There are people who are not satisfied with the status quo in their careers and instead help shape their vocations. They are the leaders in their professions. Nurses are no different. There are many movers and shakers within the nursing ranks, and Minority Nurse selected five such individuals to highlight.
Maria Gomez, RN, MPH
Maria Gomez, the founder, president, and CEO of Mary’s Center, is no stranger to the spotlight. She has won a plethora of awards, perhaps none bigger than the nation’s second-highest civilian honor. Gomez was selected by the White House as one of 18 recipients of the 2012 Presidential Citizens Medal. “It was a great honor coming from a president like Barack Obama because I think it is very clear that his priorities are very much aligned with our priorities at the health center,” says Gomez.
Gomez was also quick to point out the role the center’s staff had in her receiving the award. “I received the medal for the collective and extraordinary work of my colleagues and our partners in the community,” she explains. “My role is to make sure that all the administrative pieces are in place and that there are sufficient funds to meet our goals. The issues that the president is diligently working on, such as health reform, early childhood education, economic equity, and immigration reform, are issues that we are dealing with day in and day out with the community that we serve.”
Gomez, along with a group of nurses and social workers, founded Mary’s Center in 1988 on an initial budget of $250,000. It served 200 participants a year at its inception. “There were so many community needs around the indigent population that were not being met,” she says. The vast majority of patients served was Hispanic women, and at that time, a small cohort of African women, according to Gomez.
Today, the center has an annual budget of $40 million and is projected to serve over 70,000 participants at six sites throughout the District of Columbia and Maryland in 2013. The Hispanic population still makes up about 75% of whom the center serves with an ever increasing number of African Americans. “But depending on the areas we are in, we serve individuals from over 110 countries throughout the world who have become uninsured, either because they lost their jobs or because they just cannot make ends meet,” says Gomez.
The center provides comprehensive primary care, intensive social services, and—in partnership with Briya Public Charter School—it provides family literacy classes and job skills with the goal of keeping families healthy, supported in their communities, and moving up the economic ladder.
“My education at Georgetown School of Nursing made me very conscious of the interconnectedness of health and the environment in which people live,” explains Gomez. “In order to keep people healthy, individuals need to be supported in the basic necessities of life, such as housing, food, and employment, before they can tackle their diabetes. This model of comprehensive care is very hard to establish within a health department where I was working, so that was our motivational factor to start Mary’s Center.”
Edward Halloran, RN, FAAN, PhD
Although he didn’t start out to be a trailblazer, Edward Halloran has traveled the road less taken. In a predominately women’s field, his career spans back almost 50 years and has seen him take on many leadership roles—a result he says goes back to a book he read at the beginning of his career.
“At that time, it was much more common for every other nurse to just want to be a nurse and just do your thing. But this book said if you are not visible no one will ever know that there is such a thing, so that is what started my interest in being more visible,” says Halloran. “It is not so much that I had any personal interest in it as much as if there were ever going to be more men in the field, it had to be because the ones that were there were more visible. That prompted my involvement over the years in the American Assembly for Men in Nursing [AAMN].”
The 2012 recipient of the AAMN’s Lee Cohen award, Halloran was selected to receive the award by the Board of Directors of AAMN to recognize his significant contributions to the organization. “I was kind of surprised by that,” says Halloran. “I was very pleased [and] delighted that the people that I have been working with for the last three or four years acknowledged that.”
Halloran is a long-time member of the American Nurses Association and the American Academy of Nursing as well as the former vice president of the National League for Nursing and past president of the AAMN. He is currently finishing his second term as vice president of the latter organization.
Halloran spent a significant amount of time in hospital management. Among his management positions, he was the coordinator of special studies and projects at the Veterans Administration Hospital in Hines, Illinois; the director of nursing at the Gottlieb Memorial Hospital in Melrose Park, Illinois; and the senior vice president, director of nursing and corporate nurse executive at the University Hospitals in Cleveland, Ohio.
“I thought there might be better opportunities to do more in a public way by writing about things or researching them then on a day-to-day basis performing them,” he says about his decision to move into academia. “I had been there and done that so the academic world offered opportunities to do something different.”
Since 1989, Halloran has been an associate professor of nursing at the University of North Carolina and UNC Hospitals at Chapel Hill. During this time, he taught two years in Hong Kong. From 1991-1992, he was a senior clinical nurse on the research unit at UNC Hospitals. He practiced involved care of patients who volunteered for experimental treatment for chronic illnesses, including cancer, HIV, end-stage renal disease, heart disease, sickle cell anemia, diabetes, and other diseases.
Halloran says the highlights of his career include changing the patient care environment. “That gave me the biggest satisfaction,” he adds. “We improved care, and this is very difficult to do from the inside-out of a major teaching hospital or even a suburban hospital or even a rural hospital.”
Halloran says he feels privileged to be considered a leader in the field of nursing. “In many ways I had … the opportunity to do these things over the years, which has been an honor, and then the second piece is to shape [nursing],” he says. “I have done that through practice and through the teaching I have done.”
Mi Ja Kim, PhD, RN, FRCN, FAAN
Mi Ja Kim is one of four nursing educators in the United States named a 2012 Living Legend by the American Academy of Nursing. Since 1994, the Academy has named just 86 Living Legends in the United States. The award honors the distinguished careers of those who have made notable contributions to nursing practice, research, and education.
Kim is a professor, dean emerita, and the executive director of the Global Health Leadership Office at the University of Illinois at Chicago (UIC), College of Nursing (CON). She is known internationally for her leadership in research, scholar training, administration, and policy development. She has published 116 scientific papers and made over 260 research and scholarly presentations at national and international conferences. She has also secured over $6 million in training and research funding from the National Institutes of Health (NIH) and other sources.
Kim served as the dean of the UIC CON which prides itself as a top 10 college in the country, and was the first nurse to be appointed as the vice chancellor for research and dean of the graduate college at UIC. She earned her PhD in physiology at UIC and—with the exception of one year as a Senior Fulbright Scholar at her alma mater, Yonsei University, in Korea—has spent her whole career at the university. “UIC really has been an incredible place for me,” Kim notes. “It is open to anyone who is accomplished in her/his field, regardless of race or ethnicity.”
Kim’s extensive list of accomplishments only reaffirms her status as a leader in her field. She is an Honorary Fellow of the Royal College of Nursing in the United Kingdom and has received the Lifetime Achievement Award from the Asian American Pacific Islanders Nurses Association. She was one of 18 charter members of the National Institute of Nursing Research’s (NINR) study section as well as a member of the NIH’s National Advisory Council. Kim has been named one of the 100 Most Influential Women in Chicago by the Chicago Tribune; has received the Recognition of Outstanding Contributions to Nursing (The Public Women’s Award), American Nurses Association Minority Fellowship Programs and the Cabinet on Human Rights; two awards for “Meritorious Service in the Fight Against Heart Diseases – Public Policy and Government Relations” from the Chicago Heart Association; and two American Journal of Nursing Book of the Year awards for the Pocket Guide to Nursing Diagnosis and Classification of Nursing Diagnoses: Proceedings of the Fifth National Conference.
Her research interests include pulmonary physiology/nursing, cardiovascular health disparities in Korean Americans, and the quality of nursing doctoral education involving seven countries. Her career documentary has been filmed by the Korean Broadcasting System, which is the largest TV network in Korea—an accolade she finds a high honor.
The students appreciate Kim. She lists two “Golden Apple” awards she received from the junior and senior undergraduate students as highlights of her career. Since 2013, she has been the program director of the Bridges to the Doctorate for Minority Nursing Students, which is funded by the NIH. Eleven PhD students have graduated under this grant and 23 are in the Bridges program currently. This program is one of the largest ones in the country that have educated and trained underrepresented minority nursing students pursuing a doctoral degree.
Omana Simon, DNP, RN, FNP-BC
Omana Simon is an advanced practice nurse who serves as the facility telehealth coordinator at Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, Texas. A native of India, Simon came to the United States in 1983 and began her health care career with a BSN before diligently working her way up the ladder.
Today, she works on the cutting edge of technology. Simon provides primary, secondary, and tertiary prevention strategies to the veteran population. For her efforts, she was the Gold Award winner in 2012 of the Good Samaritan Foundation’s Excellence in Nursing Awards in the Clinical Practice in the Large Hospital category and a recipient of the 2012 Nursing Excellence award in the Advancing and Leading the Profession category for the Texas region.
As the facility telehealth coordinator at MEDVAMC, Simon is responsible for a program that allows vets to receive home telehealth, store and forward, and clinical video telehealth (different modalities of telehealth). “Telehealth in Veterans Affairs is a huge project,” says Simon. “We can provide health care through the use of telehealth devices, video conferencing equipment, or Jabber/MOVI.”
Simon is a true leader in her field, implementing a number of clinical video telehealth programs at her facility, including telepreop, telerehab, and tele-epilepsy, to name a few. These programs connect the veterans in the rural areas where health care is not easily available to a provider at a distant site.
She also oversees telehealth equipment and telehealth programs. “I never thought when I went into nursing I would be on the forefront providing care to the patients using telehealth technology,” says Simon.
Under her direction, the home telehealth program at MEDVAMC received three hospital-wide recognitions. “She is very hard working, very intelligent, and very insightful,” says Nicholas Masozera, MD, the primary care director atMEDVAMC.
For her part, Simon says she gets her inspiration from the veterans she serves. “It is truly an honor to serve the nation’s heroes by providing exceptional 21st century health care that improves their health and well-being,” she notes. Simon exemplifies excellence in her role as a family nurse practitioner as well as a mentor and teacher of future caregivers. Simon upholds the tradition of nursing by being a caring, compassionate nurse who settles for nothing but health care excellence for veterans and the community she serves.
Ora Strickland, PhD, RN, FAAN
Ora Strickland is a nationally recognized leader in women’s health, minority health, and nursing measurement. Not only has Strickland won nine American Journal of Nursing Book of the Year awards, but she was also the first person to hold an endowed professorship in the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Georgia. Formerly a professor at Emory, Strickland is now the dean and a professor at the College of Nursing and Health Sciences at Florida International University in Miami.
Strickland began her writing career early. “Writing is storytelling but on paper. If you are excellent at writing, your work will last a long time; its imprint will be longer,” notes Strickland. “You can build and extend on knowledge and present problems and their solutions in new and unique ways.”
Strickland says she recognized that she could write textbooks when she was a student herself. “You can blaze trails [writing],” she adds. “You can really make a difference if you are good at writing textbooks. You can have an impact on how people are taken care of.”
Strickland is the founding editor and served as senior editor of the Journal of Nursing Measurement for 20 years. She has been on a plethora of prestigious editorial boards and panels, including Advances in Nursing Science, Research in Nursing and Health, Nursing Outlook, Journal of Professional Nursing, Scholarly Inquiry for Nursing Practice: An International Journal, Encyclopedia of Nursing Research, Health Care for Women International, Nursing Leadership Forum, and the American Journal of Public Health.
Strickland has been recognized by many groups and organizations. She was the youngest person inducted into American Academy of Nursing at age 29 and has won the “Trailblazer Award” from the National Black Nurses Association (NBNA). She also earned the Mary Elizabeth Carnegie Award from the Southern Council on Collegiate Nursing for her contributions to health and nursing. Additionally, she was inducted into the NBNA Institute of Excellence.
“I don’t think about the awards I won. It isn’t important,” says Strickland. “I get joy in what my students have produced, the research and work they are doing. That is where I find my joy and that is where my rewards come from.”
Hurley Medical Center in Flint, Michigan, is in the middle of a firestorm of criticism over the reaction to a white man with a swastika tattoo who insisted black nurses not be allowed to touch his newborn. Hospital officials indicated they did not want to put the nurse in harm’s way once the request was made, but what harm was ultimately done?
Two lawsuits followed the incident: one was settled and one is pending. Tonya Battle, a nurse at Flint’s Hurley Medical Center, filed the first complaint against the hospital and a nursing manager. She alleged that a note was posted on an assignment clipboard that read, “No African-American nurse to take care of baby.”
The federal lawsuit was quickly settled. The hospital paid $200,000 to settle the suit, MLive-Flint Journal reported.
Battle and the hospital quickly released a statement. When Minority Nurse requested an interview, the joint statement was released. The parties were “happy to report” they amicably resolved this matter according to the statement, which did not report the financial settlement.
“This situation in the NICU was triggered by conduct, which is not consistent with Hurley’s policies. We regret that our policies were not well enough understood and followed causing the perception that Hurley condoned this conduct,” Melany Gavulic, RN, MBA, President and CEO of Hurley Medical Center, noted in the written statement. “We thank Tonya Battle, Lakisha Bah Stewart and Latoya Butler for bringing this situation to light.
“Hurley Medical Center is fundamentally opposed to any form of racial discrimination. As previously reported, we will use the circumstances of this issue in future training sessions to ensure that employees are prepared to appropriately handle situations like this. Hurley is proud to be the safety net provider for this community for over 105 years. We value the support of the patients who entrust us with their care and the dedication of our physicians and staff. This includes Nurse Tonya Battle and her 25 years of professionalism and dedication. We are eager to move forward as a stronger, more unified facility.”
But before the hospital can move forward it has to deal with a suit filed by nurse Carlotta Armstrong, who is being represented by civil rights attorney Tom Pabst. The second suit was filed in late February.
“Whenever you have a major hospital instructing black nurses to keep their hands off this white baby, you don’t have to be a rocket scientist to figure out that is wrong. That is like we are living in 1813 instead of 2013. I am still in disbelief. I have been practicing 35 years and that is just wrong, any way you look at it,” Pabst told Minority Nurse.
A patient can make any request they want, but “the real rub here is that the hospital agreed to it,” Pabst noted. “The hospital controls the workplace, not some white swastika-tattooed guy. It is indefensible.”
Minority Nurse requested a second interview with the hospital officials and again received a written statement. “While I cannot comment on the suit and answer questions, I can share some insights,” Gavulic said in the written media release.
“The issue was triggered by a father of a baby who demanded that no African American nurse be involved in his baby’s care. Upon making his demand, he then showed Nurse Battle’s supervisor his swastika tattoo, which created anger and outrage in our staff. This resulted in concern by supervisors for the safety of the staff. For these reasons, the request was initially evaluated; however, the father was informed that his request could not be granted.”
Gavulic noted that Hurley Medical Center has had a rich history and reputation of supporting and valuing diversity and remains committed to its policy of nondiscrimination. “As a premier academic medical center, Hurley strives to continuously provide education to our staff,” the statement said. “We appreciate the community’s concern and involvement, as we publicly clarify the facts of this case.”
In an interesting twist, Armstrong’s attorney reported his children were born in the hospital. “Both of my sons—one of them is 35 and the other one is 31—they were both born there. I took them there specifically because it is a great neonatal unit,” Pabst noted. “If the mom who is having the baby is having any trouble with that baby, you want to be at the Hurley neonatal unit. Everybody knows it is a great facility.”
But that is where Pabst’s praise ended. “How this white supremacist—or whatever he is—can go there and think he can just demand a white nurse, and to compound it, why the hospital would go along with that is just beyond me,” Pabst said. “I can’t even fathom what happened here. It is just beyond belief. If you would have told me a couple of months ago that is what happened, I would have said, ‘No way, not at Hurley.’”
“There is a mindset here that needs to change, I think, and I just don’t think just because they pass laws that the battle is over. Obviously it is not. Look at what happened here,” Pabst said. “These people were discriminated against. That is not what my country stands for.”
Using evidence-based practice (EBP) to give patients the best possible care is one of the hottest topics in nursing today. Yet evidence-based nursing is not a new model of care. In fact, says Linda Burnes Bolton, DrPH, RN, FAAN, vice president and chief nursing officer at Cedars-Sinai Medical Center in Los Angeles, it is simply another way of looking at the traditional theme of nurses living up to their sacred trust with society.
“The sacred trust is based on the belief that nursing professionals will always act in the best interest of the patient,” Burnes Bolton explains. “We cannot do that without knowing what would best benefit and assist the patient. Part of that trust and commitment to patients is to give the very best care for each individual. We cannot be lulled into a false sense [of security] that it is OK to do something just because ‘this is the way we have always done it.'”
These days, it’s hard to open up a nursing magazine and not see an article about evidence-based practice. But because it’s a complex concept, many nurses still don’t completely understand what EBP is all about.
One of the best explanations of what EBP is and is not comes from Bernadette Melnyk, PhD, RN, PNP/NPP, FAAN, FNAP, dean of Arizona State University (ASU) College of Nursing & Healthcare Innovation in Phoenix. Three years ago, Melnyk founded the nursing school’s Center for the Advancement of Evidence-Based Practice (CAEP), one of a handful of university-based centers across the country dedicated to this paradigm of care.
Speaking at the 2006 National Black Nurses Association annual conference, Melnyk noted that “improving health care through EBP is a problem-solving approach that integrates the best research data with the nurse’s clinical expertise and the patient’s individual needs and preferences. It is not just research utilization or translating research into practice. It’s the process of synthesizing the best evidence across multiple studies to come up with what’s best for [that particular patient in that particular situation].”
With its emphasis on developing interventions based on sound clinical evidence and proven best practices, evidence-based practice is an ideal tool for nurses to use in their efforts to eliminate racial and ethnic health disparities. Yet using EBP in the specific context of improving minority health outcomes poses unique challenges—from where to find research data that is inclusive of minority populations to understanding how culture and language may influence a patient’s preferences.
Defining EBP: A Closer Look
David Sackett, MD, a Canadian physician, is considered the father of evidence-based practice, according to Cheryl Fisher, MSN, RN, program manager for professional practice development of nursing and patient care services at the National Institutes of Health (NIH) Clinical Center. Located in Bethesda, Md., the center is the nation’s largest hospital devoted entirely to clinical research.
Fisher has adopted Sackett’s definition of EBP. “He states that evidence-based practice is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. . .[by] integrating individual clinical expertise with the best available external clinical evidence from systematic research.’ In our hospital setting, we also take into consideration the patient’s preference since our care is patient-centered.”
Searching the literature to find the best evidence doesn’t have to be an overwhelming or time-consuming process. To target their search and quickly find the relevant research, says Melnyk, nurses should formulate a clinical question using the PICO framework:
P = Patient, Population, Problem
I = Intervention
C = Comparison
O = Outcome
“When you phrase questions in that way [with these criteria in mind], you will not spend days and days searching for the evidence to answer your question,” she says. “You will know how to put key words from PICO into a database search and rebuild your answer in a short period of time.”
Once you have come up with the key words to focus your inquiry, the next steps in the EBP process are to:
1. Search for the best research studies relating to your question;
2. Do a rapid critical appraisal of the research findings;
3. Integrate the evidence with your clinical expertise as well as the patient’s circumstances and preferences; and
4. Evaluate the outcome in the context of your own practice setting and, if necessary, make changes to current practices to give the patient better care.
A rapid critical appraisal helps clinicians establish the validity, reliability and patient applicability of a study or group of studies and find the most important nuggets of evidence to use in their practice. “And then you have to make the decision as to whether or not you are going make a practice change and integrate Step 4,” Melnyk says.
For Adelita G. Cantu, PhD, RN, a clinical instructor in the Department of Family Nursing Care at the University of Texas Health Science Center at San Antonio School of Nursing and a researcher who focuses on Hispanic health disparities, EBP means looking at what clinicians are doing on a daily basis, looking at patient care and knowing it is based on research. “You need to know there is some evidence that says this is the way you should do it and why you are doing it,” she emphasizes. “[As nurses], we need to explain to the patient why something is being done and that there is a reason it is being done a particular way. That should translate into better patient compliance.”
Sandra Millon Underwood, PhD, RN, FAAN, American Cancer Society Oncology Nursing Professor at the University of Wisconsin-Milwaukee College of Nursing, is a researcher who has devoted much of her work to cancer prevention and early detection among medically underserved minority populations. She cautions against taking too narrow a view of what EBP can accomplish. All too often, Underwood says, when clinicians think about evidence-based practice they focus solely on using the data from research to guide decisions.
“I think in many ways that is short-sighted, because most evidence-based practice models expand that vision,” she explains. “The evidence and research is critical but so are the other domains of EBP in making decisions for individuals, for communities and for population groups at risk.”
Underwood believes there are six domains that come into play when using EBP: scientific evidence, clinical experiences, the resources that are available within the academic arena or clinical environment, patient preferences, patient condition and patient characteristics.
The Importance of Inclusive Research
One of the biggest challenges nurses face in using evidence-based practice to address minority health disparities is finding enough evidence that is relevant to the needs of minority patients. There are many areas of medical research where people of color are underrepresented in clinical studies, or not included at all.
Burnes Bolton stresses the need to use research that is based on minorities to treat these populations. She points to skin cancer as an example. Skin assessments for people with dark skin will be vastly different than those done on Caucasians. “Generally, you look for changes in a [mole or spot on the body] where the skin is a different color,” Burnes Bolton explains. “With African Americans, they may not be able to see that.”
To share resources in support of evidence-based projects for reducing Native American health disparities, nursing leaders from the National Institutes of Health, the Indian Health Service and the National Alaska Native American Indian Nurses Association teamed up to create a collaborative online community
The end result can be deadly. According to the American Academy of Dermatology, failure to recognize skin cancer in people of color can lead to late diagnosis and lower long-term survival rates—only 58.8% compared to 84.8% for Caucasians. Furthermore, many people are under the misconception that melanoma is not a threat for individuals with darker skin. And studies of African Americans who are diagnosed with melanoma highlight another relatively unknown fact: In African Americans the condition most often develops on areas of the body that are not exposed to the sun.
“You can’t only use skin texture as a factor,” Burnes Bolton says. “You have to ask patients questions in a culturally appropriate manner.”
Another example, she continues, is the effects medications may have on different populations. “Many of the research studies [of medications] have been conducted [only] on white males,” Burnes Bolton points out. “It is very important when someone is prescribing a medication to know if that drug was tested on diverse populations. When reviewing the research, you must make sure you know what is the best evidence [about the drug’s effect on different populations].”
What Underwood finds disheartening is that even when a research study does include racially diverse participants, often the results are not analyzed by subgroups. “Inclusion [of minorities in a study] is not sufficient if one is not looking carefully at the outcomes of the research to determine whether or not there are similarities or differences for minorities, or nuances that need to be addressed in nursing practice,” she says.
Another factor that must be taken into account is the diversity that exists within a particular racial or ethnic group, Cantu advises. She says it’s critical for nurses to analyze the data and make sure there was a good research design in place. “Hispanics living on the U.S./Mexican border are going to be different than those living in an upscale suburban setting. You have to ask yourself: Is the population [in the study] similar to the one you treat? Where do they live? Do they have a high economic status? Do they have a low economic status? Make sure you are looking at evidence that pertains to your population.”
Where to Find Data
There are a number of ways to gather research data. Searching Internet databases is one of the fastest. Some of the best evidence-based health care databases include:
• The Cochrane Collaboration
• MEDLINE COS
• Cinahl Information Systems
• Agency for Healthcare Research and Quality (AHRQ)
There are also some databases and EBP online communities that focus specifically on minority health and health disparities, such as:
• American Public Health Association (APHA) Health Disparities Community Solutions Database
• National Minority Quality Forum
• Health Disparities Collaboratives
The Office of Minority Health Resource Center (OMHRC), the nation’s largest repository of information on minority health issues, provides free customized database searches on request. This service can be obtained by calling (800) 444-6472 or emailing the center at [email protected].
Another valuable source of data and best practices is other nurses—both researchers and clinicians. Burnes Bolton suggests tapping into the resources of professional nursing organizations, such as the American Academy of Nursing, for information. AAN initiatives such as Raise the Voice, which showcases the work of nurse “Edge Runners” who have created successful interventions and care models, may offer insights, she says.
Cantu suggests tapping into national and regional minority nursing associations. In addition, she says, many hospitals have clinical nurse specialists and nurse educators on their units. “They are a resource to go to. Schools of nursing are another place to use as an information resource. Maybe you can partner with them. Using these community resources is very appropriate and saves time for the bedside nurse.”
Sharing EBP Resources Online
Fisher has been working with the National Alaska Native American Indian Nurses Association (NANAINA), the Indian Health Service (IHS) and the NIH to create an online virtual community that helps promote the use of EBP to advance the agenda for reducing American Indian/Alaska Native health disparities. The online community links NANAINA faculty mentors with nurse clinicians at remote IHS sites and research staff from the NIH Clinical Center to collaborate and share resources in support of evidence-based projects.
According to Fisher, the virtual community grew out of a series of face-to-face meetings held in 2006-07 to establish relationships between the three collaborating organizations and to define evidence-based projects the nurses would work on. She says the Web-based community was launched last fall to provide technical support for the project’s mission and to enable the mentors and mentees to collaborate in an online environment.
“The virtual community provides a way to communicate and collaborate with the Indian Health Service nurses to promote evidence-based practice in their work settings,” Fisher explains. “The goal of the community was to provide a way for us to stay in touch following face-to-face meetings in order to continue our work.”
The online community includes such features as a discussion board, a resource center, a links section to help members quickly find Web-based information that will support their work, and opportunities for live chat or real-time meetings between two or more members.
Although the community is less than a year old, it has already accomplished a great deal, Fisher reports. “We were able to develop a list of members with contact information, share resources and develop posters for national presentation utilizing the virtual community—which would have otherwise been very difficult, since we [are all physically located in different parts] of the country. The virtual community has provided us with a means for staying connected.”
Filling Evidence Gaps
Another challenge that can arise when using EBP as a model of nursing care is: What do you do if the specific research data you need to answer your clinical question just isn’t out there—or at least not yet? Finding enough minority-inclusive research is just one part of the problem. Another obstacle, says Melnyk, is that it currently takes an average of 17 years for the findings of a study to become a valid, accepted part of the nursing literature.
“That [time lag] is a huge issue,” she emphasizes. “There are many areas in nursing where we do not yet have good evidence-based interventions to improve health outcomes. There are a lot of gaps in the evidence. That is why we need outstanding nurse researchers to generate evidence where we do not have it. Then we need outstanding clinicians to take the evidence that is generated and [apply evidence-based nursing skills] to translate it into clinical practice.”
One strategy for filling evidence gaps, Melnyk adds, is for nurses to generate practice-based evidence in their own clinical site by using outcome management. “Collect data through your chart records, do a certain practice and then look at outcomes and look at the data you have available,” she says. “The message I want to get out is that you do not have to be a rigorous researcher to be able to do outcome management and generate some evidence to guide your own practice in your [clinical] setting.”
This do-it-yourself approach to evidence generation can also be extremely helpful for busy nurses who might otherwise not have time to sit down at a computer and search for research data. “I think that many nurses, particularly bedside nurses, are so involved in patient care that they do not have the time to review on their own or attend meetings, workshops or seminars where evidence-based practice is discussed,” says Cantu.
Using EBP Effectively
Ellen Fineout-Overholt, PhD, RN, FNAP, director of the Center for the Advancement of Evidence-Based Practice at ASU College of Nursing, believes that having open communication with patients and colleagues plays a key role in providing evidence-based care.
“If I am taking care of a patient of color and do not know anything about that [person’s] culture, it is incumbent upon me to find out, to ask some questions,” she says. “Then it is incumbent on the patient to tell me, to talk to me. We need to have a dialogue so we can come to understand and know one another better to get the best outcome. Nurses need to [look at patients’ cultural beliefs and values] to see what they want and what they may need [in terms of care].”
That isn’t to say every outcome will be positive. Sometimes patients may not be willing to make a change in their behavior, especially if it goes against their belief system. “Then you need to tell them, ‘This is what the evidence says might happen. If you still want to go ahead [with that behavior], be informed of what your outcome may be,” Fineout-Overholt explains.
To use EBP effectively, she continues, nurses must always keep two things in mind: Why are we doing this and what outcome are we trying to achieve? “[Whatever you’re doing, whether it’s] inserting a Foley catheter into a bladder or holding a dying patient’s hand during a procedure, if you can keep those [two questions] as your focus it will really help you to understand what aspects [of the evidence] to put into practice. With hand-holding, culture . What does it mean to comfort someone in certain situations? With putting in a catheter, what you are trying to accomplish depends on what kind of circumstances there are. Keeping patient care front and center is imperative.”
Nurses should question the research data if it does not seem to fit in with their own clinical experiences, Cantu says. “We teach critical thinking [at our university]. In your experience, if you have seen something different, you cannot discount that. Then you may need to ask, ‘How do I get [these two pieces] to fit together?'”
Melnyk stresses that nurses need to work in a culture that supports EBP. “[Buy-in from] upper management is critical. Nurse managers and nurse executives need to understand EBP, practice it and create a culture that [encourages their nursing staff] to implement it. Part of that culture is having a cadre of It is critically important for nurses of color to be in the forefront of the evidence-based practice movement, Fisher emphasizes. “Minority nurses can help pave the way through modeling and dissemination of their EBP projects, which was the goal of our work with NANAINA and the Indian Health Service. It is exciting to see the nurses get involved with EBP and use their creativity to improve patient care. Once EBP becomes [more widely accepted] as a new way of practicing and providing care on a daily basis, both nurses and patients will benefit.”
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Two years ago, Pattie Soltero, BSN, RN, MAOM, operations manager for 6 North, a pediatric rehab and med-surg unit at Childrens Hospital Los Angeles, was looking for a way to help introduce the unit’s nursing staff to evidence-based practice (EBP). So she started a journal club. Journal clubs—also known as research clubs—are so called because they involve reading and discussing research studies published in clinical journals.
Soltero was introduced to the concept of EBP when she went to a professional conference. “There was a group of critical care nurses from a hospital here in L.A. who wanted to develop [a procedure for] providing their intubated patients with the best oral care possible,” she says. “So they went and researched the best mouthwash, the best toothbrush or utensil, and all the things related to providing the best oral care for intubated patients. Then they went to their manager and said, ‘These are the items we need.’ It turned out that the hospital already had a contract with a supplier that had every single item they needed. Based on that, they were able to develop a package for every single intubated patient in the ICU based on the evidence and their practice. Now [this hospital system] uses it in all of their facilities.”
The nursing staff on 6 North have varying levels of education, which is another reason Soltero started the journal club. “We have nurses with advanced degrees who are nurse practitioners and we have other nurses who have two-year associate’s degrees,” she explains. “Nurses with a two-year degree have had [little or no exposure to nursing research]. So we have taught them how to read a research article. We have taught them that nursing research is not something to be afraid of: It is done by nurses, it is not in a foreign language and it is applicable to our practice.”
Attend an EBP Conference Focusing on Vulnerable Populations WHEN:
February 19-20, 2009 WHAT:
10th Annual Evidence-Based Practice Conference: “Translating Research into Best Practice with Vulnerable Populations” WHERE:
Renaissance Glendale Hotel & Spa, Glendale, Ariz. SPONSORED BY:
Center for the Advancement of Evidence-Based Practice at Arizona State University College of Nursing & Healthcare Innovation FOR MORE INFORMATION:
Amy Fitzgerald, [email protected]
When the club first started, Soltero picked a research article once a month, posted it for everyone to read and then scheduled a meeting to discuss the study. “Little by little, after about six or seven months, some nurses started to really enjoy the journal club, so the staff [eventually took it over themselves],” she says. “Now it is just positive peer pressure [that motivates them to participate], so they meet on the weekend to do the journal club. I am not involved in it.”
While approximately 75% of the children the hospital treats are Hispanic, the facility also serves a variety of other ethnic communities. “We have an Armenian community close by and a Chinese community close by. And the rest of [our patient population] is a very diverse mix,” Soltero says.
She feels the journal club has been an excellent vehicle for implementing evidence-based practice to better meet the nursing needs of children of color. “For example, we looked at the spiritual care of our kids and how we are meeting those needs [given] the diversity of our population. People think because you are Hispanic you are Catholic, but that is not always true,” she notes. “We found a research article that focused on the spiritual care that was delivered to pediatric patients. Based on that, we were able to talk about how important that aspect is to their care.”
One of the nation’s great success stories of the past two decades is in danger of unraveling, according to the National Campaign to Prevent Teen and Unplanned Pregnancy. “After impressive declines nationally in all 50 states and among all racial-ethnic groups, progress in preventing teen pregnancy and child bearing has come to a virtual standstill,” says Bill Albert, the Chief Program Officer for the National Campaign.
The teen pregnancy rate in the United States peaked in 1990, Albert says, and declined every year through 2005. In those 15 years, the teen pregnancy rate dropped 37%, but those numbers have begun to creep in the other direction, according to the newest data available. Between 2005 and 2006, the pregnancy rate among teens increased a full 3%.
America has the highest teen pregnancy rate of any Western industrialized country, and within certain racial and ethnic groups, the numbers are disproportionately high. Among Hispanic/Latina teen girls in the United States, 53% get pregnant at least once before the age of 20, according to the National Campaign. Among African American teen girls, the figure is 51%; for white, non-Hispanic teens, it’s 19%.
“One way to look at it is to say that more Latino and African American teens get pregnant than don’t. If that isn’t alarming, if that isn’t a call to action, I am not sure what is,” Albert says.
Loretta Ebison, M.A., M.F.C., L.P.N., is the Adolescent Parenting Program (APP) coordinator for the Beaufort County School District in North Carolina, a statewide initiative of the Department of Health and Human Services. Seventy-five percent of the program’s participants in her county are Hispanic/Latina or African American. “It saddens me,” says Ebison, who is African American. “That is why I think education is very important. We need to discuss these issues before a teen experiences a pregnancy.”
As outlined by the National Campaign, teen pregnancy is linked to a number of other social issues:
Less than half of teen mothers (age 17 and younger) graduate from high school, and fewer than 2% earn a college degree by the age of 30.
Children of teen mothers are more likely to be born prematurely and at low birth weight and are twice as likely to suffer abuse and neglect than children born to older mothers.
Two-thirds of families begun by a young unmarried mother are poor.
Daughters of teen mothers are more likely to become teen mothers themselves than daughters born to older women.
Children of teen mothers are 50% more likely to repeat a grade and less likely to complete high school than the children of older mothers; they also score lower on standardized tests.
Teen childbearing in the United States costs taxpayers (federal, state, and local) at least $9.1 billion in a single year (2004), according to a 2006 report by Saul Hoffman, Ph.D., an economics professor at the University of Delaware and a member of the National Campaign’s Effective Programs and Research Committee Advisory Panel.
“When you look at the challenges of teen pregnancy and child bearing, the glass-half-full interpretation, which is true, is we have made extraordinary progress as a nation,” Albert says. “The glass-half-empty interpretation, which is also correct, is that despite this enormous progress, our rates in this country nationally and by race and ethnicity are out of whack with the rest of the industrialized world.”
Ebison is one of many nurses who have made it their mission to work with teen moms. Nationwide there are programs being run and/or staffed by nurses who help pregnant and parenting teens in their efforts to become self-sufficient through education on a variety of issues, from parenting to job skills.
In the APP, a nurse or social worker visits each teen one-on-one, 12 times a year, with eight of those visits occurring in the teen’s home. The program can provide resources for up to 25 students in each of its funded institutions. It aims to improve the development of the participants’ children by increasing their number of healthy births as well as by providing resources to improve their age-appropriate physical, emotional, cognitive, and social development. The APP also offers at least 25 hours of educational group instruction annually.
“When I am working one-on-one with the girls, I feel fulfilled,” says Ebison, who was a teenage mom. “I feel like I am doing what I was called to do. At the end of the day, if I feel like maybe I prevented one girl from having a secondary pregnancy and maybe I helped one girl decide to stay in school and go to college [I feel good]. That is my ultimate goal, because I understand that without a college degree you are going to have a tough time.”
Ebison’s home state of North Carolina enacted the Healthy Youth Act in 2009, requiring comprehensive sex education in schools. “Before, we were abstinence-based schools…but obviously they are [having sex]. I think it is important to find the teen where they are; whether they [practice] abstinence or they may be having sex, and we can address it either way now,” she says.
One national program serving vulnerable first-time mothers and low-income families is the Nurse-Family Partnership (NFP), an evidence-based community health program. It partners young mothers with a registered nurse during pregnancy and coordinates home visits that continue through the child’s second birthday.
The NFP program that runs out of North Central Community Health Center in St. Louis, Missouri, works with 100 families. The median age of the mothers is 19, and 85% are minorities, according to program supervisor Vanessa Davis, B.A., R.N. Once enrolled, participants see a nurse weekly for four weeks and then every other week until the baby’s birth. By working with the women during pregnancy, Davis says, the nurses can change the course of a potential negative outcome. “We make sure she gets that prenatal care…and educate her on nutrition.” After delivery, the visits are weekly for six weeks and then return to bi-weekly. “We build strong relationships and are the support person for them,” says Davis.
NFP goals include long-term family improvements in health, education, and economic self-sufficiency as well as help with planning future pregnancies. “The last piece is finding out what is this mom’s heart’s desire. ‘What do you see yourself doing in the future and how can we help get you there?’ We talk about those future goals,” Davis says.
The NFP has observed a number of positive outcomes in 30 years of research from various controlled trials. In at least one of the trials of the program, the following outcomes were observed:
48% reduction in child abuse and neglect
56% reduction in ER visits for accidents and poisonings
67% reduction in behavioral and intellectual problems in the children when they reach age six
Today, NFP serves first-time moms and their babies in 32 states. The New York City chapter is the largest NFP urban site in the nation. Any low-income, first-time expectant mother can enroll, regardless of age or immigration status, if she lives in a zip code served by NFP, and is less than 28 weeks pregnant. All teens under 18 are eligible.
The NYC NFP had 2,313 active clients as of July 31, 2010; it hopes to increase that figure to 3,015 by 2011. The median age of clients is 20, with many who first became pregnant as teens. Forty-three percent are African American, 42% Hispanic, 8% multi-racial, 4% Asian, and 3% white/non-Hispanic.
Beatriz Lugo, R.N., C.L.C., is the NFP program coordinator at Harlem Hospital Center, which covers East, West, and Central Harlem; Washington Heights; and Inwood. Lugo’s clients are primarily minority teens. Lugo, who is of Hispanic descent, says there is great diversity in that ethnic population. “Hispanics are a mix of many races. Many of the clients I have are from the Dominican Republic and Mexico,” she says. “In these countries they are usually allowed to get married at age 14. Many of them have been married in their country. With a lot of minorities, it is part of their culture [to have children young].” Many of these teens have family in countries outside the United States, but they don’t have anyone to turn to here. That scenario makes NFP so critical. “With the involvement of a nurse, they are more likely to stay in school,” says Lugo, who became a mother at age19.
Enrolling teens while they are pregnant gives nurses time to build trust with clients. “For teenagers, pregnancy is not just about pregnancy; it is about dealing with their futures,” Lugo says. “Oftentimes clients don’t see the baby as a baby or an individual until the baby moves. We teach them to bond with the baby [while they are pregnant].”
Organizations like the NFP provide more than clinical care and guidance; they also try to give the teens hope. “Sometimes they feel hopeless. They didn’t plan this pregnancy. We have to give them support. In terms of family relationships, we will work with it,” says Lugo, who has a caseload of 25 clients. Fathers and other family members are also encouraged to take part in the program. “Sometimes it is the grandmother who is there and we will work with her…. We make mom #1, but we allow these [other family members] to be part of it.”
The biggest challenge for teen moms is education. “Many stop school,” Lugo says. “We have to incorporate in our teaching that just because you have a baby doesn’t mean you cannot go back to school. We guide them to daycare centers and the support they need.”
The New York City Department of Education operates 38 Living for the Young Family Through Education, or LYFE centers, mostly in high schools. Each LYFE site has a childcare center and is linked to a social services and health referral network. Last year 21 of Lugo’s clients graduated from the program.
Another successful pregnancy support program for high school students can be found in the Brownsville Independent School District (BISD), on the southern-most tip of Texas on the Mexican border. Run primarily by nurses, BISD won the 2008 Broad Prize for Urban Education and a $1 million award (the largest education prize in the country) as the most improved urban school district. The Broad Prize also recognizes schools that reduce achievement gaps affecting poor or minority students.
Among its 57 schools, BISD has seven high schools and three alternative schools, including the Lincoln Park School for pregnant and parenting teens. “It is an alternative school of 150 girls, which can fluctuate, and its [population] is 99.9% Hispanic,” says principal Hector Hernandez. Lincoln Park also offers an accelerated program.
Outreach worker Vici McClure, R.N., travels to the district’s middle and high schools. She worked as the Lincoln Park school nurse for 13 years. McClure says culture and the media play a role in teenage pregnancy in the district. “The things that the kids see, everything that bombards them through the media, makes it kind of acceptable to them. There is no stigma to it any more,” McClure says. “People just accept the fact, assimilate that child into the family, and they just go on. There are no consequences . There are the welfare programs and government programs that help the child take care of her child, making it much easier than it was 25 or 30 years ago.”
But that doesn’t mean it is easy for teen mothers. School attendance can be an issue for pregnant and parenting teens. “If a kid complains they are sick, I try to keep them here on campus as much as possible,” says Martha Ledezma, R.N., the school nurse. “I may say to them, ‘You are pregnant. Nausea comes with pregnancy.’ I try to let them rest.”
The school has a licensed daycare center, and sick children must be sent home. “Unfortunately, if the baby has to go home…nine out of 10 times the mom is going home with that baby,” Hernandez says.
Lincoln Park became an alternative school in 1991. Since then, 500 girls have graduated. Some pregnant teens choose to stay at their home campuses, rather than travel to Lincoln Park, although pregnant middle school students are strongly encouraged to enroll at the alternative school. Lincoln Park offers two parenting classes: one that deals with pregnancy through birth; the other, with the first five years of childhood. The school nurse is very involved in those classes. “They learn parenting skills, good nutrition for their baby, safety issues, well baby visits, anger management, how to deal with a toddler, and teaching a toddler,” McClure says.
The outreach program is in its third year, and its numbers have steadily increased from 100 to 140 to 200 young women. McClure does one-on-one and small group sessions before school, after school, or during the lunch period. “On their home campuses they are not required to do parenting classes, so it is possible that they do not get anything unless we do something supplemental for them. We are also working toward getting a pregnancy prevention curriculum in place at the middle school level,” McClure says. “That is a big goal we have.”
Nationwide there are also many local agencies, headed and staffed by nurses, working with pregnant and parenting teens. Pernet Family Health, based in Worcester, Massachusetts, the second-largest city in New England, is a major provider of home health care and early intervention services to families in the area. The agency’s roots date back to 1955 when the Little Sisters of the Assumption came to the city to provide health care and support to disadvantaged families and to revitalize the spirit of those degraded by poverty. The agency, named after its order’s founder, is certified by the Massachusetts Department of Public Health.
Stephanie Omuemu, B.S.N., R.N., works for Pernet in the Worcester Healthy Start Initiative. Over the past 15 years, Worcester has had a higher infant mortality rate than that of Massachusetts and the nation. The program aims to reduce infant mortality and improve the birth outcomes for high-risk populations. Eligible mothers, some of whom are teens, receive a case manager and a nurse who provide assessments and resource referrals.
Omuemu, who is of Nigerian descent, and another nurse share a caseload of 90 families. Approximately 90% are minorities. “Our program deals with immigrant populations and African and Spanish populations. That is the majority of our caseload,” Omuemu says. “They are new to this country, haven’t received their full citizenship yet, or maybe some of them are on green cards . . . or starting the citizenship process.” Teenage moms head about 20% of the families.
Omuemu visits clients in their homes and at Pernet’s office. She says there are many challenges to working with teenagers. “When they are not showing, they don’t grasp the fact that they are pregnant. They will take the test and they will see that it is positive, and then they will go to the doctor. But until the baby starts to be very visible and they can feel the baby moving, I think they sort of disconnect. They seem to think, ‘Okay, this is something that is going to happen, but it is way in the future.’ They do not see that they need to prepare for this now.”
Getting the teenagers to attend birthing classes is also difficult. “I tell them that knowledge is power. If you go to the class you will know exactly what is going to happen, and you are going to feel more in control,” Omuemu says.
Omuemu became a nurse, in part, to work with minority populations. “My goal, which is a very large one, is to eliminate health disparities within vulnerable communities, within racial and ethnic groups. Health care should be universal. It is not something that only certain people should have,” she says.”Being of Nigerian descent and coming from what would be deemed a vulnerable population, I know what it is like. I have lived it. I know how scared one can be of the system. I know how difficult it is to assimilate to this country, learn the culture, and still try to maintain your culture as much as you can. I am aware of the problems.”
Pernet offers an early intervention program as well, which provides family-centered developmental services to children aged two months to three years who are experiencing or are at risk of developmental delay. Miriam E. Torres, R.N., a clinical child developmental specialist for Pernet, has been a registered nurse since 1980. She says about 50%–60% of the children she works with were born to teen mothers. Approximately 30% are minorities. Torres visits clients at home and works on the child’s development, alongside parents, through play.
Torres says her background can be an asset or detriment when working with some minorities. “They can be feeling comfortable because I speak their language and I understand what is going on,” she says. “Or they could feel threatened because…I understand the conversation and the surroundings.”
While teenage pregnancy is associated with a host of challenges, it can also inspire the young mother. “Sometimes it gives them the incentive to better themselves,” Torres says. “I have had teen moms who have gone on to be lawyers.”
Ledezma, who grew up in the Texas district she now serves, uses her Hispanic background to inspire and connect with her students. “I let them know that they need an education. They need to apply themselves,” she says. “I am a nurse and I show them that you can come from anywhere and be anything. I am 27 years old and I became a nurse at 21. As a minority nurse I am showing them I did it and they can do it.”
Many nurses of color say their own ethnic or racial background has a positive influence on their practice. “To be able to give back to your own personal ethnic group, it is a bonus as well. In turn, it helps out the community that you may be involved with or part of,” Davis says. “I am able to share cultural experiences with my own personal team, with the nurses I work with. That is beneficial too because the more diverse it is, the you are able to pull in those different pieces to make the best outcome for the client. You are able to come up with creative and innovative ideas, keep these teen moms involved, wanting to come, and wanting to change.”
The last hurdle a new nursing school graduate must clear before he or she can practice as a nurse is often the most stressful one: taking the NCLEX-RN®. This licensing examination, developed by the National Council of State Boards of Nursing, Inc. (NCSBN), makes it official: Pass “the boards” (as the exam is familiarly called) and you become an RN.
This grueling, five-hour test of entry-level nursing knowledge and skills can be an intimidating experience for any new graduate. But some minority nursing leaders have voiced concerns that the NCLEX-RN playing field may not be level when it comes to students of color, especially if they were educated outside the U.S. Others dismiss these claims, arguing that the exam is indeed culturally sensitive and unbiased. Either way, strong feelings seem to arise when the subject of the NCLEX comes up.
Charlotte Richmond, RN, PhD, scientific director of anesthesia research at Mount Sinai Medical Center & Miami Heart Institute and an adjunct professor at the College of Health and Urban Affairs at Florida International University, believes that language barriers can sometimes hinder minority and international students taking the NCLEX.
“Here in Miami, the cultural diversity is very great,” says Richmond, who is part Cherokee Indian. “South Florida, particularly, has influences that come from the Caribbean Islands, Central and South America. The majority of international students who are attending the local nursing schools are having a difficult time passing the NCLEX, and it perhaps could be due to language problems.”
Americans use different terminology that international students might not know, Richmond explains. She likens it to the variations in word usage between America and England. “In that sense, the NCLEX questions are based on the American culture and not necessarily [other languages or cultures],” she adds.
Graciela Reyes, RN, BSN, CRRN, a member of the Dallas Chapter of the National Association of Hispanic Nurses (NAHN), agrees. “The [international] nurses’ difficulty is not with the content [of the test] but with the language,” says Reyes, a native of Mexico. “The medical terminology is not that much of a problem, because most of it is very similar in English and Spanish. What gave me the hardest time was the day-to-day English.”
Back in 2001, Jodi Gooden, RN, BC, PhD, an assistant professor in the College of Nursing at the University of Oklahoma, wrote an article for Minority Nurse about culturally biased classroom testing. She believes this same problem persists today. “I see it here where I teach,” says Gooden, who is part American Indian. “What I see today for some minority students is that there is a difference in their language.”
Gooden believes this issue could affect minority nursing students’ performance not just on classroom tests but also on the NCLEX–a situation that she finds particularly unfortunate. “I hate to see students put in a position where they are very knowledgeable in a clinical area, yet because of the NCLEX [and potential cultural barriers] they are limited in whether or not they can become a nurse.”
A Question of Culture
Language isn’t the only issue cited by those who feel minority and/or international nursing graduates may be at a disadvantage when taking the NCLEX-RN. “Some people don’t believe that cultural differences can be a problem,” says Richmond. “I have taught in three different states and the cultural diversity is different in each one. Language is part of [the potential difficulty for minority students], but the culture is another part of it.”
Jacqueline Crespo Perry, RN, BSN, president of NAHN’s Houston Chapter, agrees that culture can influence what minority nursing students learn. Perry has three nieces who are planning to go to nursing school. “One of them is really deep into her Hispanic roots and it is going to be a little hard for her to adjust to a lot of things she will encounter in her nursing courses,” she says. “The other two will swing right through.”
For example, Perry explains, traditional Hispanic families’ view of health care emphasizes treatment of illness rather than disease prevention. This cultural orientation can affect the way some Hispanic candidates may interpret and respond to questions on the NCLEX.
“When they read a question about children’s health, they are focusing on the illness. They look for the sick child and how you will treat that child,” Perry says. “But because the majority culture emphasizes preventing the child from getting sick, this would not be considered the ‘right’ answer.”
To cite another example, she continues, mental illness is considered a stigma in Hispanic culture. As a result, it is often not talked about, treated, or even taught in some international nursing programs. That knowledge deficiency, which can impair nurses’ performance on the psychiatric section of the NCLEX, needs to be addressed as well, Perry maintains.
In addition, the exam’s multiple-choice format can pose problems for international students, according to Cora Munoz, RN, PhD, an associate professor at Capital University in Columbus, Ohio. A native of the Philippines, Munoz is also a reviewer for the NCLEX-RN at the Kaplan Review Center in Columbus.
“I will not go so far as to say the test is not culturally sensitive,” she comments. “But I think that foreign graduates do have a problem, not so much with content but with format. Multiple choice is not a common testing format in other countries. The format itself becomes problematic.”
In Mexico, nurses take their licensing exams orally in front of a panel of judges, Reyes points out. “Then you come here, and it’s multiple choice and done on computers.”
Narrowing the International Gap
On the other side of the argument, Barbara Nichols, RN, MS, DHL, FAAN, chief executive officer of the Commission on Graduates of Foreign Nursing Schools (CGFNS), believes the NCLEX-RN is culturally sensitive. The CGFNS has a certificate program that internationally educated nurses must complete before they can sit for their boards in some U.S. states. Currently, 36 states have this requirement.
Nichols, who is African American, says the National Council of State Boards of Nursing has put many safeguards in place to ensure the testing process is fair to everyone. “The NCLEX is testing minimal knowledge,” she asserts. “It is not a test of excellence. It is a test of basics.”
The CGFNS, a private, independent, non-profit organization, was created in 1977 at the height of a severe nursing shortage that had prompted many hospitals to import nurses from the Philippines and other countries to fill their staffing gaps. “At that time, only about 15% to 20% of these nurses educated outside the United States were passing the NCLEX-RN,” Nichols explains. “This was really a big dilemma. You had all of these foreign nurses coming in but not passing the licensing exam.”
Today, statistics from the NCSBN clearly show that CGFNS’ efforts have made a difference. In 2001, out of 8,613 foreign-educated candidates taking the NCLEX-RN for the first time, nearly half (49.4%) passed the exam. But a considerable gap still needs to be closed: The first-time pass rate for U.S.-educated candidates is 85.5%.
International nursing graduates earn their CGFNS Certificate through a three-step process: a credentials review of their foreign education, registration and licensure; the CGFNS Qualifying Exam, a one-day test of nursing knowledge; and the Test of English as a Foreign Language (TOEFL), an English proficiency exam.
Passing the Qualifying Exam, says Nichols, is a good predictor of who will pass the U.S. licensing exam. Fifty percent of the nurses who take the Qualifying Exam pass it, she reports; of that 50%, 90% pass the NCLEX. Those who fail the CGFNS exam receive a letter explaining their score and indicating the areas that need to be improved.
Despite this success rate, not all advocates for international nurses are enthusiastic about the CGFNS Certificate process being linked with the NCLEX. Perry believes it is another obstacle for international nurses. Test fees and translation costs are significant, she points out. If foreign credentials to be reviewed by CGFNS are not written in English, nurses must have them translated and pay for it themselves.
Reyes, too, feels the CGFNS Qualifying Exam is an extra step that international students shouldn’t have to face before taking the boards. “If CGFNS is saying foreign nurses and U.S. nurses are equally educated, why are they holding international nurses to a higher standard?” she argues.
The NCSBN Responds
What does the National Council of State Boards of Nursing have to say about all this?
“The [NCLEX-RN] includes effective checks to minimize the potential for bias due to culture, gender and other background factors,” NCSBN maintains. “It is important that each [question] development panel is composed of nurses representing each region, a variety of practice areas, and minority populations. . .
“Differential item functioning (DIF) is the statistical approach [we use] to determine potential bias. [Questions] flagged for high levels of DIF are reviewed by a group of trained sensitivity reviewers, consisting of at least five members: one male, one representative of three of the ethnic focal groups of NCLEX examination candidates, one member with prior experience on a DIF Review Panel [and] one member with a linguistic background. . .The panel’s recommendations are forwarded to the Examination Committee for final disposition of the items. Additionally, judgments of trained individuals are used to screen [questions] for potential bias.”
In addition to the numerous content reviews conducted by the NCSBN and its member boards of nursing, the National Council also does two formal reviews looking exclusively at issues of cultural sensitivity, adds Casey Marks, PhD, director of NCBSN Testing Services.
When asked if he believes minority nurses may have more trouble passing the NCLEX than their majority counterparts, Casey answers: “We have no reason to suspect that individuals of the same ability level have anything but equal opportunity to pass the examination at the same rate, regardless of their cultural, ethnic, linguistic or racial background.”
Strategies for Success
The current debate about whether or not the NCLEX-RN is a culturally sensitive, equal opportunity exam is unlikely to be resolved any time soon. But regardless of where they stand on the issue, many minority nursing leaders believe there are steps that nursing students of color and internationally educated nurses can take to maximize their chances of successfully passing the boards.
Munoz advises international candidates to take NCLEX review courses, such as those offered by Kaplan, to gain experience in how to take multiple choice tests and to practice taking exams on a computer. Kaplan’s test-prep centers provide all candidates with test-taking strategies, she says, “but if you have international graduate nurses, probably my recommendation is to spend even more time in this area and maybe on how to handle anxiety when taking a test.”
Lilianne Cooper, RN, BSN, a member of the National Association of Hispanic Nurses, passed the NCLEX in August 2002. She agrees that preparation is crucial. “I started studying for the exam months in advance,” Cooper recalls. “The way they format the questions, you could be looking at four correct answers and your job is to pick the best one for that particular scenario. It’s the most frustrating kind of question I’ve ever had to work with.”
A recent graduate of Boston College’s William F. Connell School of Nursing who now works on med/surg floors at Brigham and Women’s Hospital in Boston, Cooper says nursing school helped prepare her for the NCLEX experience. “I received the tutoring and support I needed to help me tackle those questions,” she explains. “I basically had to learn how to answer these types of questions from scratch.”
Cooper also bought a NCLEX-RN review book with a computer CD included. “I encourage all nursing students to invest in some kind of computer review to get the feel for the computer format,” she says. “The one I purchased gave me the opportunity to take 100-question practice tests that were timed.”
Many international candidates must take English language courses before they can sit for the TOEFL. To address this need, Perry and Reyes, through the NAHN chapters in their respective cities, each run programs designed to help immigrant nurses from Spanish-speaking countries strengthen their English and other skills they need to obtain U.S. licenses.
Currently, some 42 nurses are taking English classes at the University of Houston through Perry’s program, which is called Nurses Helping Nurses. In Dallas, Reyes has set up a volunteer program in the Veterans Affairs North Texas Health Care System, where she works as a nurse educator. Internationally educated nurses who have not yet taken the NCLEX volunteer in the system’s hospitals, gaining the opportunity to work on their English with other nurses, doctors and patients. Reyes meets with the volunteers at lunch most days to discuss any language problems they may be facing.
The Dallas Chapter of NAHN also provides nursing review courses and helps candidates prepare for the NCLEX. The Houston program assists nurses who fail to pass the CGFNS Qualifying Exam by sending them to a local college to take a refresher class in the areas of nursing in which they scored poorly.
Licensing Has a Price
Many of the experts interviewed for this article believe there is still another area in which the NCLEX-RN playing field is not level: the costs associated with taking the exam. “For those in the minority community who may not be in the same socioeconomic bracket as majority candidates, there could be some disadvantages,” says Cooper. “First of all, [the cost of] taking the NCLEX alone is $300. Then on top of that, if you want to prepare for the test, you have to buy a review book and/or go to a review course. Either way, it’s more money out of pocket.”
Casquese Chaffin, RN, MSN, MA, a member of the Los Angeles chapter of the National Black Nurses Association, agrees that the cost of review courses could be a barrier blocking some minority students’ access to the licensing exam. She believes the foundations of large companies should be targeted to help foot the bill for such courses.
“These companies target their endowments [to causes] where they can ,” she contends. “It isn’t popular [to spend money] on review seminars for nurses. They won’t get a handshake for that. Until the minority community itself makes some noise–yells, screams and hollers–that won’t change.”
Money can be a big issue for international candidate as well. Munoz calls it the single biggest obstacle for nurses emigrating from the Philippines to the United States. Many Filipino nurses go to Faipan, a U.S. territory near Guam in the Pacific, to take the NCLEX exam before they come to America, and that travel represents an additional cost.
Perry’s Nurses Helping Nurses program is working to help immigrant nurses offset the costs of getting their credentials translated for CGFNS review, which can run as high as $70 per page. “We have found people who have been able to translate for us at a low cost,” she reports. “But you have to be careful. If CGFNS doesn’t think the translator is an acceptable source, they will send it back.”
Cooper thinks some minority students may not be aware of cost-cutting options available to help make the NCLEX process more affordable. “Every little bit helps,” she says. “I believe there are some [nursing employers] that offer reimbursements after new nurses take their boards and get their license. Whether it’s buying a used review book, spending an extra hour after seminar with your professor or even inquiring about a reimbursement at the hospital you applied to, it’s all more than worth it in the end when you get that license in the mail.”