In today’s global society, nurses care for patients with diverse cultural backgrounds and varied expectations about the role of health care in their own lives. Though often unintentional, cultural insensitivity by health care staff can hinder a positive patient experience—and even physical health. As the role of medicine and nursing practices vary greatly from culture to culture, nursing schools are strengthening their efforts to attract more minority students and diversify the nursing workforce.
Why is it important to attract underrepresented groups into nursing? According to the U.S. Census Bureau, individuals from ethnic and racial minority groups accounted for more than one third of the U.S. population (37%) in 2012, with projections pointing to minority populations becoming the majority by 2043. A 2013 survey conducted by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers found that nurses from minority backgrounds represent approximately 17% of the registered nurse workforce: African Americans 6%; Asians 6%; Hispanic/Latinos 3%; American Indian/Alaskan Natives 1%; and Native Hawaiian/Pacific Islanders 1%.
Jan Jones-Schenk, DHSc, RN, NE-BC, national director for the College of Health Professions at Western Governors University, believes that achieving greater health in our nation depends on having health care providers that “are like” the patients we care for in ethnicity, culture, and other demographics.
“The insights and understanding [that] people of like cultures and backgrounds can bring to the health care experience are difficult, if not impossible, to teach,” says Jones-Schenk. “The shared, lived experience can create a bridge for understanding and improving patient and family acceptance and engagement in health-related activities and behaviors.”
By using a combination of targeted outreach programs, eliminating cultural barriers, and preparing students to treat diverse populations, nursing schools are rising to meet the challenge of expanding student diversity and promoting a diverse image of the nursing profession.
Recognizing the Need
Numerous schools are looking at strengthening their recruitment through outreach campaigns that serve to develop community partnerships with culturally diverse organizations and geographical areas. Last year, the University of Delaware School of Nursing won a three-year, $1 million grant from the federal Human Resources and Services Administration to enhance nursing workforce diversity. The purpose of this grant is to implement an innovative and comprehensive recruitment and retention model that will help increase the diversity of the nursing student body, as well as foster a welcoming environment that promotes interest and success for underrepresented minority and disadvantaged students.
The Nursing Workforce Diversity (NWD) grant funds nine undergraduate nursing students from underrepresented minorities and from economically disadvantaged or educationally disadvantaged groups. Current NWD scholars hail from four different countries; six have parents who were born outside the United States; and the participants speak six languages among them: Spanish, Tagalog, Korean, Shona, German, and English.
“Enhancing nursing student diversity contributes to the value of every student’s learning experience, as each person brings their own unique cultural and ethnic backgrounds to the classroom with discussions and interactions that serve to enrich and enlighten everyone’s academic, professional, and personal development,” says Kathy Kump, RN, MSN, MHSA, CWOCN, FNP-C, the director of nursing at Ottawa University. “This will positively impact the needs of all individuals in our culturally rich and linguistically diverse society that complements the demographics of our current population.”
Removing barriers that may have historically prevented culturally diverse nurses from entering the workforce is an effective tool in diversifying the nursing student population. While Chamberlain College of Nursing does not have a program specifically for Arab American students, in an effort to address their unique cultural needs, Chamberlain College introduced the concept of Chamberlain Care, which encourages colleagues to consider the whole student and not just his or her academic needs.
As an example of Chamberlain’s focus on students, after noticing a number of Arab American student nurses enrolled in the nursing program, one professor contacted the executive director of the National American Arab Nurses Association and helped coordinate a workshop for students and colleagues to gain greater understanding of the cultural differences of the Arab American community. Additionally, for an upcoming clinical course, Arab American students who wear hijabs and long, modest skirts daily requested to wear an alternative to the standard scrub pants. The campus dean, student services advisor, and clinical coordinator worked together to identify a long, scrub dress option that complied with the students’ needs while also meeting the clinical site’s requirements.
“It is a priority at Chamberlain College of Nursing to prepare student nurses to enter the workforce with the knowledge and skills to provide extraordinary care, help our students identify resources that will help them feel more comfortable in their future profession, and engage with peers in different ways outside of the classroom,” says Jaime Sinutko, PhD, MSN, RN, the dean at Chamberlain College of Nursing’s Troy Campus. “We are all vested in all our students’ positive outcomes.”
Preparing Students to Treat Diverse Patient Needs
Central to any nursing school is preparing nursing students to treat diverse patient needs and develop empathy in the workforce. As part of the RN-to-BSN curriculum, Ottawa University offers a Nursing and Cultural Diversity in Healthcare course, which assists the student in improving cultural awareness, cultural sensitivity, and cultural competency as a nursing professional. The course examines how cultural diversity affects health beliefs, health care behaviors, and health/illness dynamics.
“Each week, the student is introduced to diverse population groups through lecture, discussions, videos, and case studies in order to expand their understanding and appreciation of various health care beliefs and health care behaviors in our society,” explains Kump. “It is also designed to prepare students to better implement and evaluate individualized plans to improve health care delivery in today’s global, but increasingly smaller, world.”
In addition to this specific class, Kump says they emphasize cultural competency as a foundation and continuing theme in each course throughout the nursing curriculum and highlight the importance of this competency not only in course objectives, but in the program’s overall learning outcomes, as well.
Workplace safety is a topic of major concern and discussion for workers and employers in a variety of occupations and workplace settings. In nursing, patient safety is an essential and vital component of quality nursing care. However, the recent Ebola outbreak and the growing risks of antibiotic-resistant microorganisms have created a heightened awareness around the fact that nursing is still one of the most dangerous occupations in the United States. This raises the following question: Just how safe are nurses in the work setting? In this 21st century, one may easily assume that nurse safety has been addressed. However, the answer is not clear.
Data from the Bureau of Labor Statistics (BLS) show that the health care sector continues to be the most dangerous place to work in America. According to the Occupational Safety and Health Administration (OSHA), health care workers are confronted with the following job hazards: bloodborne pathogens and biological hazards; potential chemical and drug exposures; waste anesthetic gas exposures; respiratory hazards; ergonomic hazards from lifting and repetitive tasks; laser hazards; workplace violence; hazards associated with laboratories; and radioactive material and X-ray hazards. In 2010, there were 653,900 workplace injuries and illnesses in the health care sector, which is more than 152,000 more injuries than the manufacturing sector, according to a 2013 Public Citizen report.
The paradigm for promoting nurse safety is changing, but slowly, and has not kept up with the technology to prevent injury, says Amber Hogan Mitchell, DrPH, MPH, CPH, president and executive director of the International Safety Center. “There have been a lot of advances over the last few decades to significantly improve nurses’ safety, but more can be done to collect and analyze data that would help speed adoption of innovative technology and spur swifter action to revise and implement stronger safety-related best practices and policies.”
The issue of nurse safety is pervasive. Unfortunately, musculoskeletal injuries are common from lifting patients without enough assistance. Nurses lift the equivalent of 1.8 tons every eight hours. Unanticipated exposures to blood and body fluids (BBFs) pose infection and illness risks to nurses on a daily basis. In the process of caregiving, patients or family members occasionally strike out at the nursing staff. Assaults from patients and patient visitors are far from being listed as isolated incidents.
“Health care has reached a critical tipping point,” says Alexandra Robbins, author of the New York Times bestseller The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. “With looming physician shortages and an increasing demand for services, workplaces will have no choice but to make changes to accommodate nurses, our largest health care provider.”
Clinically Proven Textile Technology
About one in two nurses experience blood exposure, other than from a needle stick, on their skin or in their eyes, nose, or mouth at least once a month, according to a 2012 study by the International Healthcare Worker Safety Center at the University of Virginia. In fact, nurses experience these exposures most often while providing direct care, when they are least expecting it and not wearing protective clothing, according to data from the International Safety Center’s Exposure Prevention Information Network (EPINet).
In order to better protect nurses from unexpected exposures to harmful pathogens, we need to first address the role their daily attire can play in protecting them, says Barbara DeBaun, RN, MSN, CIC, consulting vice president of clinical affairs at Vestagen Technical Textiles, Inc. When exposure is unexpected and nurses are not donning personal protective equipment (PPE), traditional scrubs leave nurses vulnerable to direct contact with harmful contaminants that stay with them all shift long.
“Traditional scrubs allow micro-organisms, blood, and other body fluids to leach through the fabric, resulting in nurses carrying contaminants from patient to patient and home to their families,” DeBaun says. “New ‘active-barrier’ textile technologies, made with fabric such as Vestex, contain fluid-repellent, antimicrobial, and breathability properties.”
Debaun explains that this innovative fabric technology combination is key in helping reduce the acquisition, retention, and transmission of harmful pathogens on health care worker attire. Working together, the fluid-repellent barrier causes harmful contaminants to bead up and roll off the fabric, and the antimicrobial agent limits growth of bacteria on the fabric. Vestex’s active-barrier apparel is currently the only textile technology that has shown clinical effectiveness at reducing MRSA infections by 99.9%, in comparison to traditional attire.
Active-barrier apparel is already available in scrubs and white coats for health care workers and health care facilities to purchase. Hospitals such as Baptist Health in Jacksonville, Florida, have already established a systemwide uniform policy that requires staff to wear active-barrier protective uniforms. The organization made a commitment in 2014 to transition more than 6,000 workers, and all patient attire, to Vestex garments to enhance their culture of safety.
“As more data shows the risk that attire can play in transferring harmful contaminants, we believe that advancements in textile technologies will soon become the new industry standard for nurses in all health care settings,” DeBaun says.
Nursing is the third most dangerous profession in the country because the vast majority of nurses are attacked by the people they are trying to help. According to data from the BLS, U.S. health care workers experience the most nonfatal workplace violence compared to other professions by a wide margin, with attacks on them accounting for almost 70% of all nonfatal workplace assaults and causing days away from work.
In 2014, 68-year-old Charles Emmett Logan, a patient at a Minnesota hospital, attacked a group of nurses with a pipe pulled from his hospital bed. The incident, which was caught on video, showed Logan running through the nurse’s station wielding a metal pole, hoisting it over his head, and hitting nearby nurses who attempted to flee the scene. One nurse suffered a collapsed lung, another fractured her wrist, and others had cuts and bruises. Medical staff told police that Logan, who died in police custody, suffered from paranoia.
“Hospitals do not protect their nurses, and it’s time they do,” says Robbins. “There is so much more that can be done, both tangible changes and major shifts in attitudes.”
Some hospitals believe that posting security personnel near triage looks negative, so they don’t put enough security staff at the entry points to the hospital and near triage. This puts the triage staff at risk when patients who are high, drunk, or psychotic come in the door, explains Robbins.
After the episode in Minnesota, the hospital initiated a training program to teach workers how to recognize and de-escalate potentially violent situations. However, many hospitals lack this basic safety measure — an oversight that leaves caregivers vulnerable.
“Understandably, nurses are focused on providing the highest quality and safest care to their patients, and often at the unintended risk of not protecting themselves,” Mitchell says. “A shift towards promoting a culture of safety that encompasses both patient and worker safety and security can create an overall better, more effective health care environment.”
To help promote a culture of safety, Robbins recommends that hospitals take the following steps:
• Install metal detectors to reduce the chances of patients or visitors injuring nurses and other staff members with weapons.
• Keep a computer database that flags patients known to be belligerent or aggressive.
• Install bulletproof glass and beef up security.
• Practice safe staffing and hire enough nurses so that the nurse–patient ratios are safe.
“The secret to improving American health care is to hire more nurses and insist that workplaces do a better job of protecting our frontline responders,” Robbins adds.
New Policies and Procedures
Exposures to BBFs pose a very large safety risk to nurses. According to data from EPINet, 47.7% of nurses were exposed to BBFs while on the job in 2012. Perhaps even more alarming, from 2003 to 2012, 83.9% had BBFs touch unprotected skin. These rates are high because nurses aren’t protected from unanticipated exposures, and compliance with PPE is surprisingly low. There is mounting evidence as well that nurses’ attire is contaminated with pathogens and can thus become a vector of transmission to other nurses as well as the patients they treat.
Mitchell believes that hospitals need to have programs in place that not only promote the use of PPE, but also measure compliance. This type of surveillance can allow the facility to identify where risks are high and compliance is low, and target programs in those areas, thus reducing exposures and reducing risk.
“EPINet is free to use and is an example of a surveillance system that can help hospitals to reduce risks,” Mitchell says. “The National Institute for Occupational Safety and Health [NIOSH] is launching a national system called the Occupational Health Safety Network [OHSN], and it is compatible with EPINet. Using systems like these allow facilities to compare themselves to others like them and to constantly improve.”
It is important to remember that safety is guided by a hierarchy of controls, which means that it is important first to eliminate hazards and risks to the lowest possible extent. Mitchell says this is done using engineering controls such as safety-engineered devices that eliminate or protect needles (e.g., needleless IV systems, retracting or shielded needles used on syringes, and blunt suture needles). For exposures to BBFs that splash and splatter, engineering controls might include closed systems for suction canisters or spill-resistant specimen containers. It may even include the use of new innovations in textiles, including those that are fluid-repellent and antimicrobial so that BBFs run right off of them, and fluids don’t soak in to the skin.
There will always be more that can be done to address nursing safety risks, Mitchell believes. Organizations like OSHA, NIOSH, and the Association of PeriOperative Registered Nurses, are always open to feedback, and it is only in providing them with your experiences and opinions that they can provide better guidance.
Mitchell adds that addressing nursing safety risks means creating the safest possible working environments and identifying and measuring hazards, so that programs and interventions can be designed to target and prevent them.
“This involves frontline nurses contributing to the review, evaluation, and selection of engineering controls, medical devices, and even textiles used in their hospitals,” Mitchell says. “Finally, it means working together across specialties, across units, across facilities, and across disciplines to share ideas, foster collaboration, and learn from each other.”
Terah Shelton Harris is a freelance writer based in Alabama.
Affirmative action has been a hot topic for decades. Since its tumultuous inception almost 50 years ago, affirmative action has been applauded, argued, and scoffed at as an answer to racial inequality.
In 1961, President John F. Kennedy was among the first to use the term “affirmative action” as a method to prevent further racial discrimination despite civil rights laws and, essentially, to temporarily level the playing field. Executive Order 10925 required that government contractors “take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, creed, color, or national origin.”
But it was President Lyndon B. Johnson who developed and enforced it for the first time in 1965 with the passage of Executive Order 11246.
“This is the next and more profound stage of the battle for civil rights,” Johnson said to a Howard University graduating class in 1965. “We seek…not just equality as a right and a theory, but equality as a fact and as a result.”
Since then, the debate over affirmative action has grown more and more contentious and problematic as the public—with divided opinions—have weighed in on a complex issue.
Robert A. Schaeffer, the public education director of
FairTest, the National Center for
Fair & Open Testing, believes that many issues relating to race are highly controversial because critics have been able to define policies as “preferences” rather than “balancing” the playing field.
“Many Americans are convinced that affirmative action creates biases in favor of certain groups,” says Schaeffer. “Particularly in economic tough times, it is not difficult to fan resentment against any plan that seems to advantage [some] while disadvantaging others.”
Schuette v. Coalition to Defend Affirmative Action
In recent months, the battle over affirmative action once again gained momentum in light of the latest Supreme Court rulings. In April, the Supreme Court upheld a constitutional amendment Michigan voters approved in 2006, banning preferential treatment based on race, gender, ethnicity, or national origin in admissions to the state’s public universities.
By a vote of 6 to 2, the court concluded that it was not up to the judges to overturn the 2006 decision by Michigan voters to bar consideration of race when deciding who gets into the state’s universities and made it clear that states are free to prohibit the use of racial considerations in university admissions.
“This case is not about how the debate about racial preferences should be resolved. It is about who may resolve it,” Justice Anthony Kennedy wrote in an opinion joined by Chief Justice John Roberts and Justice Samuel Alito. “There is no authority in the Constitution of the United States or in this court’s precedents for the judiciary to set aside Michigan laws that commit this policy determination to the voters.”
Justice Sonia Sotomayor, on the other hand, blasted the majority, who she said attempts to “sit back and wish away” evidence that racial inequality exists.
“The stark reality is that race still matters,” Sotomayor wrote in her 58-page dissenting opinion joined only by Justice Ruth Bader Ginsburg. “The way to stop discrimination on the basis of race is to speak openly and candidly on the subject of race, and to apply the Constitution with eyes open to the unfortunate effects of centuries of racial discrimination.”
It is unclear how the decision might move other states. Eight states, including Nebraska, Arizona, and Washington, now have bans on affirmative action. The ruling could encourage other states to join the handful that already have such prohibitions, such as California and Florida.
But what’s worrisome to proponents of affirmative action is the precedent that may have been set with the court’s ruling, potentially, further energizing opponents of racial preferences, who have already outlined plans to put Michigan-style constitutional amendments on the ballot in Utah, Ohio, and Missouri.
A survey conducted by ABC News and The Washington Post last year found that 79% of whites and 71% of non-whites oppose the consideration of race and ethnic preferences in college admissions, suggesting that any affirmative action ballot measures are likely to be voted down.
Moving forward, Roger Clegg, president and general counsel of the Center for Equal Opportunity believes that the court’s decision means that colleges in states that have banned racial preferences must follow those laws and other states without bans should reexamine with current plans.
“It also means that colleges in other states must take into account the fact that their continued use of racial preferences, which is unpopular, should consider getting rid of that policy since it may be banned in their states, too,” Clegg adds.
Quite the contrary, says Michael Olivas, director of the Institute for Higher Education Law and Governance at the University of Houston Law Center. “It hurt the choices that Michigan colleges wanted to make, and this violated their academic freedom.”
But it need not be a regressive process, Olivas continues. In Maryland, voters approved resident tuition for the undocumented in a ballot measure, and Colorado voters turned down a Michigan-type measure.
“They are neither good nor bad in and of themselves, except we should not make such important decisions for colleges by this means,” Olivas adds.
The groups that challenged the Michigan affirmative action ban pointed out the basic unfairness of giving preferences in admission to some groups while banning similar treatment of African Americans, Latinos, Native Americans, and women.
“Michigan higher education leaders and most major civil rights groups reinforced our arguments,” says Schaeffer, who provided expert assistance to the groups challenging Michigan’s ban. “However, the judicial system held that voters could impose whatever distinctions they determined to be reasonable.”
Impact on Minority Enrollment
What is not clear is the ruling’s impact on minority enrollment. While the US Supreme Court affirmed Michigan’s constitutional amendment banning race-conscious admissions, states that forbid affirmative action in higher education, like Florida and California, as well as Michigan, have seen a significant drop in the enrollment of black and Hispanic students.
In April 2014, The New York Times published an article examining how minorities have fared in states with affirmative action bans, including California, Florida, and Michigan. At UC Berkeley and UCLA in California, for example, the graphs showed that 49% of the state’s college-aged residents are Hispanic, though only 11% and 17% of freshmen are Hispanic at those two schools, respectively.
In Florida, 27% of the state’s college-aged residents are Hispanic at Florida State and the University of Florida, yet both universities showed that only 18% of their freshmen was Hispanic.
While the decision didn’t address the constitutionality of race-conscious admission policies, Justice Sotomayor cited student-demographic data as proof that the ban, which went into effect in December 2006, has adversely affected minority enrollment and diversity at the University of Michigan (UM) in Ann Arbor.
“A white graduate of a public Michigan university who wishes to pass his historical privilege on to his children may freely lobby the board of that university in favor of an expanded legacy admissions policy,” she wrote. “Whereas a black Michigander who was denied the opportunity to attend that very university cannot lobby the board in favor of a policy that might give his children a chance that he never had and that they might never have absent that policy.”
According to the policy brief, “Restructuring Higher Education Opportunity?: African American Degree Attainment after Michigan’s Ban on Affirmative Action,” which Justice Sotomayor cited in her dissenting opinion, the proportion of African Americans who obtained a bachelor’s degree at UM dropped by about one-third after the ban on race-conscious admissions went into effect.
Additionally, The New York Times article revealed that the enrollment of black freshmen at UM between 2006 and 2011 dropped from 7% to 5%, despite the number of black college-aged persons in Michigan increasing from 16% to 19%.
While Justice Sotomayor argued that the ban on race-conscious admissions might have had a negative effect on the number of minority students who enrolled, it has not necessarily stopped colleges from looking at alternative procedures to maintain and promote diversity.
A 2012 study by The Century Foundation, a nonpartisan group, found that at seven of 10 major schools where racial preferences could not be used, race-neutral alternatives helped maintain or even raise minority representation.
For example, Texas’s Top Ten Percent Rule—which guarantees admission to the University of Texas (or any state-funded university) to any high school senior graduating in the top 10% of his or her class—helps ensure diverse college student bodies. A combination of measures, including affirmative action based on class, increasing financial grants, and de-emphasizing standardized tests are just a few promising race-neutral options that have allowed minority enrollment to return to pre-ban levels.
“From FairTest’s perspectives, all these initiatives are worthy of consideration,” says Schaeffer. “But none fully replace affirmative action as a tool for addressing past and present discrimination.”
Fisher vs. University of Texas at Austin
Last June, the justices had a chance to make another big statement on affirmative action with its decision in Fisher vs. University of Texas at Austin (UT Austin). The case was filed by Abigail Fisher, a young woman from Texas who applied to the university but was rejected. Fisher, who is white, then filed a lawsuit, arguing that she had been a victim of racial discrimination because minority students with less impressive credentials than hers had been admitted.
The Supreme Court did not immediately decide the fate of Fisher. Instead, the justices voted 7-1 to return the case to the lower courts to determine whether the use of race is “necessary” and have “the ultimate burden of demonstrating, before turning to racial classifications, that available, workable race-neutral alternatives do not suffice.”
“Strict scrutiny must not be strict in theory but feeble in fact,” Justice Kennedy wrote. “The reviewing court must ultimately be satisfied that no workable race-neutral alternatives would produce the educational benefits of diversity.”
Only Justice Ginsburg dissented in the decision to send the case back.
“I would not return this case for a second look,” Ginsburg wrote in her dissent. “The University reached the reasonable, good-faith judgment that supposedly race-neutral initiatives were insufficient to achieve, in appropriate measure, the educational benefits of student-body diversity.”
The ruling upheld Gratz v. Bollinger and Grutter v. Bollinger, two cases fundamental in defining universities’ rights to consider race as an admissions factor. Though many argue that the court’s decision preserves the principle that affirmative action is permissible in some circumstances. That, according to Olivas, depends upon the narrow tailoring that the remand requires.
“UT Austin is allowed to use race (by Grutter), and the top ten percent plan—which I helped write—is race-neutral, so Fisher was not harmed. She was simply not admissible,” Olivas argues. “The plan allows in over 50% whites, in a state where whites are only 30% of the [high school] population. It does not harm them, nor does the modest affirmative action policy.”
It can be said both decisions illustrate the court’s skepticism about race-conscious government programs. The Schuette v. Coalition to Defend Affirmative Action ruling alone took five separate opinions totaling 102 pages written over six months—a sign of how divided the court remains on the issue and the role the judiciary should play in protecting racial and ethnic minorities.
To most, the recent Supreme Court’s decision upholding Michigan’s affirmative action ban was far from a shock, but many believe the ruling could symbolize a steady march to the end of the use of race in higher education.
But, for now, the most recent Supreme Court decision only impacts public colleges and universities in the state of Michigan. The voter-approved Constitutional amendment clearly bars them from considering race, gender, ethnicity, or national origin in admissions and related decisions.
“For higher education institutions in other jurisdictions that are not operating under similar bans [some states, such as California, have their own prohibitions], affirmative action policies that comply with the court’s Hopwood [v. Texas] and Grutter decisions remain legally permissible,” says Schaeffer. “However, many who closely observe the Court believe that further restrictions on affirmative action are likely as the result of Fisher and other cases, currently moving through the judicial system.”
Terah Shelton Harris is a freelance writer based in Alabama.
Nurses are at a greater risk of back pain than many other occupations. According to a study by the University of Alberta’s faculty of rehabilitation medicine, 65% of orthopedic nurses and 58% of ICU nurses develop debilitating lower back pain at some point in their careers. Due to the nature of the job, it isn’t hard to see why. Nurses often work with poor posture (repetitively leaning and bending over bedridden patients, lifting and transferring heavy and slumped patients), so it’s no surprise that they have the greatest incidence of back pain.
Todd Sinett, a chiropractor and author of The Truth about Back Pain, says back pain sends more patients to the doctor than every other condition except the common cold and is the leading cause of job disability in people under 45.
“Nurses often suffer from back pain more than other professions because they are susceptible to many triggers that can cause back pain,” he says. “Standing for long hours, reaching over patients, and doing heavy lifting are all contributing factors to structural causes of back pain.”
He adds that back pain affects all ages and demographic groups, so all nurses, not just minority nurses, are equally at risk of getting lower back pain.
Michael Ho, a chiropractor and acupuncturist, adds that nurses’ high stress levels often causes chronic muscle fatigue and strain, which can lead to the eventual hardening of muscles, loss of range of motion, and early degeneration of the lower back structure.
“The subluxation of spinal joints over time causes premature degeneration of the facet joints and spinal disc,” he says. “Over time, degeneration of the disc causes herniation and irritation of spinal nerves. This, with the combination of tight muscles, joint restrictions, disc herniation, and nerve impingement can cause local back pain as well as radiating hip and leg pain.”
Poor dietary practices are the most overlooked causes of back pain, Sinett adds. Nurses tend to have long shifts that can make eating right difficult. Diets filled with caffeine and sugar elevate the body’s cortisol levels. Elevated cortisol levels often raise the inflammatory factors in the body, which can result in back pain.
“We are what we eat, so make sure that you are eating good, healthy, wholesome foods,” he says. “Plan ahead and make healthier eating choices [and] your back will thank you.”
Avoid Back Pain During Long Shifts
Even though back pain is quite common, it doesn’t make it normal. Sadly, some nurses have resigned themselves to living with some level of discomfort. But they don’t have to.
David Simpson, a chiropractor and owner of Gotham Healing Arts, believes a few simple changes such as proper posture and body usage may prevent nurses from sustaining injuries. He recommends the following tips for nurses:
Don’t slouch. The lower back or lumbar spine joints are like moist sponges, he says. Healthy joints contain a lot of fluid, and sitting for an hour squeezes most of the water out of this spongy tissue; quicker if you slouch. Without the water, your joints become brittle and susceptible to wear and tear.
Lift with your legs. “In spite of this advice, most lift improperly,” says Simpson. “Most people bend their knees first, but only for about 30 degrees, then they involve their back, and they start to bend at the waist, especially if the object is not directly under them.” Ideally, the back should never round like that of a low-humped camel. This body position puts pressure on the spinal joints, which leads to damage over time and will eventually turn into pain at some point in your life, he adds.
Erect, good posture. At best it is a bad habit, but there are practical biomechanical reasons for standing up straight, Simpson says. Proper standing helps you keep your normal spinal curves, reduces the compressive forces on those joints, and reduces the likelihood of painful episodes of back pain.
Sinett says stretching is one of the best back-pain-relieving exercises and suggests nurses stretch at least for 3 sets at 12 petitions each day. “Stand up straight, raise both arms above your head, and gently lean back approximately 35 degrees,” he says. “Extending the spine will counteract the forward hunch that nurses do by sitting in front of the computer and being hunched over patients.”
Overall, Ho stresses the importance of nurses taking care of themselves first. He recommends all nurses exercise, rest, and eat properly every day, and more importantly, get the treatment they need to relieve any minor problems in their back before it gets more severe and becomes more chronic in nature.
“It’s important to remember that it’s better to get rid of a mild back problem before it becomes a serious degenerative problem that can lead to disability,” he says.
Terah Shelton Harris is a freelance writer based in Alabama.
Since the first identification of AIDS in 1981, and the eventual discovery of HIV two years later, HIV/AIDS has become a dominant global public health priority with a wide range of humanitarian and economic implications.
According to the World Health Organization, nearly 70 million people have been infected with the HIV virus since the beginning of the epidemic, and approximately 35 million people have died of AIDS since the 1980’s. The Centers for Disease Control (CDC) estimates that there are approximately 1.3 million people in the United States who are infected with HIV.
While those statistics are alarming, it is important to acknowledge how far we have come in the fight against HIV/AIDS in the last three decades. “For those of us that have worked in HIV/AIDS over the past 20 years it’s almost impossible to imagine where we are now,” says Liza Solomon, MHS, DrPH, an HIV/AIDS public policy leader and a principal associate at Abt Associates. “Treatments were rudimentary and there seemed to be very little that medicine could offer.”
Since that time, new drugs have become available, medications have improved, side effects have lessened, and death rates have declined. Even more, AVERT, an international HIV and AIDS charity, estimates that in 2008 alone, over $15 billion dollars was spent on HIV and AIDS compared to $300 million dollars spent in 1996. This money from donor governments, low-income and middle-income country governments, the private sector, and individuals has helped fund research and treatments as well as fuel scientific advances in the fight against HIV/AIDS.
Scott Kim, MD, Medical Director for HIV Medicine at AltaMed Health Services, believes that new developments not only attest to the tremendous importance of government-funded basic science research, visionary pharmaceutical leaders, strong public advocates, and a federal government committed to extending care to all HIV-infected patients, but confirms that we have gone from a disease with a life expectancy that was barely a few years to a chronic disease with a long life expectancy.
Simply put, an HIV/AIDS diagnosis is no longer the automatic death sentence it was once considered.
“We can now speak of HIV/AIDS as a chronic disease, and for the first time, researchers and public health practitioners talk about an AIDS-free world,” Solomon says. “It is clearly not here now, but there is the sense that perhaps we can hope to achieve that within the foreseeable future.”
Research and Medications
Medications have changed significantly since combination antiretroviral drugs (ARVs) were first available in 1996. The development of ARVs—medications for the treatment of infection by retroviruses like HIV—has resulted in greater control of the disease and a prolonged, better quality of life for those infected.
Recent clinical studies have proved conclusively that individuals who are on effective antiretroviral treatments are significantly less likely to transmit HIV to an uninfected partner. The clinical trial called HPTN 052 (HIV Prevention Trials Network) showed a 96% reduction in transmission from an individual infected with HIV to their uninfected partner.
JoAnn D. Kuruc, MSN, RN, a program manager in the AIDS Clinical Trials Unit at the University of North Carolina at Chapel Hill, believes research related to HIV and treatments for the disease is responsible for the great strides achieved in the development of medications over the last 30 years.
In the past, HIV drug treatments consisted of a large number of pills taken at multiple points throughout a day. “Not only was it challenging to remember to take the pills, but the sheer volume that you had to swallow was an obstacle to overcome,” says Kuruc.
Additionally, side effects (nausea, vomiting, and diarrhea) associated with early medications were themselves a barrier to adherence and compliance. Kim says toxicities associated with frequent dosing included lipodystrophy, kidney stones, hepatic inflammation, diarrhea, and nausea.
Today, treatments have improved greatly, resulting in minimal side effects and requiring fewer pills—and in some cases—just one pill per day.
“Research in the drug development has led to more options, allowing individuals with severe side effects or drug resistance to switch to different medication regimens,” Kuruc says. “Years ago, there was only one class of drug available to treat a person with HIV infection, but now this has increased to five different mechanisms or classes of drugs.”
Kali Lindsey, Director of Legislative and Public Affairs at National Minority AIDS Council, reports a swarm of new biomedical interventions resulting from investment in research—including scientific advances such as treatment as prevention and pre-exposure prophylaxis—that have provided exciting new tools to combat the spread of HIV.
The CDC defines pre-exposure prophylaxis, or PrEP, as a new HIV prevention method in which people who do not have HIV infection take a pill daily to reduce their risk of becoming infected.
“Pre-exposure prophylaxis is the use of an antiretroviral drug in HIV-negative individuals who engage in behaviors that place them at heightened risk for acquiring HIV,” says Amesh Adalja, MD, FACP, an infectious diseases physician at the University of Pittsburgh Medical Center. “By taking anti-HIV medications prior to exposure, they substantially decrease the risk of acquiring HIV if they are exposed.”
The pill contains medicines that prevent HIV from making a new virus as it enters the body and helps keep the virus from establishing a permanent infection. If used effectively and by persons at high risk, PrEP has been shown to reduce the risk of HIV infection.
According to the CDC, in July 2011, researchers announced the results of the TDF2 study that found a once-daily tablet containing tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) reduced the risk of acquiring HIV infection by roughly 62% overall in the study population of uninfected, heterosexual men and women. The Partners PrEP study also found that daily doses of TDF/FTC or daily doses of tenofovir alone reduced HIV transmission among heterosexual serodiscordant couples (in which one partner is infected with HIV and the other is not) by 73% and 62%, respectively.
CDC is also evaluating PrEP’s effectiveness in preventing HIV infection among individuals exposed to HIV through injecting drugs, but those results are not yet available.
Eradicating HIV Reservoirs
While drug treatment has not provided an actual cure, research is now honing in on ways to eradicate the remaining reservoirs of HIV from infected individuals whose HIV is fully suppressed by therapy. Research focused on eradication is still in the early phases and much of the analysis and data to date has been obtained from ex vivo studies, as well as a few Phase I clinical trials, Kuruc explains.
Highly active antiretroviral therapy (HAART) is capable of suppressing HIV viral replication in the body; however, it is incapable of eradicating the virus. When HAART is stopped, viral replication reemerges. The viral rebound stems from virus that exists in latent reservoirs. There may be distinct sites throughout the body that function as “latent cell reservoirs,” perhaps in the lymphoid tissue, the gastrointestinal tract, or the central nervous system. Virus is also known to persist in CD4 cells (T cells) that are in the resting, or quiescent state, found either in the blood or in tissue.
“One of the first steps in developing a cure involves the identification, activation, and elimination of the resting CD4 cells from the reservoir and getting the virus released,” Kuruc says. “Once expressed from the cells, the patient’s current HAART would inhibit new infection from occurring.”
Kuruc adds that scientists are looking at various ways to express the virus from the latently infected cells. Stimulating key areas of the cell that are known to play integral parts in HIV storage (chromatin) or transcription (P-TEFb, or the NF-kB proteins) have been the focus of much of this research.
One approach proposed to stimulate HIV-1 expression is the use of a histone deacetylase (HDAC) inhibitor. Suberoylanilide hydroxamic acid (SAHA), or Vorinostat, is one HDAC inhibitor that is getting much attention in this field. In 2006, Vorinostat was approved by the Food and Drug Administration for the treatment of cutaneous T-cell lymphoma. A recent ex vivo study confirmed the ability of the drug to disrupt latently infected cells. David Margolis at UNC, in a proof of concept study, demonstrated significant increase in the expression of viral RNA when SAHA was given in a clinical trial.
“Although this was an enormous breakthrough, research still needs to determine: if the reservoirs are depleted; if the cells die after releasing the virus; and if the drug is safe to take for an extended period of time without any adverse effects,” Kuruc says.
Kuruc explains that once the virus is released by the latent cell, eradication of the virus and obliteration of the cells remain a concern. Recent ex vivo research illustrated that viral expression from the latent cell may not lead to cell death. Thus, it may be necessary to combine the activation and expression of the virus from the latent cell (SAHA) with other therapies.
“Few scientific and medical challenges are as daunting and complex as the attempts to develop a cure for HIV infection,” says Kuruc. “The progress made so far in understanding the complex biology of HIV infection and the stunning achievements of HAART should give us hope that we can overcome the recognized and the yet-to-be-discovered challenges of persistent, latent HIV infection.”
Vaccines will lead the upcoming fight against HIV, says Robert McNally, PhD, President and CEO of GeoVax, a biotechnology company developing human vaccines for diseases caused by HIV and AIDS.
So far the results have been encouraging. In 2009, Sanofi Pasteur, the vaccines division of Sanofi-Aventis, participated in a preventive vaccine trial that lowered the rate of HIV infection by 31.2%. The trial, involving more than 16,000 adult volunteers in Thailand, demonstrated that an investigational HIV vaccine regimen was safe and modestly effective in preventing HIV infection.
“Albeit modest, the reduction of risk of HIV infection is statistically significant. This is the first concrete evidence, since the discovery of the virus in 1983, that a vaccine against HIV is eventually feasible,” says Michel DeWilde, R&D Senior Vice President for Sanofi Pasteur, in a 2009 press release.
McNally says GeoVax is also at the forefront of this effort, with a substantial scientific lead for an effective preventive vaccine, thanks to the door opened by the Sanofi Pasteur trial. “This glimmer of hope for an effective vaccine has paved the way for biotech companies like GeoVax to gain traction with the next generation of products.”
Currently, McNally reports that human clinical trials for the preventive use of the GeoVax HIV/AIDS vaccine found that their vaccines were well tolerated with no or mild, local and systemic reactions in the majority of trial participants and that 80% of both low and full dose trial participants responded to the vaccine, which stimulated anti-HIV T cells (white blood cells) and antibody responses.
“The goal is to produce a vaccine like the one for polio where large portions of the at-risk population could be vaccinated; thus, over time, the incidence of HIV will decline to the point where the vaccine will hopefully become unnecessary,” he says.
Decades ago, HIV testing initially consisted of a series of blood tests that took several weeks for the results. Now HIV testing has become easier and more accessible with rapid testing where the test results are available within 45 minutes.
“Newer blood testing techniques currently being marketed not only allows for quicker turnaround of test results but is sensitive enough to detect HIV prior to the body developing antibodies to the virus, thus having persons diagnosed in the earliest stages of the disease (known as the acute phase); [and] therefore, allowing individuals to be diagnosed and treated prior to the virus doing severe damage to the immune system,” says Kuruc.
Solomon says that researchers at Abt Associates are working on two different projects with the goal of educating individuals about HIV, making HIV testing available, and linking individuals into care. The first project involves working with minority serving institutions (colleges or universities that serve predominantly minority students) to develop HIV prevention programs for their students.
“The nursing school at Florida International University’s program is designed to train nursing students to be peer educators and provide HIV prevention education while at school,” Solomon says. “The students are a resource to their peers while they are students, and will develop skills regarding HIV testing and prevention that they will utilize in their future role as practicing nurses.”
Abt Associates’ other HIV project involves a large effort to provide HIV testing to minority men who have sex with men and do not know their HIV serostatus. The goal is to identify 3,000 previously undiagnosed HIV positive men and link them into care.
“We are working with community-based organizations and academic institutions throughout the country to implement this three-year testing and linkage program. A critical component of this program is to bring HIV testing to non-traditional settings so that individuals who may not routinely interact with the medical care system have access to testing,” says Solomon.
Patient Protection and Affordable Care Act
While the developments in biomedical research over the last few years has been exciting to witness, nothing is as critical to the fight against the HIV/AIDS epidemic than the passage and now implementation of the Patient Protection and Affordable Care Act (ACA), according to Lindsey.
“The single largest barrier to HIV/AIDS services in this country, whether prevention or care, is lack of access to quality, affordable health care,” says Lindsey. “While not perfect, the ACA will go far to providing such access, both through its insurance exchanges and its Medicaid expansion. Its patient’s bill of rights will also help ensure that people living with HIV or AIDS cannot be discriminated against by insurance companies through rescission or denial of coverage based on preexisting conditions.”
Currently, only about 13% of people living with HIV/AIDS have access to private insurance. What’s more, less than 30% have achieved viral suppression through adherence to a treatment regimen. Another 20% of people living with HIV are not even aware that they carry the virus. Minorities not only have higher rates of infection, but also suffer significantly poorer health outcomes, including increased mortality.
With more than 56,000 new HIV infections in the United States each year, the AIDS epidemic is far from over. And despite better treatments, there is still no cure. Lindsey believes that expanding access to health care is the single most important thing our nation can do to both improve health outcomes for those living with HIV/AIDS while also working to bring an end to the epidemic itself.
“For the first time in over thirty years, it is possible to realistically envision an end to HIV/AIDS. But ending this epidemic will not be easy. It will require bold, visionary leadership and the commitment of all of us to successfully translate the promise of this moment into a world without HIV/AIDS. Science and research have given us powerful tools; now we must decide to act.”