Dr. Greenwood, an associate professor at George Mason University School of Business, took time to answer questions about this research.
Did you determine why Black babies have a better chance of survival?
I want to emphasize how cautious we need to be about speculating about the “why” question, because it is speculative. This is secondary data, so nailing down the exact mechanism is difficult, even if we do see the effect get larger in some places (hospitals that deliver more Black newborns) and smaller in others (Black newborns without comorbidities). But there are several possible explanations:
We want to be careful not to pathologize Black newborns, but there is evidence that Black newborns can be more medically challenging to treat due to social risk factors and cumulative racial and socioeconomic disadvantages of Black pregnant women. As a result, it may be that Black physicians are more aware and attuned to these challenges than white physicians.
Issues of spontaneous racial bias, which research does suggest manifest towards both adults and children, could also be at play. As a result, it is conceivable that the newborns are treated differently.
There may also be challenges accessing preferred caretakers for Black mothers, or an inefficient process of allocating physicians at the hospital level.
There is evidence in the literature that racial concordance increases trust and communication between patients and providers. While the newborn obviously won’t be speaking to the pediatrician, the mother may be, and this might have an effect.
All of these are possible, so we want to be very careful about the interpretation, since we cannot come down firmly on one mechanism or another. Likely, it is a mix of all these things and potentially more. What we do know is that the effect is persistent under a lot of conditions and gets bigger when Black newborns are born in hospitals which deliver many Black babies. This at least suggests part of the explanation may be institutional.
Your findings state that it doesn’t matter if the birth mothers share the same race as the physician. So if a white mom gives birth to a Black baby, the chances of the baby surviving are increased here as well if the doctor is Black?
When we are investigating the mother, the physician changes from being the pediatrician to being the obstetrician (the two physicians are almost always different). There is no spillover examination where we look at the effect of the mother’s physician on the newborn.
Why the effect doesn’t manifest for mothers is also speculative. While absence of evidence is not evidence of absence, it could simply be that maternal mortality is an order of magnitude lower than newborn mortality. It is also possible that there is no effect of concordance in these situations.
According to the Association of American Medical Colleges (AAMC) in 2018, 5% of all physicians identified as Black. If there are so few Black physicians overall, what will need to happen so that babies of color get the care they need to survive?What do your results mean for the care of newborn babies of color now and in the future? How can your study’s results impact the health care system for the better?How can health care workers prevent this disparity from occurring? If they can’t on their own, what needs to happen?
I will answer these all together as they seem to be related. The speculative nature of the mechanism, to me, highlights that more research is needed to understand the precise dynamics behind the finding. Specifically:
whether physician race serves as a proxy for differences in physician practice behavior,
if so, which practices, and
what actions can be taken by policy makers, administrators, and physicians to ensure that all newborns receive optimal care.
The work, in my mind, is a starting point. It identifies an issue that is a real problem and provides some paths forward. But a lot of work remains to understand the issue in its entirety.
More directly to your question, I also think the work underscores the need to continue the diversification of the medical workforce. Inasmuch as research suggests stereotyping and implicit bias contribute to racial disparities in health outcomes, I think the work also highlights the need for hospitals and other care organizations to invest in efforts to reduce such biases and explore their connection to institutional racism. But the effort doesn’t simply rest on the shoulders of hospital administrators. Reducing racial disparities in newborn mortality also requires raising awareness among physicians, nurses, and other health care actors about the prevalence of these disparities, furthering diversity initiatives, and revisiting the organizational routines in low performing hospitals in order to determine why these effects persist.
What is key is that we identify high performing physicians, teams, and acute care centers, identify what makes them higher performing, and then promulgate that information to lower performing locations.
What else should our readers know?
There is one thing I think bears specific note. One conclusion we have heard is that this means Black newborns should immediately be funneled to Black physicians. There are three critical flaws with this logic:
The disproportionately white physician workforce makes this untenable because there are too few Black physicians to service the entire population (5% of practitioners vs 13% of the population). This would mean the market is functionally underserved as you highlight above.
It avoids the foundational concern of resolving the disparities in care offered by white physicians. This would mean that even if improvements are made there is still the chance that a newborn would not receive sufficient care in an emergency situation.
Physician performance varies widely among physicians of both races. There are tremendous physicians of both races, and there are underperforming physicians of both races too. So it isn’t really an effective selection criteria.
What we have is a situation where structural issues are causing babies to die. I don’t think any of the members of the coauthor team would claim this is a function of malice on the part of physicians. But if we are going to solve the problem, we first need to acknowledge that disparities of care exist. Once we do that, we can start to fix them.
Flight/Transport nurses travel throughout the country and even throughout the world. An issue in the field, though, is that not many minorities are choosing this line of work. So, how can we attract more minority nurses to flight nursing?
Bob Bacheler, MSN, CCRN, CFRN, Managing Director of Flying Angels, as well as a Board Member at Large for the Air & Surface Transport Nurses Association (ASTNA), brought this to our attention. He then took time to answer questions about why more minorities aren’t in this line of nursing world and how they can become involved if they want to pursue it.
About how many flight nurses are there in all? Do you know what percentage are minorities? Why do you think that there has been a historic underrepresentation of minority nurses in the transport nursing field? Why aren’t more BIPOC working in this field?
The shortage in minority nurses is not unique to transport/flight nursing. According to the 2017 National Nursing Workforce Survey, the nursing profession is comprised of a workforce which is predominantly female and Caucasian. Eighty-percent of all nurses identify as white, twenty percent of all nurses are BIPOC, and seven percent of the overall nursing workforce is male (2017 National Nursing Workforce Survey).
Of the overall nursing workforce, over 165,000 nurses are providing direct patient care in the transport environment (Board of Certification for Emergency Nursing (BCEN)). The flight nurse workforce trends higher in male nurses (18% in flight nursing compared to 7% overall), but lower in the percentage of BIPOC nurses (13% compared to 20% overall). Given the competitive nature getting into flight nursing, it’s beneficial for potential applicants to get their Bachelor’s or even Master’s degrees and certifications such as Critical Care Registered Nurse (CCRN), Certified Emergency Nurse (CEN), Trauma Certified Registered Nurse (TCRN), Transport Professional Advanced Trauma Course (TPATC) and/or Certified Pediatric Emergency Nurse (CPEN).
Becoming a Transport/Flight RN is only the beginning of the educational process. Obtaining certifications such as Certified Transport Registered Nurse (CRTN) or Certified Flight Registered Nurse (CFRN) requires considerable effort. Maintaining those certifications as well as usual requirements of most positions require continued education. According to BCEN, the average transport RN has 16 years of experience, with 78% holding a Bachelor’s degree or higher, which is far higher than the average RN population. Most of the applicants for Transport/Flight Nurses come from critical care nursing positions.
While the underrepresentation of BIPOC in flight nursing could possibly be attributed to a number of factors, a primary factor could be lack of access to the licensure requirements/higher education credentials necessary to obtain a flight nurse position. According to the American Association of Colleges of Nursing (AACN) report on 2018-2019 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, nursing students from minority backgrounds represented only 34.2% of students in entry-level baccalaureate programs, 34.7% of master’s students, 33.0% of students in research-focused doctoral programs, and 34.6% of Doctor of Nursing Practice (DNP).
According to the 2018 AACN Healthy Work Environment National Workforce Survey Results, minority representation in critical care nursing has only increased slightly from 14% to 20% in the past 15 years. As identified earlier, critical care nursing is one of the primary career pathways to transport/flight nursing. Public policy interventions that would increase minority access to higher education could help to increase the number of minority nurses who enter the critical care nursing field, which would eventually increase the available pool of qualified applicants for transport positions.
Why are companies looking to hire BIPOC as transport nurses? What do they bring to the field?
As the percentage of BIPOC population increases nationally, companies realize that patients are often best served when the flight RN reflects the community they are serving.
Explain what a flight nurse does. Would someone need to get additional credentials to become a transport nurse?
Flight nurses are registered nurses that have specialty training to provide medical care as they transport patients in either rotor (helicopter) or fixed-wing (plane), or either by air ambulance or commercial aircraft. Flight nurses work with other trained medical professionals like paramedics and physicians. Helicopter RNs are often called upon to help transport critically ill or injured patients to trauma centers. Air Ambulance RNs are often transporting ICU level care patients long distances.
With Commercial Medical Transport, which is Flying Angels’ specialty, RNs are tasked with accompanying patients on commercial airlines transporting patients around the country and the world. These are people who need to be transported long distances, and while they do not need the ICU level of care provided by an Air Ambulance, they do require a nurse with significant experience and skill.
What are some of the benefits of working as a flying nurse? What are the challenges?
Each specialty—Rotor Wing, Air Ambulance, Ground Ambulance, and Commercial Medical Escort—have their own rewards. All have a higher degree of autonomy than nurses who work in hospitals. Rotor Wing nurses are saving lives every day, transporting critically ill patients from trauma scenes to hospitals. Air and Ground Ambulance RNs are practicing at the peak of their skills, in cramped quarters to make sure people are where they can get the best care. Commercial Medical Escort RNs are often reuniting families around the country and the world. In many cases, they are getting people home who would otherwise have no way of getting there. All share in the reward of doing good for their patients as well as sharing a high degree of job security.
Why do you think more minorities should look into this as a career choice?
All Transport/Flight RNs practice the peak of their skills and enjoy tremendous job satisfaction. Opportunities for Transport/Flight RNs are growing each year. Transport/Flight RNs enjoy an esprit de corps and a sense of community. They are also some of the highest-paid nurses working.
What would readers be most surprised about regarding being a flying nurse?
Being a Transport/Flight RN is often hard work, in cramped quarters, for long hours. The emotional toll can be draining. Adjusting to jet lag/time zone transferring can often prove to be difficult.
Is there anything else that is important for our readers to know?
Professional associations in transport/flight nursing promote the esprit de corps. These associations give you a place where you can connect with others and share best practices. Join a professional organization such as ASTNA, which has an employment job board, and attend conferences such as the Air Medical Transport Conference (AMTC).
The Supreme Court of the United States recently ruled to strike the Patient Protection and ACA’s requirement for health insurance plans to cover the total costs of contraception. The American Nurses Association (ANA) released a statement about their disappointment in this ruling.
We interviewed Cheryl Peterson, MSN, RN, the ANA Vice President of Nursing Practice and Work Environment about ANA’s stance and what this ruling means for the nation.
Why is ANA disappointed in the recent ruling of the Supreme Court to strike down the Patient Protection and ACA’s requirement for health insurance plans to cover the total costs of contraception?
ANA firmly believes all people have the right to determine how and in what form they receive health care. This recent decision from the Supreme Court affects millions of women and health care consumers who have depended on this mandate to offset some of the costs of reproductive health care. For some people, contraception can be a considerable expense. During this COVID-19 pandemic, many people are furloughed or receiving a limited income. Therefore, they may have no choice but to go without contraception health services.
Why is ANA taking a stand on this?
The American Nurses Association (ANA) has advocated for not only nurses, but for quality health care of all people—for decades. With regard to the recent SCOTUS decision on the ACA contraception mandate, we must ensure that all women and health care consumers are provided equal access to quality health care and are provided the proper counseling. All patients have a right to make their own decision about their medical care and treatment.
What do you think is going to happen to the women who counted on this coverage? Why? Do you think this may result in more unplanned pregnancies?
Unfortunately, many women are already facing tough economic challenges due to the COVID-19 pandemic. These women might have to compromise other necessities to obtain contraception coverage or may even have to sacrifice their own reproductive health because they simply don’t have the financial means to obtain these health services. The latter scenario could possibly lead to unplanned pregnancies.
What can be done to help them? What can nurses do in their proverbial “own back yards” to help these women?
Nurses can use their voices to educate women on what their best options are for affordable, quality reproductive health care, which includes contraception and contraception counseling. Nurses can also provide insights and advice on types of contraception for women with particular health needs and concerns.
What kind of challenges is the Supreme Court’s ruling going to cause?
Decisions regarding reproductive health and family planning are inherently personal. The outcome of this ruling jeopardizes a women’s ability to collaborate with her trusted primary health care provider or see the same practitioner for follow-up visits. In addition, this could result in reduced access to crucial and medically necessary health care services and the further exacerbation of health disparities.
Are there any other places that may cover the cost that remains for contraception?
Title X family planning programs have a decades long history of bridging gaps and providing comprehensive family planning and preventive health services to individuals needing access to these services.
Milestones are a big deal, and they are often times of celebration. Throughout July, that’s exactly what the Board of Certification for Emergency Nursing (BCEN) has done. This month marks the 40th of the Certified Emergency Nurse (CEN) as well as of the emergency nursing specialty certification. What makes this all even more significant is that the CEN was the first emergency nursing specialty certification offered anywhere in the world.
“As emergency medicine was becoming recognized as a specialty, emergency nurses formed the Emergency Department Nurses Association (today’s Emergency Nurses Association) and in the mid- to late-1970s recognized the need for a certification program for emergency nurses. Thanks to the forethought and efforts of the association and some extraordinary nurse-pioneers, the Board of Certification for Emergency Nursing (BCEN) came into being and several years after its creation was purposefully separated from the professional association to become a fully independent certification body,” explains Janie Schumaker, MBA, BSN, RN, CEN, CENP, CPHA, FABC, the Executive Director of BCEN, which is based in Oak Brook, Illinois.
Taking that first CEN exam was much different than it is today. “During BCEN’s first full year of operations in 1980, the very first emergency certification exam was offered on July 19 at over 30 sites around the country, including Alaska,” says Schumaker. “More than 1,400 RNs took the four-hour, 250-item, pencil-and-paper exam. After waiting several weeks for notification by mail, 1,274 nurses received the news that they had passed and became the first RNs to earn the Certified Emergency Nurse (CEN) credential.
“While BCEN has operated independently from ENA for many decades, we support each other and strongly believe professional membership and board certification are both important for RN success and to advance nursing excellence across every nursing specialty.”
Two years later, in 1982, that number of nurses who held the CEN had increased to 6,000. By 2005, 23,000 nurses held a CEN. By the end of 2020, BCEN expects to have 40,000 CENs.
“As the years went by and emergency nursing knowledge and patient care needs evolved, for instance with the introduction of medevac flights and taking into the consideration the unique physiology of pediatric patients, BCEN developed and introduced certification programs for flight nurses, the Certified Flight Registered Nurse (CFRN®) in 1993, the Certified Transport Registered Nurse (CTRN®) in 2006 for critical care ground transport nurses, and the Certified Pediatric Registered Nurse (CPEN®) in 2009. BCEN’s newest certification, introduced a little over 4 years ago (in 2016) is the Trauma Certified Registered Nurse (TCRN®) for nurses who practice across the trauma continuum from prehospital care to rehabilitation and including injury prevention. This is our fastest growing certification program, which is not surprising given that trauma is a major public health issue affecting people of all ages,” says Schumaker.
And BCEN keeps making sure that nurses can learn more. This past May, it began offering its first certificate program BCEN EDvantage.
Schumaker, a certified nurse, says that she is sure the skills she learned through becoming certified saved lives. “Once the connection between my knowledge, the care I was providing, and the correlation to studying for the Certified Emergency Nurses exam was clear to me, I became a lifelong certification advocate. I have since become certified in other areas of practice that have been a part of my career. Certification has helped ensure I have the knowledge and expertise to do the best possible job in my given role,” says Schumaker. “To me that is huge because I want to be a strong contributor and make a difference.”
Advance Your Career and Become a Certified Emergency Nurse!
As a certified emergency nurse, you will work in a fast-paced hospital-based or standalone emergency department, providing urgent care to patients who need immediate medical attention for a variety of conditions including injury, trauma, or illness.
In 2001, Noriyuki Matsuda, CEO of Sourcenext, realized a need—people wanted to be able to understand others when they didn’t speak the same language. He wanted to create a mechanism that could do this. But at the time, the hardware and software to make this happen didn’t exist. What he envisioned would eventually be known as Pocketalk.
By early 2020, Pocketalk launched their latest device. When COVID-19 hit the United States, the company started a relief program that donated 850 Pocketalk devices to first responders and health care providers on the front lines.
Matsuda talked with us about their relief program and how Pocketalk has helped so many across the country during this stressful time.
Why did Pocketalk feel it was needed to come up with a relief program?
Creating connections and enabling conversations is at the heart of why I founded Pocketalk. Before coming to the U.S., I saw people firsthand in Japan using Pocketalk to hold conversations in different languages and break down cultural barriers, reaffirming our need to take Pocketalk to the rest of the world.
Japan was one of the first countries affected by COVID-19. I started to think about the true mission of Pocketalk, after witnessing the impact the pandemic was having on our communities. And then, I saw the Diamond Princess cruise ship quarantined at Yokohoma, where Pocketalk helped staff members provide information and updates to concerned passengers quickly and accurately.
I wanted to—we had to—do more to help others during this time of need, and that is what led to the creation of our relief program.
We initiated the Relief Program in the U.S. in March because we knew we had the resources to be helpful for hospitals and first responders, and we wanted to give back during this global health crisis by providing translation services to those in most need. We set out to donate 600 Pocketalk Classic units to qualifying medical facilities, first responders, testing sites, and those in need of translation services. Units were given out on a first-come, first-served basis to those that applied through our website, with a maximum of three units per organization.
Over the course of just three weeks, the Pocketalk Relief Program saw widespread interest from all corners of the U.S. and officially donated more than 850 Pocketalks to qualifying applicants in 41 states to aid in the fight. We hope to be able to continue to give back to the medical community, especially during this time of great need.
Explain to our readers what Pocketalk is. How does it work? How many languages can it translate?
Pocketalk is a multi-sensory, two-way translation device. With a large touchscreen, noise-cancelling microphones and a text-to-translate camera, Pocketalk is able to create connections across 74 different languages. It’s equipped with high-quality, noise-cancelling microphones and two powerful speakers so it’s easy to have full conversations, even in noisy environments. The camera instantly recognizes and translates text, the written word, and signs. A large touch screen provides a text translation for additional clarity.
It seems that Pocketalk was initially designed for businesses/companies. Has it been used by health care workers from the start or did that come about because of the COVID-19 outbreak?
While we appeal to a variety of businesses and individuals who travel for both work and leisure, we knew we also have the technologies capable of helping many people in important industries to perform crucial day-to-day tasks. This includes teachers in our education system who work with students and parents who may not speak English as a first language, medical professionals and first responders who need quick, accurate translations on the job, and flight attendants who require translation services when assisting passengers.
Over the last few months as our world has changed, the need to share Pocketalk with health care professionals and first responders, as well as other industries, has grown immensely. Prior to COVID-19, Pocketalk was already in use at hospitals across Japan—including at the National Cancer Research Center and Ehime University General Hospital—to handle the influx of hospital visits by foreigners.
Pocketalk has also been increasingly used in the classroom by teachers and by volunteers in Minneapolis helping on the ground during recent protests and cleanup efforts. As these opportunities became more apparent, we wanted to do our part to give back to those making differences in their communities.
How has Pocketalk been helpful to first responders and medical professionals?
There are many beneficial features and aspects of Pocketalk offering critical value to medical professionals during the coronavirus outbreak. Our handheld translator is designed for accurate two-way communication at the touch of a button, reducing the time needed to communicate with patients. With the ability to translate 74 languages addressing 90% of the world’s population, Pocketalk also ensures that medical professionals can communicate with most, if not all, potential patients that come to their facilities in an emergency. While Pocketalk is able to support translation in emergencies, it can also be used by medical professionals to help with daily tasks, such as talking with family members of patients and communicating with patients who need assistance throughout the day, such as the need for an extra pillow or a meal.
Most importantly, Pocketalk eliminates the need for a human translator, reducing any human translators’ risk of exposure to COVID-19 and other contagious diseases. By dedicating ourselves to developing a product that is accurate, quick, and efficient in high-risk situations like those in the medical industry, we are trying to do our part to keep people safe and well-equipped to handle any translation challenges.
Do you have any anecdotes you can share about how they’ve made a difference?
After conducting our relief program, we did hear back from a number of members in the medical community about how Pocketalk has made a difference on the job after only a few weeks.
One respondent, an advanced emergency medical technician, told us that he was able to use Pocketalk to attend to and triage three different patients—who were native Vietnamese speakers and the other a native Spanish speaker. “What typically took 30 minutes, only took five minutes,” said the respondent.
An emergency medical specialist has spoken about Pocketalk’s immediate impact in the ER, noting how much easier it is now to talk with patients for quick reassessments and during critical moments without having to call a human translator. They said, “It’s in my whitecoat pocket on every shift.”
Is there anything else about Pocketalk or your relief program that you think is important for our readers to know?
As our world continues to tackle COVID-19, we are identifying other ways in which we can help other communities in other industries. Translation services are in higher demand right now not just within the medical community, but within other industries. Translators without Borders recently gave community organizations open access to their services, after receiving multiple requests from local organizations and nonprofits that need to translate information for their non-English speaking community members.
In addition to medical professionals, Pocketalk relief units were also given to members within other industries to help with translation needs. While most units were given to doctors and nurses in hospitals, a number of units were also given to workers in fire departments, law enforcement and pharmacies.
This is a time for us to come together as one voice made of many languages to help each other through the power of connection.
Starting now, medical professionals and first responders can purchase a Pocketalk Classic for $129 ($70 discount) using the special code MinorityNurse70 at discount–while supplies last.