Coping with the potential loss of one’s child is a devastating experience, and cultural influences may further hinder the opportunity for the integration of pediatric palliative care. A 2008 survey published in Pediatrics reported that over 40% of health care providers identified cultural differences as a frequently occurring barrier to adequate pediatric palliative care. Children with life-limiting illnesses deserve a cultural reassessment of how we care for them when the goal of care has changed from curative to palliative.
The concept of cultural competence and its necessity in the treatment of diverse patients
has come to the surface of the medical community within the last decade. Health care providers must demonstrate knowledge and respect of individual as well as group value systems to become effective in providing care to this population. In response to the United States becoming increasingly multicultural, the Institute of Medicine has published two reports that support the need for cross-cultural training: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare and The Future of Nursing: Leading Change, Advancing Health.
According to the American Academy of Pediatrics, the goals of pediatric palliative care are the same goals as adult palliative care, which includes providing support and care for pain, psychological and social stress, physical symptom management, and spirituality. However, the difference regarding pediatric palliative care is that the focus is specifically aimed at serving the needs of the child as well as the family. A challenge specific to pediatric palliative services is that end-of-life care for a child seems inherently unnatural in the mind of many parents and family members who often struggle to accept that nothing more can be done for a child.
The literature frequently references the underutilization of palliative care services among ethnic minorities, including African American, Latino, Native American, Russian, and Vietnamese cultures. The following attributes have been identified in the literature as a source of underutilization: a lack of the family’s familiarity with hospice and palliative care services; language barriers; religious differences; difficulties in accessing insurance; distrust of the health care services; and discomfort with introducing additional health care with professionals not of one’s ethnic or cultural background.
In 2002, the Initiative for Pediatric Palliative Care (IPPC) published recommendations for providing culturally sensitive end-of-life care that utilizes a framework that includes: improving pediatric palliative care by maximizing family involvement; understanding the influence of religion in pediatric palliative care; and understanding how culture influences lifestyle and shapes the universal experiences of illness, pain, and death across the cultural barriers. An appreciation for cultural norms and customs is critical if we are to be successful in supporting the child and the family in reducing suffering and providing comfort and support.
Cultural Influence in Decision Making
As a result of the IPPC recommendations, several organizations have created reference materials and guidelines for clinicians to use. For instance, the University Of California School Of Nursing published Culture and Clinical Care, which discusses culturally competent care across 35 cultural groups. The University of Washington Medical Center (UWMC) offers Culture Clues fact sheets of useful tips when communicating with Latino, Russian, and Vietnamese cultures (among others). The journal Palliative and Supportive Care published an article in 2013 comparing cultural and religious considerations in pediatric palliative care. These resources cited the following cultural differences in end-of-life decision making:
• Many aspects of African American culture today reflect the culture of the general U.S. population.
• The structure in African American families is often nuclear and extended with nonrelated “family” members.
• The family may be matriarchal, although father or mother may take on the decision-making role.
• Family involvement is very important in the Latino culture.
• The family-centered model of decision making is highly valued and may be more important than patient autonomy.
• The mother is typically regarded as the primary caregiver and often will make the decisions regarding care; however, when possible, Latino women will seek permission of the child’s father before a decision is made regarding continuing or discontinuing treatment.
• Often, when language becomes a barrier, the normative hierarchical family structure is waived and deferred to the family spokesperson who speaks the best English.
• Given the importance of family in the Native American culture, the entire family may be included when making decisions and signing documents.
• Native Americans may also desire that information is shared with community leaders so that they can assist in the decision-making process for the child.
• Health care information is shared with family members.
• The entire family makes decisions along with the patient, and the person closest to the patient often has the most influence.
• The doctor—not the nurse—is expected to share the patient’s prognosis with the patient and family, as he or she is typically regarded as the ultimate authority in all medical matters.
• Family has a central role.
• Decisions are often the responsibility of the eldest male, yet older women may also have significant influence.
• Traditionally, the eldest male is the family spokesman; however, the person with the best English often assumes this role.
• Removal of life support may require extensive family discussion, which places the responsibility for the decision on the entire family instead of one individual.
Importance of Faith and Religious Traditions
Faith and religious traditions are held of great importance in the majority of cultures; however, it is important to note that cultural traditions are dynamic and cannot be generalized to all families. While guidelines may offer an approach to religious considerations pertaining to end-of-life care, the provider must perform an individual assessment of the family as to their beliefs and practices. The UWMC’s tip sheets and the 2013 study in Palliative and Supportive Care offer a glimpse of the cultural differences in religious traditions during end-of-life care:
• Death rituals for African Americans vary widely, related to the diversity in religious affiliations, geographic region, education, and economics.
• Emotional expression varies; you are likely to see a mix ranging from public displays of crying and wailing to silent and stoic behavior.
• Death is not viewed as a formal break with life, given the belief that the spirit/soul continues and may be able to interact from the next plane of existence.
• Bereaved African Americans are more likely to seek help from clergy than from health care professionals.
• Depending on their specific cultural beliefs, African Americans might involve a healer or “root worker” whose role is important in orchestrating the natural, spiritual, and relational aspects of life.
• African Americans often rely on the health care team for help with cleaning and preparation of the body.
• African Americans may refuse to stop life-prolonging treatments because of belief in divine rescue.
• Prayer and ritual may be a part of the end-of-life process for the patient and family members.
• Latino families may request that they keep candles burning 24 hours a day as a way of sustaining worship. Since candles are not permissible in hospital settings, the suggestion of using electric candles is often viewed as an appreciated gesture of respecting one’s beliefs.
• The patient and the family may wish to display pictures of saints, as saints have specialized as well as general meanings for Catholics.
• Some Latino families may want to honor their deceased relative by cleansing the body.
• The last rites are often important for Latinos who are Catholic when a person is close to death. If your patient is Catholic, ask about their preference and plans for this ritual.
• Latinos often demonstrate wailing and strong emotions at the time of death, which may be considered a sign of respect.
• Death rituals among the Native American tribes vary widely because they all have different religious and spiritual beliefs. It is important to assess the religious practice of the individual and follow accordingly.
• Native Americans may wish to seek traditional healers for help in restoring harmony of life.
• Herbal remedies may be used in healing ceremonies.
• The medicine man or spiritual leader leads the ritual.
• The circle is symbolic in the ritual, as in the circle of life; therefore, the family and relatives may form a circle around the patient’s bed.
• Native Americans follow the belief that the spirit of the person never dies.
• Silence is highly valued.
• Native Americans may be hesitant to sign advanced directives or other end-of-life documents because of general mistrust related to past misuse of written treaties and documents with the U.S. government.
• Russians may practice different denominations. Depending on the denomination, the family may desire to have a pastor, priest, or rabbi present at the moment of death.
• The family plays a major role in supporting the sick. Usually, there is a family member present at the bedside to attend to the patient at all times.
• Russians who practice their religion may consider prayer an important and powerful healing tool.
• In the Russian culture, relatives and friends are all expected to visit the patient. They frequently bring food and may include gifts for the clinicians as a sign of respect and thanks.
• Wailing and other displays of grief may not be demonstrated as they may be reserved primarily for expression in the home (as opposed to public display).
• Often, the family may have some specific practices for washing the body after the death. It is important to ask about preferences and try to accommodate.
• It is important to note that there are a variety of Vietnamese cultures and religious practices. Most Vietnamese are Buddhist; however, other religious preferences include Catholic, Evangelical Protestant, and Chinese Confucianism.
• Vietnamese who practice the Buddhist faith may call a monk to give blessings. Buddhist patients and family may chant and create an altar for prayer. Vietnamese who are Catholic may ask for a priest for last rites.
• In the Vietnamese culture, white is considered the color for mourning.
• The expression of grief varies in the Vietnamese culture. Families may express grief with either a stoic response or with crying and weeping.
• Upon death, organ transplant and/or autopsies may be accepted by the Vietnamese family with very careful explanation.
• The bereavement process of the Vietnamese culture has an extremely positive impact on family health. There is intensive and extensive community involvement with frequent visits from family and friends when death first occurs and then visits are slowly weaned off over a 2- to 3-year period.
Today’s multicultural society presents health care providers with unique challenges for providing cultural care and competence to the pediatric palliative care population. This article attempts to provide insight to but a few of the cultures that we may come across in our practice. Every person is unique, and clinicians who understand their patients’ cultural values, beliefs, and practices are more likely to have positive interactions with their patients and provide culturally acceptable care.
In nursing school, we were often told by our instructors to “treat the patient as you would want to be treated.” When it comes to treating patients with a different cultural background, this mantra should translate to “treat your patients as they want to be treated instead of how you would want to be treated.”
Karen J. Smith, MSN, CRNP, NP-C, is a doctoral nursing student at Wilkes University in Wilkes-Barre, Pennsylvania. Her background includes hospice and palliative care, and she has written health-related articles for West End Happenings.
The first national study on Hispanic health risks and leading causes of death in the United States by the Centers for Disease Control and Prevention (CDC) showed that similar to non-Hispanic whites (whites), the two leading causes of death in Hispanics are heart disease and cancer. Fewer Hispanics than whites die from the 10 leading causes of death, but Hispanics had higher death rates than whites from diabetes and chronic liver disease and cirrhosis. They have similar death rates from kidney diseases, according to the new Vital Signs.
Health risk can vary by Hispanic subgroup. For example, nearly 66% more Puerto Ricans smoke than Mexicans. Health risk also varies partly by whether Hispanics were born in the United States or in another country. Hispanics are almost three times as likely to be uninsured as whites. Hispanics in the United States are on average nearly 15 years younger than whites, so taking steps now to prevent disease could mean longer, healthier lives for Hispanics.
“Four out of 10 Hispanics die of heart disease or cancer. By not smoking and staying physically active, such as walking briskly for 30 minutes a day, Hispanics can reduce their risk for these chronic diseases and others such as diabetes,” says CDC Director Tom Frieden, MD, MPH. “Health professionals can help Hispanics protect their health by learning about their specific risk factors and addressing barriers to care.”
This Vital Signs report recommends that doctors, nurses, and other health professionals
• work with interpreters to eliminate language barriers when patients prefer to speak Spanish.
• counsel patients with or at high risk for high blood pressure, diabetes, or cancer on weight control and diet.
• ask patients if they smoke and, if they do, help them quit.
• engage community health workers (promotores de salud) to educate and link people to free or low-cost services.
Hispanic and other Spanish-speaking doctors and clinicians, as well as community health workers or promotores de salud, play a key role in helping to provide culturally and linguistically appropriate outreach to Hispanic patients.
The Vital Signs report used recent national census and health surveillance data to determine differences between Hispanics and whites, and among Hispanic subgroups. Hispanics are the largest racial and ethnic minority group in the United States. Currently, nearly one in six people living in the United States (almost 57 million) is Hispanic, and this is projected to increase to nearly one in four (more than 85 million) by 2035.
Despite lower overall death rates, the study stressed that Hispanics may face challenges in getting the care needed to protect their health. Sociodemographic findings include:
• About one in three Hispanics have limited English proficiency.
• About one in four Hispanics live below the poverty line, compared with whites.
• About one in three has not completed high school.
These sociodemographic gaps are even wider for foreign-born Hispanics, but foreign-born Hispanics experience better health and fewer health risks than U.S.-born Hispanics for some key health indicators, such as cancer, heart disease, obesity, hypertension, and smoking, the report said.
The report also found different degrees of health risk among Hispanics by country of origin:
• Mexicans and Puerto Ricans are about twice as likely to die from diabetes as whites. Mexicans also are nearly twice as likely to die from chronic liver disease and cirrhosis as whites.
• Smoking overall among Hispanics (14%) is less common than among whites (24%), but is high among Puerto Rican males (26%) and Cuban males (22%).
• Colorectal cancer screening varies for Hispanics aged 50 to 75 years.
• About 40% of Cubans get screened (29% of men and 49% of women).
• About 58% of Puerto Ricans get screened (54% of men and 61% of women).
• Hispanics are as likely as whites to have high blood pressure. But Hispanic women with high blood pressure are twice as likely as Hispanic men to get it under control.
“This report reinforces the need to sustain strong community, public health, and health care linkages that support Hispanic health,” says CDC Associate Director for Minority Health and Health Equity, Leandris C. Liburd, PhD, MPH, MA.
As the United States becomes more of a melting pot, encouraging and nurturing a workplace that welcomes the different cultures, ethnicities, and lifestyles of staff are paramount to optimal collaboration, productivity, and success. In health care, where diversity increasingly is exemplified among patients as well as employees, such an embrace is critical to achieving best outcomes.
Health care institutions across the country are heeding the call for inclusion. Many have implemented initiatives to not only attract diverse staff, but also to keep and engage them.
The Mayo Clinic in Rochester, Minnesota, for instance, launched the Multicultural Nurses Mayo Employee Resource Group (MNMERG) in July 2014 to recruit and retain nurses from diverse cultures and offer them professional support and networking opportunities. The MNMERG also mentors and educates Mayo’s diverse nurses and involves them in community programs.
With some 25 members, the MNMERG welcomes all Mayo staff. It meets monthly at the hospital, but this year will add quarterly dinners off site and is evaluating online technologies such as Skype and Sharepoint to “engage a 24/7 workforce,” says MNMERG cochair Deborah A. Delgado, MS, RN-BC, a nursing education specialist in psychiatry.
Mayo Employee Resource Groups (MERGs) have been an important component of Mayo’s overall diversity initiative; the goal is to have the following five core MERGs—African American, LGBTI, Hispanic, Disability, and Veterans—at Mayo’s three major clinical sites. Each MERG has an executive sponsor who is a leader at Mayo, but not a member of the group. For example, the MNMERG’s sponsor is a male cardiologist with experience in developing family/patient advisory groups. All of Mayo’s MERGs have formally chartered to align with at least one of the organization’s strategic diversity goals.
“These range from culturally competent care to inclusion and addressing health disparities,” says Sharonne N. Hayes, MD, FACC, FAHA, director of diversity and inclusion and professor of medicine at the Women’s Heart Clinic at Mayo. She notes that the groups share innovations and hold cross activities. “By that collaboration,” she says, “you get more hands to do the work obviously, but you also get a wonderful side product of some cross-cultural mentoring and some cross-cultural experience.”
While the MNMERG is in its infancy, feedback has been positive. “By being visible, by engaging, and by contributing, it just leads to retainment,” Delgado offers. “People want to stay because they’re able to use all of their gifts and talents to affect the organization’s purpose and goals.”
The Clinical Leadership Collaborative for Diversity in Nursing (CLCDN) at Massachusetts General Hospital in Boston has realized recruitment and retention success with diverse students of nursing. A scholarship and mentoring program established in 2007 by Partners HealthCare (PHC), an integrated system of which Mass General is a member, the CLCDN draws applicants from the nursing program at University of Massachusetts Boston.
Students must demonstrate leadership qualities, have cumulative general and nursing GPAs of 3.0 or higher, and must be entering their junior year of study since the CLCDN will carry them through their senior year. They link with racially and ethnically diverse nurse mentors, attend unit meetings and social and educational events, and observe nurses and nursing leaders in action. Additionally, they receive a stipend and financial support for tuition and fees with the expectation they will pursue employment at a PHC institution after graduating.
“When you’re a minority and you’re going into an environment where you might be the only diverse person on your clinical unit, as an example, it can be really challenging; it can be very lonely,“ says Gaurdia E. Banister, PhD, RN, FAAN, the PHC CLCDN liaison to UMass Boston and executive director of the hospital’s Institute for Patient Care. “We wanted to put mechanisms in place to ensure the success of our students and, certainly once they graduated, the best possible [career] alternatives,” she says.
Mass General diverse nurse leaders who have successfully navigated such waters can “provide these wonderful, wonderful pearls of wisdom and support and encouragement and listening skills,” explains Banister, and they serve as mentors, as do CLCDN graduates. Of the 54 mentors to date (32 from Mass General), some are repeats. Other statistics are just as impressive—such as PHC’s 82.6% hiring rate among the 69 graduates thus far (47.8% of whom have been employed by Mass General) and the almost 80% retention rate for these graduates.
“They love being a nurse. It’s exactly what they anticipated their career to be,” says Banister. “They are constantly promoting how positive it has been for them and that they feel like our organizations are becoming much more of a welcoming and diverse place to work.”
At the Cleveland Clinic, location-specific Diversity Councils at each of the enterprise’s community hospitals and family health centers are effectively supporting and sustaining an inclusive work environment. These employee-led councils implement action plans and sponsor activities based on strategies and goals defined by an Executive Diversity Council, all aimed to enhance employee engagement and cultural competence.
While the Executive Diversity Council works “to set the tone and the agenda,” the location-specific councils “serve as the tactical team,” explains Diana Gueits, director of diversity and inclusion. The main-campus council, for one, formed the Nursing Cultural Competence Committee and the Disability Task Force; the task force, in turn, developed the Disability Etiquette Lunch ’n Learn, a program to assist caregivers in their interaction and communication with disabled individuals that has since been taken enterprise-wide. Gueits notes the councils share and cross-pollinate ideas.
Cleveland Clinic’s chief nursing officer sits on the Executive Diversity Council, and many nurses participate in the location-specific councils with several diverse nurses serving in leadership roles (the councils overall represent a cross-section of the clinic’s workforce). Two cochairs and a cochair-elect lead each council, act as local ambassadors for diversity, engage with executive leadership, and provide feedback to the Office of Diversity and Inclusion, which facilitates the business-like, SMART-goals approach of the councils.
“This is a passion for them,” says Gueits of the cochairs, who are selected based on their experience in leading transformative teams and their commitment to diversity and inclusion. “I think that what the councils provide them is an opportunity to see, to actually be part of an initiative and be part of that process from A to Z.”
Cleveland Clinic has 21 location-specific councils, a number that is sure to increase as the enterprise expands. “That is the intention,” Gueits says, “to make sure that we embed diversity and inclusion in our commitment to all our locations and give an opportunity or platform for all our caregivers to be engaged.”
Julie Jacobs is an award-winning writer with special interest and expertise in health care, wellness, and lifestyle. Visit her at www.wynnecommunications.com.
Shifting demographics and other market conditions have created a greater need for minority nurses, particularly in certain roles. With a growing multicultural and aging population in the United States, the need for medical case managers to serve patients of various ethnic and minority groups has significantly increased. Regulatory reform—specifically, the enactment of the Patient Protection and Affordable Care Act, which ushered in new preventable readmission requirements for hospitals, along with new models of care (e.g., patient-centered medical homes and physician-hospital organizations) and more prevalent consumer-driven health care plans—has created new opportunities for minority nurses in case management. For minority nurses whose goals are to help serve these largely underserved patient populations and advance in their careers, it is important to understand the changing health care landscape.
Let’s look first at our nation’s changing demographics. The graying of America has resulted in more Americans living longer with more age-related, chronic medical conditions, ranging from arthritis, hypertension, and heart disease to hearing impairments and cataracts. According to the National Academy on an Aging Society (NAAS), almost 100 million Americans have chronic conditions, with millions more developing chronic conditions as they age. By 2040, the NAAS estimates that the number of people in the United States with chronic conditions will increase by 50%. The cost of medical care for Americans with chronic conditions could approach $864 billion in 2040—almost double what it was in 1995. While the most common chronic conditions are the same for blacks and whites, the conditions are generally more serious among minority populations, particularly individuals with lower incomes.
Another major factor in our changing health care landscape is the higher percentage of racially and ethnically diverse individuals. An AARP Bulletin article titled “Where We Stand: New Realities in Aging” reported that minorities are expected to comprise 42% of the American population by 2030. Currently, the United States has 150 different ethnic cultures represented within its population, with over 300 different languages spoken and a wide range of cultural nuances reflected. For health care providers, this broad spectrum of cultural diversity in its patients introduces higher incidences of certain conditions, while also posing challenges relating to care and communications.
Addressing Cultural Challenges
On the disease front, we know that certain ethnic groups are more prone to certain medical conditions. Many health care providers and insurers are responding with targeted initiatives, such as: the Chinese Community Health Plan’s Diabetes Self Management: A Cultural Approach initiative to enhance diabetes knowledge and management in the Chinese population; Excellus Health Plan’s Healthy Beginnings Prenatal Care program to decrease NICU admission rates for African American teens; and Med One Medical Group’s Adherence to Hypertension Treatment and Measurement project to educate English, Arabic, and Vietnamese-speaking hypertensive patients.
Beyond the obvious language and communication barriers that can prevent quality health care delivery and optimum patient outcomes, there are cultural issues that, if mismanaged, can also interfere with providing quality health care. For example, in Latin culture, religious healing, praying to certain saints, and relying on religious symbols to address health issues are not uncommon. Patients of African descent are inclined to believe in the healing power of nature and their religion. Within Asian groups, achieving balance between yin and yang, using certain herbs and foods, and relying on acupuncture to unblock the free flow of energy (chi) are common practices. Health behaviors also vary among ethnic groups. Armenians are tolerant of county health facilities, whereas the Vietnamese regard them and the related bureaucracy associated with government facilities as degrading. They, therefore, prefer receiving care in a physicians’ office, even if higher costs are incurred.
There also are differences relating to how certain minority and ethnic groups want to hear about their medical conditions. Did you know that the majority of African Americans and European Americans believe patients should be informed of terminal illnesses, while fewer Mexican Americans and Korean Americans agree? Family values relating to health care decisions also differ among minority and ethnic groups. Within the Mexican, Filipino, Chinese, and Iranian cultures, for example, there is the belief that a patient’s family should be first informed about a loved one’s poor prognosis so they can decide whether or not the patient should be informed. Obviously, these variables and many others are important for health care professionals to understand when caring for a patient. This is an area where minority nurses of different backgrounds and cultures can be a tremendous asset to their patients and to the overall health care system. Studies have demonstrated that case managers help strengthen primary care. This is particularly true when patients have complex or multiple medical conditions—as many elderly people do—or chronic conditions such as diabetes or chronic obstructive pulmonary disease.
Combating Disparities in Health Care
It is widely known that disparities exist in the care of minority patients. While this is more pronounced in rural primary care practices, it holds true across the board. An Institute of Medicine report found that “racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as insurance status and income, are controlled.” Other studies also have explored these disparities, including Aetna’s “Breast Health Ethnic Disparity Initiative and Research Study” and Health Alliance Plan’s “Addressing Disparities in Breast Cancer Screening.” Collectively, they further make the case for minority nurse case managers to advocate for minority patients.
Related research supports the fact that, where minority case managers are in place, there is a significant improvement in patient outcomes. This was evident in a study of rural African American patients with diabetes mellitus where it was found that they were able to better control their blood sugar levels with a redesigned care management model, which incorporated nurse-led case management and structured education visits into rural primary care practices.
From Public Sector to Hospitals, Physicians’ Offices, and Entrepreneurial Settings
There is no question that, given today’s health care landscape, minority nurses have a great opportunity to help make a difference in the care of minority groups and enjoy heightened career fulfillment and potential advancement. Among the settings minority nurses can consider are:
• The public sector—serving within the Veterans Health Administration system for our veterans, many of whom are minorities, or the Indian Health System for our nation’s native American populations;
• Hospitals—helping hospitals achieve lower rates of preventable hospital readmissions, caring for minority and ethnic patients, and serving as a patient advocate and liaison with family members;
• Physicians’ offices—facilitating patient-physician communications, assuring appropriate records are communicated between treating physicians, monitoring patients’ adherence to treatment plans, and identifying any family and/or home issues that might affect a patient’s well-being;
• Financial advisors and estate planning attorneys—working with these professionals who are becoming increasingly more involved in the financial aspects of their clients’ health care and the costs associated with their care, as well as protecting their clients’ estates;
• Independent practice—working for a case management firm or establishing your own practice.
Independent practices present an opportunity for minority nurses to shape their own destiny and financial reward. Through one’s own practice, a minority nurse can focus more fully on his or her patients’ well-being without the over-emphasis on cost containment we see in many other practice settings, especially hospitals. These nurses can decide that they want to specifically dedicate their practice to a certain minority and/or ethnic group. They can establish a truly patient-centered care management business model, performing health risk assessments, providing health coaching, disease education and management, assisting with patient transitions of care, coordinating health care resources on behalf of their patients, reviewing hospital bills, helping patients assemble their health records, and providing end-of-life care coordination.
Based on a 2013 survey by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, nurses from minority backgrounds represent 17% of the registered nurse (RN) workforce. Currently, the RN population consists of 83% white/Caucasian, 6% African American, 6% Asian, 3% Hispanic/Latino, 1% American Indian/Alaska Native, 1% Native Hawaiian/Pacific Islander, and 1% other. Given the increasing shortage of nurses, combined with the growing demand based on our shifting demographics, it appears that the time has never been better for minority nurses, while fewer in number, to take center stage in case management.
Catherine M. Mullahy, RN, BS, CRRN, CCM, is president of Mullahy & Associates www.mullahyassociates.com, and author of The Case Manager’s Handbook, Fifth Edition.
Where nurses work, as well as their education level and specialty, can all influence how much they earn in salary. But all in all, respondents to the third annual Minority Nurse salary survey report making more this year than they did last year.
With rising salaries, the outlook for nurses may be getting brighter, but there are still some differences in pay by ethnicity.
Last year, nurses reported earning a median $68,000, and this year they reported an increase that brought their median salary to $71,000—a $6,000 jump over what they’d said they earned five years ago.
While African American nurses reported earning more this year than last, a median $60,200 in 2014 as compared to this year’s $70,000, they still took home slightly less than the overall median. Hispanic and Asian nurses said they earned slightly more than the overall median salary, and more than they reported earning last year, while white nurses reported a salary close to the overall median salary and similar to what they reported taking home last year.
To collect this data, Minority Nurse and Springer Publishing e-mailed a link to an online survey that asked respondents about their jobs, educational background, ethnicity, and more.
Nearly 2,400 nurses from a variety of backgrounds and filling different job descriptions responded to the survey to provide a glimpse into their day-to-day roles, their plans for the future, and their current and past salaries.
The respondents work in various aspects of nursing from patient care to education and research, and have certifications in critical care, advanced practice nursing, and family health, among others. The nurses also work for a range of employers, from large organizations with more than 10,000 employees to ones with a hundred or fewer employees, and from public hospitals to colleges to home health care services.
Drilling down deeper into the data, wider gaps in pay start to emerge. For instance, white nurses working at private hospitals earn a median $80,000, while African American nurses earn a median $62,000. Similarly, at public hospitals white nurses earn $79,500, and African American nurses $71,000. However, nurses employed by college or universities reported largely similar salaries falling between $70,000 and $80,000, with African American and Asian nurses reporting receiving the higher end of that range.
Salaries also vary by region in the United States. Nurses take home the most in the Northeast, followed by the West, though there also appear to be slight variations by ethnicity as white and Hispanic nurses living in the western US earn a median $80,000, while African American nurses earn a median $73,000.
Education also affects take-home pay, and nurses reported higher salaries with increased education. Nurses with associate’s-level degrees reported earning $67,000, while nurses with bachelor’s-level degrees said they earned $70,000. And that increased further with advanced degrees as those with master’s degrees reported taking home a median $72,000 and those with doctoral degrees said they made $82,000.
There, too, were slight differences by ethnicity. For instance, African American nurses with associate’s-level degrees reported taking home a median $65,119, less than the overall median, while white nurses took home a median $68,320, slightly more than the median. At the bachelor’s and doctoral levels, though, African American and white nurses reported earning approximately the same salary.
Despite rising salaries—and recent raises—more than a third of nurses still said they are contemplating leaving their current jobs in the next few years. When they left previous jobs, respondents said it was mostly to pursue better opportunities, and this year’s respondents reported that the best-paying places to work are in private practice or at private or public hospitals.
Inclusion tops the list of many workplace must-haves. But what exactly does inclusion mean?
According to G. Rumay Alexander, EdD, RN, FAAN, clinical professor and director of the Office of Multicultural Affairs at the University of North Carolina at Chapel Hill, when people talk about inclusion they can’t ignore one very important fact – inclusion means something different for each person.
“You have to define terms and explore it and explain it a little more carefully,” says Alexander, who recently moderated the American Nurses Association webinar Diversity Matters: Create an Inclusive Nursing Culture that Leads to Better Outcomes. “A prime example is that people talk about respect. The fact of the matter is that ten different people have ten different definitions of respect.”
How can you begin talking about inclusion?
1. Define It
Nurses excel at critical thinking skills, says Alexander, so sitting down to talk about what inclusion means in your workplace should be the first step.
2. Think About What Inclusion Means to You
“Self-awareness is so key to the work of an inclusive space,” says Alexander. “Understanding and knowing yourself is important. Know what pushes and doesn’t push your buttons.” Use honest self examination of your biases and prejudices so you become aware of them and realize how they could impact your work. Everyone has had different experiences, says Alexander, and each of those can change your outlook. The important work is understanding how that happens and making sure it doesn’t invade your work.
3. Be Willing to Change
When you do some honest reflection, you might realize where you need to make changes. That’s not a bad thing. Almost everyone needs to do something better, so having an open mind and understanding that you are part of a team trying to change takes the personal sting out. Be willing to learn. “Understand that your private decisions have public ramifications,” says Alexander. “You can’t talk your way out of what you behaved your way into.”
4. Change Your Culture
“Culture will trump strategy every time,” says Alexander. If everyone isn’t on board, any changes and any strategies put in place won’t hold. Understanding workplace culture means understanding who shapes the culture and how they interact. “You have to understand culture,” says Alexander. “Culture is the way you approach your work.”
5. Be Patient
“You have to understand when you are changing culture you are dealing with a process and that takes time,” says Alexander. A new environment won’t happen overnight, but it will happen with self reflection, new approaches, and honest and open communication.