The recent news of elite Olympic athletes prioritizing their mental health and their own physical wellness over their sport has focused a national spotlight on the complexities and the prevalence of mental health struggles. And while seeing people who are suffering from mental health issues is difficult, the athletes’ public struggles have opened a door that allows healthcare providers to raise the issue with patients and loved ones.
In some minority communities, mental health struggles remain taboo to discuss openly. People who are experiencing symptoms of illness such as depression, anxiety, or obsessive-compulsive disorder, or even life-threatening suicidal thoughts face a stigma that prevents them from even seeking care. When the issues are discussed, access to affordable and high-quality mental health providers can be a barrier to getting help, as can lack of insurance and any language barriers.
According to the OMH, mental health is a serious and common health issue with approximately 18 percent of the entire U.S. population having a diagnosable mental illness within any given year. Of that percentage, only 43 percent of people who need mental health care receive treatment or counseling. For minority mental health needs, the numbers are even more concerning. While 48 percent of whites receive care, only 31 percent of Blacks and Hispanics do. And statistics for Asians were even lower at just 22 percent receiving needed mental health services. Disparities in mental health care can lead to lack of treatment or ineffective treatment.
For most people, mental health treatment is effective and improves their quality of life. Whether people choose medication (psychiatric nurse practitioners are especially), talk therapy, or a combination of both, getting help can make symptoms abate significantly. In more transient cases of mental illness, for example depressive symptoms caused by a major life change, treatment can get someone back to feeling like their old selves and can improve their resiliency moving forward.
These care disparities have lasting impact. According to the American Psychiatric Association minority and white populations have similar rates of mental illness, with white populations being slightly higher in some instances. But when Black and Hispanic people have depression, for example, the effects are more persistent. And systemic racism plays a role in proper care. The report states that “Racial/ethnic minority youth with behavioral health issues are more readily referred to the juvenile justice system than to specialty primary care, compared with white youth.” If mental health needs aren’t addressed and youth don’t receive proper care, that can lead to a disciplinary cycle that impedes educational and employment opportunities.
As a healthcare provider, keeping conversations about minority mental health open and ongoing with patients and having easily accessible resources available can make all the difference to helping patients get the care they need. From understanding the different types of mental health professionals and what they do to addressing medications or alternative therapies in a comprehensive treatment approach can help patients understand the range of help available. And with a recent uptick in the availability and acceptance of virtual therapy appointments, accessing care is somewhat easier for people.
Raising awareness and broaching the topic about minority mental health is important to removing the stigma and helping people move toward care that works for them.
The Future of Nursing 2020–2030 Charting a Path to Achieve Health Equity report, issued by the National Academy of Medicine Committee on the Future of Nursing 2020-2030, is addressing topics that will impact the nursing industry in the coming years. Sponsored by the Robert Wood Johnson Foundation, the report examined issues and topics foremost on the minds of those in the industry and brought forward recommendations to help guide important changes including scope of practice regulations, health and well-being of nurses, and better payment models.
Currently, 27 states restrict the autonomous practice of nurse practitioners, despite the nurses having the education and training to practice in such a manner. With advocates working to remove these remaining restrictions, Cunningham says the progress is happening, but slow. “Each state has regulations that govern advanced practice registered nurse scope of practice,” she says. “When we say APRN, there are really four groups of nurses we are talking about. Most commonly it is nurse practitioners, but also includes certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.” The report also looks at the institutional barriers for other nurses, including registered nurses (RNs) and licensed practical nurses (LPNs), to allow them to practice to the top of their education and training.
The restrictions have been loosening ever so slowly. “There has been considerable progress in this area, I will says that,” says Cunningham, “but it has taken a couple of decades. There are 27 states that don’t allow APRNs in those states to do things they are educationally prepared to do. Examples include prescribing medicine, diagnosing a patient, and providing treatment independent of a physician. Even when it is allowed, there are administrative burdens. It’s not a very nimble system.”
Increasing Access to High-quality Care
The Future of Nursing report did a lot of research on the elements and regulations that limit access to care in general and to the high-quality care offered by APRNs, says Cunningham. And while opponents say that non-physician providers are less likely to provide high-quality care because they don’t have the same training or clinical experience, Cunningham disagrees saying the data doesn’t show that quality of patient care is reduced. “Arguments are made against scope of practice being relaxed really are not keeping the patient at the center of the discussion and it should be at the center of the discussion,” she says. “APRNs bring specific skills and knowledge. In states with restrictions, patients have less access to primary care.”
What autonomous practice does, she says, is significantly increase access to care, especially in rural and underserved communities where physician care may be scarce or difficult to access. APRNs aren’t looking to practice brain surgery, says Cunningham. What they will do, and are trained to do, is provide high-quality primary care services.
At various times, changes to these rules have proven to be especially effective. Interestingly, Cunningham says the COVID-19 pandemic inspired eight states to suspend scope of practice restrictions as a key strategy to manage the pandemic care in the interests of the public and when the health of the nation was at risk. The strategy worked so well, some of those states have moved to make those changes permanent, she says. In 2016 APRNs also saw expanded practice regulations when the Comprehensive Addiction and Recovery Act allowed nurse practitioners to prescribe buprenorphine, a drug used to manage addiction, says Cunningham. The bill increased access to care in rural areas and helped keep patients with substance use disorder safe. When federal authority supersedes state regulations (such as this instance), says Cunningham, that should be looked at more closely as it gives evidence of how loosening regulations can protect public health.
Reducing Administrative Burden
Granting nurses autonomy also helps organizations stay nimble, says Cunningham. It allows them to move nurses where they are needed during times of crisis like COVID, without the extensive forms and processes typically required. COVID, says Cunningham, showed how being able to move nurses to different areas to treat patients or to cover for nurses who were called to a different area, was essential to patient health.
And while the immediate outcomes look positive, Cunningham says the data that emerges from the pandemic will tell a more complete story. “Reductions in mortality especially will be the kind of outcomes data that will be compelling to make this permanent,” she says. “The current recommendation is that all changes that were adopted in response to COVID should be made permanent by 2022. That’s a strong recommendation coming out of the report, but there’s good data to show this is a strong direction.”
Improving Care Access Through the Workforce
And the sheer number of working APRNs would offer a significant boost to primary care efforts where they are especially needed such as in rural or low-income areas. “For counties that are deficient in the number of primary care providers, meeting the needs of the population is important,” says Cunningham. “It creates more equitable communities.”
To remain focused on the patient, the report’s findings show many ways APRNs are trained and educated to improve patient outcomes. “We should be focused on the health of the nation,” says Cunningham. “The current situation is antiquated given the health concerns of the nation. It is not focused on the patient. We need to ask, ‘How do we improve the health of the nation?'”
The report finds removing restrictions also has other benefits. “The clinical piece of this,” says Cunningham, “is that it would be extremely empowering for nurses to do all the things they are prepared to do.”
Although Henderson says community health is covered in nursing education, the standards in place don’t reveal how often or how well community health and public health nursing competencies are covered in individual programs. Sometimes it’s just as one course or an elective course.
“We argue in the report that these areas of community health, public health, social determinants, and population health need to be comprehensively threaded throughout the curriculum,” Henderson says, “so it’s not an add-on. It’s baked in fundamentally into everything we do in our nursing practice.” As nursing education changes, schools and students will begin to collaborate more across disciplines.
Changing how nursing is taught and how students gain experience means more nursing students need to spend time working in various community settings. Nurses learn best through experiential learning, says Henderson, especially with community-based social issues. “Put students in the community and put students in settings where they are finding experts,” he says. And when students find the specialty that appeals to them, letting nurses deviate from the typical path will get them started quickly. “Telling nurses they need one to two years of med-surge under their belts is unnecessary,” says Henderson, “and we have to stop perpetuating that.”
Experience in the Right Settings
For nurses who know they aren’t interested in a med-surge path, those two years could be better spent gaining targeted skills. Immersing themselves with on-site community health work strengthens their commitment to the role.
“Without that kind of immersion, you are reinforcing stereotypes because what you read is not contextualized by what happens,” says Henderson. For instance, he says, nurses may read that “because you’re African American, you’re more at risk for ‘A'” or “because you live in this community, you’re more at risk for ‘Y.'” It’s not contextualized as to why any health impacts are happening, he says.
Nursing education depends on nurses understanding the socioeconomic influences of disease. Henderson says nurses who are immersed in a community may see that patients lack access to green spaces to exercise or may not feel safe in their neighborhood. They may see patients don’t have easy and affordable access to healthy foods.
“The context is the patients don’t live in a community that sets them up to eat healthy, exercise, and take care of themselves to reduce the risk for something like diabetes,” he says. “It has nothing to do with them being African American and has to do more with community conditions. You have to see that and experience it.” Henderson, whose own career was deeply influenced by his early work in community health, says nurses can’t address the health needs in a community without addressing the social needs. “The community is the teacher,” he says. “We go into a community with preconceived notions. But patient-centered care is community-centered care.”
Reading something in a book gives nursing students a theoretical background, but going out into the community, often sparks a passion about uncovering a solution to the root causes of some of the issues patients are facing. “There are downstream effects of that,” says Henderson.
Shift in Nursing Education
As nursing education changes to a community focus, nursing students will need faculty leaders who can talk to them about how to change approaches to tasks like screenings.
“One of the biggest hurdles is getting students out of the mindset of I have to get out to do a specific task,” he says. “It’s about what kinds of conversations are you having during the screening when you’re checking someone’s eyes. Are you learning about their home life? In community public health, you’re exploring the issues that are surrounding their lives and the issues that impact their wellness so you can focus on intervention and prevention.” Nursing students have to be taught about it in their classroom work so they can merge their knowledge and hands-on experience to examine the root causes of illness differently.
Workforce Preparation and Qualification
People want to work in the settings they are exposed to, says Henderson, so nursing students should work in settings that let them see a nurse’s role in schools, correctional facilities, public libraries, preschools, community health centers, homeless shelters, and public housing, and learn from the experts who work in those settings.
Sometimes, says Henderson, the best professional to explain those topics are the ones on the front lines, like the social workers or school counselors who see people for issues that might not be related to an immediate health concern, but that most certainly impact health. With a chronic nursing faculty shortage, allowing educators who don’t have a nursing degree might help fill some gaps in staffing and course content, he says.
Henderson says the Future of Nursing Report calls for including curriculum topics around nursing policy, structural racism, and health equity to help nurses over their entire careers.
And, Henderson says, the report also advocates for nursing schools to address racism in society and within its own professional structures. “Nursing as a profession for a long time hasn’t addressed how racism has impacted our own profession,” says Henderson. “We say in this report we want to go out and do all this good and improve health equity, but we still have to clean our own house a little bit and examine how nurses of color are still discriminated against within our own schools and our own workplaces. And we talk about that in this report and that’s crucial.”
Higher education also must take a new look at its environment. “Schools of nursing need to acknowledge the impact of structural racism has within their own institution and how that disadvantages nursing students and faculty of color,” says Henderson. “That means critical examination of curriculum policy practices, curriculum strategies, and how they allocate resources. Who has the power and what do those dynamics look like?”
Diversity and Equity
A diverse, inclusive, and equitable nursing environment needs to be clearly defined. “Many people say diversity and think just by being diverse, we are equitable,” Henderson says. “But that’s not the case. You can be diverse but not equitable. You can have diverse people at the table, but it’s not equitable if they aren’t valued and their voices aren’t heard.” Lots of groups are recognizing that, says Henderson, but now they have to decide how to act on it and raise awareness about it.
Continually advocating for change in nursing and working to keep uncomfortable conversations ongoing and productive encompasses topics both new and historic, says Henderson, and is the focus of the next decades of nursing education. “It’s about who is having these conversations,” he says. “If we keep having the same people at the table, we won’t get far.”
Nacole Riccaboni, MSN, APRN, AGAC-NP, started to document her nursing journey years ago as a way to track her experiences as she began as a nursing student on a challenging career path. As she progressed, gaining advanced degrees and nursing responsibility along the way, she publicized it all on NurseNacole.com where she now offers daily nursing tips and a supportive environment for other nurses. Minority Nurse caught up with Nacole to ask her about her career, inspirations, and her life as a nurse.
Why did you want to be a nurse?
I wanted to help the people within my community. I was involved in a car accident (as a child), and the interaction with the nurse changed my trajectory towards a career in nursing. Since that encounter, I’ve always wanted to be a nurse. I started with an ASN (at a local community college), proceeded to get my BSN, then MSN, and now I’m working on my DNP. Nursing is an ever-evolving profession with many opportunities, I love what (nursing) has given me knowledge-wise, and I love caring for the people in my community. The act of wanting to help people in their time of need resonated with as a child, and I wanted to be that person to others when I grew up. The medical field always caught my attention, but that singular experience solidified what I needed to do and what I needed to work toward in my career.
Your nursing journey was not a straight line, but it seems like that helped you prepare both professionally and psychologically for the rigors of nursing. Can you talk a little about your path from a progressive care unit to the ICU?
As a new nurse, I started on a progressive care unit (PCU). It was a powerful experience. I had patients with various diseases and symptoms. Nursing leadership assisted me in cultivating the proper critical-thinking and time-management skills to manage many things all at once. After two years, I moved to the intensive care unit (ICU) and used those very skills to care for the most acute patient populations. I faced anxiety and the stress linked to caring and being responsible for vulnerable individuals throughout my journey. Nursing can be stressful, but I had a good support system (both professional and psychologically) that helped me through these many issues. From a medication error to the general emotional burden of healthcare itself, it indeed was a journey that I look back often and continue to respect and use the skills obtained in my journey.
How important was it for you to continue your education and receive an advanced degree and several certifications? What benefits do you see from continuing your education?
It was imperative to me that I continued my education journey. Yes, I’m one of those people who say, “knowledge is power.” I believe knowledge and education are keys that will open the doors for opportunities. I don’t consider education to simply be a set of courses and exams. With each certification, each class, and each degree I obtained came with many hours of knowledge and experiences I use to as I move forward professionally. I know formal education gets a bad rap for being expensive, and some people have negative experiences in such environments. But, I did my research and made sure the exchange (knowledge for funds) would benefit me in my professional journey and would be a good investment. I wouldn’t continue for the sake of continuing or for acquiring ‘alphabet soup’ (all the titles behind my name). I seek an education because I value the wisdom obtained during the process. I use this knowledge to help my community and my loved ones.
Can you talk a little about how you found the goal-setting structure that works for you?
I have an odd goal-setting structure in that, I have daily goals (micro-goals, is what I call them). I learned that if I don’t set daily goals, my bigger goals would not be accomplished. Life is about the small choices we make. Everyone talks about the big decisions–going to college or changing careers (and those events are essential). But those big moves can’t exist without the smaller choices being made and built upon. In school, you study each day to pass the exam, then pass the class, so you graduate and achieve your goal of graduation. Bigger goals overwhelmed me as a teenager, so I reprogrammed my mind to only focus on smaller moves and tinier bits. When I started nursing school, the idea of being a nurse was out of this world. Why did I think I deserved to be a nurse? Could I do this? Am I even smart enough to do this? The anxiety would wash over me, and it would make me want to give up. So instead, when I wake up, I have a post-it note of things I needed to do that day. Either reading a chapter on cardiovascular disease or cleaning the kitchen all builds onto and into something bigger. It’s one step of many, and I purposely focus only on one step at a time, so my anxiety isn’t triggered into obsessing over the larger picture.
What led you to begin your NurseNacole blog and YouTube?
As a nursing student, I figured I’d fail and rather spectacularly. I was terrible at math and wasn’t a good student (academically) in high school. I just thought I’d track my journey in video form as a way to look back and reflect. Not sure why someone would want to look back on a possible failure in their life, but that’s me for you, haha. But that’s what I did. Each week or so, I’d go into my bathroom and record my nursing school journey. I didn’t know how the journey would end up, but I knew I wanted to track it in some way (perhaps out of curiosity of the unknown). Fast forward, I graduated, and now I’m an acute care nurse practitioner, and I’m trying to post when I can. Although I’m now married with two kids (three kids in a month) – recording is more difficult as my house is nothing but noises! But I’m still active on social media, and I post when I can and provide daily nursing tips on my blog (www.nursenacole.com).
How has the response to NurseNacole.com been? What are nurses telling you?
The responses have been supportive and fantastic, although the internet has its dark sides as well. I focus my energy and time on interacting with only supportive people and providing advice and tips to these said individuals who seek support from me or the nursing community in general. As a black female in the medical field, I’ve had my fair share of racism and microaggressions. Luckily, online, I control (to a certain degree) what I read and who I allow into my little online worlds. I try to focus on what will enable me to grow and develop and less time on people who tarnish and injure my self-esteem and mindset. Most nurses are fantastic human beings, though, so the ability for me to maintain my perspective is somewhat uncomplicated. I don’t feed the monster, so to speak, nor do I allow myself to be drawn into certain encounters to preserve who I am and my mental health.
What makes you so passionate about nursing?
Someone helped me when I was young, and that experience was powerful. I want people to feel support in their weakest moment. My husband had a heart attack that required cardiothoracic surgery at a young age. I myself had a C-section that rocked my birthing plan and mindset at the last minute, and I also had a same-day abdominal surgery I wasn’t planning for. Life is unpredictable, and in those moments in the hospital, we all deserve someone who understands our fragility and assists us throughout the entire physiological and emotional healing process. I’m passionate because my family members and I have been there, and we know how important it is to be present and simply help those in need. All medications and monitors aside, nurses are healthcare, and I wanted to be a part of that world and impact the profession.
What’s next for you?
I’m finishing up my DNP. I recently completed my MBA. My goal is to work towards opening my homeless shelter or community clinic. I feel my community needs more resources like this, and I want to use my knowledge base in this regard.
As rates of COVID-19 infections continue to decrease and rates of vaccinations continue to increase, nurses will hopefully have a summer that gives them time to recharge and rest.
If you’re able to take some time to rest and recharge over the next couple of months, you’ll want to think of the best ways to take advantage of time that will help you. You’re likely still reeling from a year of work levels and stress that you probably hadn’t experienced before. Warmer weather and longer days lend themselves naturally to inviting less rushing, and more time to do what is good for you.
Here are a few ideas to get you thinking about how to feed your soul and start to recover from 2020.
Start with Gratitude
Today is Memorial Day and honoring those who have given their lives for our country inspires a deep well of gratitude. If you or a loved one has served the nation through military service, you deserve enormous thanks for all your sacrifice. And for anyone who has lost a loved one, the nation will never forget their bravery and dedication to defending the freedom we all enjoy.
Rest, Rest, Rest
Sleep is important for every part of your body, but when you’re under immense stress, it’s often hard to come by. If you have trouble sleeping, worrying about your sleep difficulties can make it worse. This summer, focus on getting rest. Read a book or listen to your backlog of podcasts in the park or in the cool air conditioning of a library. Binge watch Netflix, meditate, and don’t underestimate the power of a well-timed nap (just keep it short so it doesn’t interfere with your regular sleep).
Change Your Scenery
Several days each week, try to spend some time in nature for restorative mental-health benefits. Take a trip to the ocean or a lake, visit a nearby park or forest, or hike a mountain on a day off. A day trip is great, but even spending a 15-minute break outside can help. Or you can focus on your living space and give it a reboot. A coat of paint in a soothing color, pillows you can sink into, new plants or fresh flowers–all of these small changes can give you a lasting sense of renewal.
When your schedule is so busy that you can’t think straight, trying to plan for one more thing might seem counterintuitive. But making plans to do something you enjoy, like a vacation, a day trip, or a get together with family and friends can give you a real boost. And studies show that taking a vacation can make you a more resilient and better employee. Time to disengage and disconnect from the stresses of work is like pushing a reset button to recharge your energy.
As a nurse, you help other people all day long, but taking a different approach to service makes you feel more connected to your community. Offer help that isn’t related to healthcare–participate in a clean-up day in your neighborhood, plant flowers with a community group, help out in a shelter, cook food for a family in need, walk your neighbor’s dog after their surgery, offer to help distribute groceries at a food pantry, or commit a few hours to a cause you are passionate about. If you have family, get them involved.
The pandemic isn’t over and flare ups are likely to happen again. If you’re able to hit pause this summer, even for an afternoon, the benefits can help recharge your mental and physical health–and you’ll enjoy yourself in the process.