at Spartanburg. “We will even go pick them up and bring them in for their mammogram, and provide a ‘buddy’ for them if that’s what they need in order to feel comfortable about coming in to get the test. And we don’t ask them any questions about their financial status, because that is also a barrier.”
What it all boils down to, everyone agreed, is empowering people of color to take control of their own health. Nurse educators, clinicians and students can do this by giving minority patients the facts about cancer, by providing accessible and affordable screening options and by encouraging them to become active participants in the health care process.
For example, the nurses stressed the importance of teaching minority patients how to communicate more effectively with their physicians, and letting them know they have the power to “fire” their doctor if necessary. In the words of Ritha Bookert, RN, MSN, FNP, of Brandon, Miss., who was so inspired by Underwood’s previous workshop that she went back and started her own 501(c)3 health education corporation: “If you are going to a doctor who is not talking to you about doing breast self-exams, you need to change doctors.”