In research released late this summer, Brad N. Greenwood, PhD, the lead author of “Physician-patient racial concordance and disparities in birthing mortality for newborns,” concluded that when Black newborns had care from a Black pediatrician, their mortality rate was decreased by half when compared to white babies.
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.
Nurses often care for patients with Alzheimer’s disease, and they also help families who are looking for guidance and resources. But many nurses also care for their own family members who have Alzheimer’s disease, and the high amount of energy spent caregiving on the job and at home is often challenging and can leave nurses depleted at home and at work. Designated as World Alzheimer’s Month, the focus on Alzheimer’s disease in September helps call attention to this devastating disease.
Cindy Keith, RN, BS, CDP, owner of M.I.N.D. in Memory Care, and author of “Love, Laughter & Mayhem – Caregiver Survival Manual for Living with a Person with Dementia,”offered some tips to nurses who also act as caregivers to loved ones with Alzheimer’s disease or dementia.
- Realize This Is a Delicate Balancing Act
“This type of caregiving is likely the toughest thing they will ever have to do,” says Keith about nurses who care for family members. “Not only must they balance their jobs with the ‘work’ at home, but they must also be cognizant of the fact that they may be (likely are) running themselves ragged trying to keep all the balls in the air.” Keith advocates for building mental health breaks into your schedule so you can continue to find the energy for so much. “Nurses cannot be a good caregiver when they are running on empty,” she says.
- Accept You Aren’t Superhuman
There is virtually no one who can take on the role of caregiver at work and at home singlehandedly without losing something in the process. “Get others to help,” she says. “Do not be shy about asking for help and then schedule that help in.” If a neighbor offers help, ask them to take the elder for a walk or just sit with your loved one while you go for a walk or run an errand. If you’re able to hire any kind of help, doing that will free up some time, and therefore, energy for your own life.
Keith says looking into resources including Meals on Wheels or something similar can take a big load off a caregiver. Faith communities often have members who drive elders to appointments, cook occasional meals, or offer companionship while you run an errand, catch up on laundry, or just take time for a cup of coffee. When you have others help you, make sure you use some of the time to recharge your own energy. “Just be sure to schedule in some time for yourself to do something you like that will reset your brain,” says Keith. Caregiving is exhausting.
- Gather Information Everywhere
Keith says you’ll find information in all kinds of places and in formats most useful to you. “Join a support group,” says Keith. “So many of my clients have been dragged kicking and screaming to support groups only to find they are a lifeline for them—and some continue to go to help others even after their loved one has passed on.” Sometimes a group may not be the right fit—for example you may want a group where the majority of the members are at a similar stage as you. If you find one group isn’t helping you, find another one and give it at least three tries, she says.
Keith also says the Alzheimer’s Foundation of America has excellent information for caregivers and there are many books that offer targeted information. Keith wrote her first book, “Love, Laughter & Mayhem – Caregiver Survival Manual for Living with a Person with Dementia,” to help answer some common caregiver questions. She also says “Elder Rage or Take My Father…Please!” is helpful for if a loved one is abusive or combative. “Creating Moments of Joy” by Jolene Brackey is also one she recommends.
- Take Care of Yourself
The constant demands of caregiving are stressful and can lead to burnout. Your level of stress has nothing to do with your love of the person you are caring for, it has to do with your need to take care of your own physical and mental health. “Don’t be afraid to seek professional help for yourself or your loved one,” says Keith. “This is a life situation that can quickly become a crisis and the more you know about it, the better prepared you will be when. not if, the crisis hits.”
Whether your classes were newly moved online due to coronavirus, or you’ve been enrolled in an online class from the get-go, nursing students all over the world have suddenly found themselves taking classes remotely. To help with the adjustment, here are our nine top tips for acing your online nursing classes.
1. Don’t assume online is easier.
Just because you can wear sweatpants, it doesn’t mean that online classes are a walk in the park. Plus, if you dress the part and wear your nursing scrubs, you’ll get into the nursing mindset. Some people make the mistake of assuming they can coast through an online class, believing that it will be easier than an in-person class. While online classes are certainly different from in-person ones, they’re not easier, just hard in a different way. Believing that you can slack off in your online classes purely because they are online will quickly lead to a failing grade. Taking it seriously from the beginning is the best recipe for success.
2. Get the equipment you need to succeed.
No, we’re not talking about clinical supplies. Take stock of what technology you currently have and what you might need to invest in. You’ll most likely need a reliable computer and other tools such as an external monitor, a mouse, and a keyboard as well. Test your internet connection and make sure that it can handle steaming lectures, video calls, and other high capacity tasks—the last thing you want is your internet cutting out in the middle of a quiz. If your internet isn’t up to the task, you might need to upgrade your plan or get a new router.
3. Embrace the possibilities of technology.
Online classes may be new and exciting territory for many people. They offer many fantastic possibilities for interactive learning that simply aren’t possible inside a physical classroom. In fact, many in-person classes still assign work that must be done online prior to class because the interactivity element of online programs can’t be reproduced. Online classes also allow you to connect with a much broader range of people from many different geographic areas, expanding your nursing network.
4. Participate digitally.
The words “class participation” probably conjure up images of raising your hand in class and speaking out loud to the group. While participation is definitely a part of online classes, it takes a different form. Usually, it means group forums where students host discussions on specific topics. It’s not the same as talking in person, but this format can actually be advantageous for quiet people who hate having to come up with comments on the fly. Due to the asynchronous nature of these message boards, you can read the discussion, take time to think it over, and post your comment when you’re ready.
5. Create a work from home space.
Even if you like to work from coffee shops or libraries, odds are that you’ll end up completing at least some of your classwork from home. If at all possible, try to create a work from home area outside your bedroom (you don’t want to associate schoolwork with your sleeping space). If that’s not possible, then at least set up a desk and chair so you’re not working from your bed. Try to place it near a window so you can take advantage of natural light. Be sure to set up some additional lamps, too, in case you end up working a lot at night.
6. Manage your time well.
Time management is one of the trickiest things for students to master during an online course, especially if the classes are pre-recorded and can be watched on-demand. Some people are distracted very easily, especially when working at home. They have every intention of watching that anatomy lecture and then end up spending an hour cleaning the house and folding laundry. Set aside blocks of time to work on your online classes and mark them off in your calendar, just like you would with an in-person class. Let your roommates or family know that you’re in school and ask them not to disturb you unless it’s an emergency.
7. Aim to turn your assignments in early.
Speaking of time management, turning in assignments early can help a lot with that. For in-person classes, you have to wait for the appointed day to turn in a physical paper. That’s not as much of a consideration for online classes. It’s a good idea to set a goal for yourself to turn in each assignment 1-2 days in advance. Even if you fall behind, which will happen eventually, you’ll still have that cushion built in so your assignment won’t truly be late.
8. Back up your work.
You should be doing this regardless of whether your nursing school classes are online or in person, but it’s doubly important for digital classes. Each week, if not each day, back up your work to an external hard drive as well as a cloud storage service such as Box, Dropbox, or Google Drive. If you must fill out quizzes or essays online, consider writing it in a separate document and then paste it into the field so you don’t lose your work if the submission doesn’t go through.
9. Ask for help.
Just because you’re physically alone in your house while you watch lectures doesn’t mean that you don’t have resources available to help. Your instructors should be able to help you via email, phone, or even video chat, and you also have your classmates to lean on. You might want to consider forming an online study group that meets regularly during Zoom calls to keep each other accountable. Don’t forget to explore any other resources offered for your classes, such as digital libraries.
Whether you’re taking online nursing classes by choice or not, digital courses are a new reality for today’s nursing students. Follow these nine strategies to knock your online nursing classes out of the park.
While industries attempt to address the spread of COVID-19, nurses have been working long hours, many times with insufficient personal protective equipment (PPE) and constantly changing state and federal requirements. They are also having to make ethical decisions about patient privacy, informing others of likely exposure, and patient treatment, and as the fight against the virus continues, we are seeing new and changing ethical issues arise.
The Code of Ethics for Nurses is the standard for ethical training and decision making, and is a resource that nurses are taught to know and implement. However, as the day to day operations of hospitals continue to be fraught with unexpected challenges, it is up to the frontline workers to fight for the ethical treatment of patients, families, and even themselves. As the front line personnel most intimately familiar with COVID-19 cases, nurses have a unique perspective on the effects that this pandemic is having on their communities and patients.
Knowing the available ethics resources, standing as an example of ethical conduct, and staying as up to date as possible on regulatory changes, are just the first steps in fighting for quality of care during this turbulent time. As a nurse in the midst of it, you can use the following tools to hold yourself, your colleagues, and your organization accountable.
Know Your Code of Ethics and Related Resources
The first step in being able to fight for strong ethical standards is knowing those standards yourself. Ethical nursing practices are taught using The Code of Ethics for Nurses, and there are now supplemental texts to deepen your understanding of how to apply them. Among them, The Code of Ethics for Nurses with Interpretive Statements, published in 2015, addresses especially difficult ethical situations such as crisis management and pandemics.
Staying up to date with the standardized documentation available will provide you with a framework for addressing new situations in conjunction with the help of your hospital or organization’s ethical resources. Organizational ethical support for nurses is a major necessity that your organization is obligated to provide, and institutions are not allowed to retaliate against nurses who bring concerns about their working conditions to management. These concerns may include unsafe exposure risks, physical safety, and the quality of ethical decision making by other personnel.
While simply knowing your ethical code cannot prepare you for all of the possible decisions you will have to make as a nurse, make sure to utilize the resources you can and bring any concerns to the attention of your organization’s management. By continuing to develop your understanding of ethical standards as they apply to the crises we are experiencing, you are better prepared to argue for both your and your patients’ safety.
Stay Up to Date and be Vocal
By staying as up to date as you can on your hospital’s current regulations, as well as government regulations, you can foster transparent communication between yourself and the organizations you interface with, making sure that you are working with the most recent information available. It is a difficult task as these regulations are changing daily, but keeping an eye on current regulatory requirements is important. This knowledge is the main factor in staying vocal in the workplace.
Addressing the ethical decisions of your colleagues can help save a patient’s life, limit spread to others in the hospital, and evaluate new symptoms of the virus. In the high-tension, high-stress situations that we are seeing right now, nurses are in a position to utilize strong ethical convictions and honesty to uphold their obligation to their patients and themselves. By staying vocal when you see a questionable decision made, bringing the information to management, and holding others accountable, you can be a force in maintaining an ethical workplace.
Part of ensuring the safety and well-being of patients is to ensure that those you work with are not endangering them. This could be simply a matter of fatigue, or of an inexperienced person attempting to complete a new procedure, but either could lead to a patient being injured or worse. Being aware of the ethical practices of those around you as well as their level of experience, is another way to help ensure that high-quality ethical practices are in place.
Stand as an Example
If you are working as a CNA, or in any other advanced position, new employees will look to you as an example of how to conduct themselves. After all, the codes of ethics apply not only to patient care, but to a nurse’s responsibilities to themselves and their team. By setting an active example for your colleagues, you can help create an environment founded on ethics that support the well-being of both patients and nurses.
There are basics of care that all nurses are trained in, including ways to protect a patient’s privacy, but we are experiencing a massive event that has taxed our medical system and its practitioners beyond any in recent history. Organizations are experiencing a lack of resources, personnel are working extremely long hours in high-risk environments, exhaustion is at a high, and newly trained medical professionals are being called on to make difficult decisions. In this environment, holding yourself to high ethical standards can help provide a path for others to follow.
Education, training, understanding, and action are all required to ensure the health and safety of patients, communities, and staff alike. While the mainstays of health and wellness are still important, the environment and stakes that medical professionals are working with have changed drastically. By fighting for ethical practices, you can become a part of the solution, and help ensure that patients, both yours and future ones, get the treatment that they deserve.
I’m doing laundry at a wash & fold in front of the house boats of Sausalito. Reminder: buy more scrubs. I’m one mile from from the hotel. Three minutes by car, 10 minutes by bicycle. The views are great. The weather is awesome. I could live here easy. Not on a house boat though.
They have a problem with the mating calls of some kind of small mud fish whose population has exploded. I guess it sounds terrible, like hammers on the hull all night long. Nature.
The hotel is a popular national chain brand in Mill Valley, gateway to Mount Tamalpais, and Muir Woods. It’s just north of San Francisco. I can just barely see Coit Tower. I’m maybe an hour and a half from my home so the commute would be brutal. The state is picking up the hotel tab thanks to a program authorized by the governor. It’s been a godsend.
The hotel is using the pandemic money to remodel. The room is nice, but there are sawzalls and hammers and loud Mariachi music playing during the day. At least I’m hardly ever there. They don’t clean the rooms as often because of the pandemic, but you can get fresh towels and coffee pods at the front desk any time.
The job is tedious, but not difficult. Basically, you make rounds on the prison population two times daily trying to root out COVID patients and separate them. I get there at 5:30 AM. There is a line to get through the gate. I have to sign four different log books in four different areas plus clock in with a time card.
We got a great tour of the prison on day one. The thing I remember the most is when the nurse educator guiding us said, “To everyone else they are prisoners, to us they are patients…all of them.” This dichotomy in mandates between prison staff and medical staff has allowed me to put the job neatly into my bailiwick. Nursing is nursing. The rest of it is for prison staff to handle.
The whole prison is on lock down. It’s quiet in the yards. It’s been grim. However there is hope. The numbers are improving. On my first day, there were over 1,300 patients in isolation. Two weeks later, the number is half of that. Everyone wears a mask. Infection control is taken seriously. Teams of nurses go out twice daily to assess the inmates. Other teams are doing COVID testing. Every staff member gets tested once per week. Cautiously, things are returning to a semblance of normalcy, whatever that means in a prison.
We pair up—an RN and an LVN—and grab our shoulder bag. Inside the bag is an IR thermometer, a pulse oximeter, a BP cuff, disposable PPE, alcohol wipes…sundries. When we get to our assigned area we put on the PPE and each team gets their own guard to keep them safe. “Don’t step into the cell, don’t put your face in front of the food port, don’t walk close to the cells…” Helpful advice and a sober reminder of the overlapping existence of prisoner and patient.
I’ve given careful thought to the nature of the job, the nature of crime and punishment, and the morally ambiguous task of providing competent health care to people who have committed terrible crimes. Thankfully, I’ve never followed crime stories. Having worked in the ER for many years, I’ve dealt exclusively with the aftermath of crime and the amelioration of its physical consequences…as best as can be done anyway. I have no curiosity about death row inmates. I can honestly say that I leave that at the door and look at each person strictly through the lens of health care. Having said that, I can tell from even the most cursory interactions with some of the patients that there are some seriously disturbed people within these walls. I’m happy to move along to lower level offenders.
From the ground, I can say the efforts to control the spread of COVID within the prison have been very successful. Again, I’m just the tip of the spear so the big picture is a little out of my view. But just judging from the numbers of patients I assess daily, things are improving very quickly. I guess that’s the benefit of working within a closed system…it was also that closed system that allowed the virus to spread so quickly in the first place, so there’s that. Wearing masks, social distancing, testing, contact tracing, quarantining…they have brought the cases of infection down so quickly that it’s possible that the job will end early. I’ll be sorry to leave. The pay is…generous.
The best part of the experience has been meeting new friends. Travel nurses are go-getters. I’ve met nurses from all over the world on this assignment. We share a common bond and have moved together from trepidation to confidence in this new role. We share stories in the break room and compare notes on our experience. Several nurses are staying in the same hotel that I am. It’s a great way to meet friends in our new socially isolated world. I hope that I have met lifelong friends here as I have on other contracts. The staff at the prison have been nothing but welcoming, same for my agency. A good experience from top to bottom.
The good news…or bad news depending on how you look at it, is that other prisons are experiencing similar outbreaks and will need COVID crisis teams to come in. There are already jobs being posted for other prisons in California. Susanville, San Lois Obispo, are two that I’ve seen. If you are interested in making some quick money, and are willing to shoulder some risk, I encourage you to contact a recruiter. The turnaround time for me was three days between first contact and clocking in. Be ready to move quickly. Have your documents together. The free hotel program is still in effect so your housing is covered. Stay safe out there.
Community health centers have taken on a big role in the nation’s healthcare as the COVID-19 pandemic has continued to impact the nation. Nurses who work in these centers find their skills in high demand.
According to the National Association of Community Health Centers (NACHC), federally funded centers provide essential access to primary care for people who may not be able to access it through traditional means. Whether there are barriers from language, income, lack of insurance, or transportation, these centrally located health centers remove many of those barriers to care.
Access to healthcare is especially important right now, as the coronavirus is having a devastating impact on communities that are predominantly of people of color and immigrants, and where people live in densely populated neighborhoods and homes. Many of these communities also have a high number of essential workers who must be out in the community daily—increasing the risks to their health and that of those around them. Some community centers provide care for rural areas, where there’s little access to healthcare, but still a high need. The Rural Health Information Hub offers a toolkit for healthcare workers in these areas.
The NACHC states that with the effective preventative care and emergency care, community health centers are able to divert people away from the emergency departments which may be their only viable healthcare option. In addition to healthcare, community health centers also offer or coordinate much needed services such as translation or interpreter services, transportation, and the case management of complex issues and conditions.
Staff also act as excellent community advocates and work to explain, distribute, and educate patients on health conditions, treatment options, home care, and disease management. By doing this, patients and their families can have better outcomes as they know how to manage all aspects of their health. Patients learn about any conditions or symptoms through education provided with a focus of culturally competent healthy practices and behaviors that will work for them.
As an affordable and viable option for approximately 29 million people in the United States, the nearly 1,400 community health center organizations nationwide provide a place where residents go for healthcare delivered by a staff that understands the specific details of their community and how those details can impact their health. Some states have organizations devoted to community healthcare, such as the Massachusetts League of Community Health Centers, that offer more information, resources, and history of these vital centers.
Nurses interested in a career working in community health can find out more through the American Public Health Association, an advocate for providing high-quality and effective public health options. A healthy community allows residents many more options, and community health centers help provide that lifeline.
From pregnancy and neonatal care to addiction or heart disease, community health nurses will see it all in their practices. It’s an excellent role for those who are committed to both lifelong learning and the foundation of a healthy community that is focused on equity.