The 57-year-old woman is standing in the hall outside of the exam room. She is agitated. “I’m waiting for the doctor. I’m freezing! My back is killing me!” I note she is pale, unable to stand still, and has a sheen of perspiration on her forehead. She is in withdrawal. I get her a blanket and ask her to wait in her room. The pain clinic nurse is downstairs at the pharmacy getting the patient’s prescription for Suboxone for induction. Induction is the process of starting the patient on medication and finetuning the dose.
An hour later the patient is back in the hall calling me, “Thanks for the blanket!” She is smiling. Her color is back. She is clear eyed, calm, and collected. What happened? Suboxone. Suboxone is a combination of buprenorphine and naloxone that is used to treat opioid addiction. Buprenorphine is a partial agonist of the μ-opioid receptor with a high affinity and low rate of dissociation from the receptor. In English, the buprenorphine molecule sticks to the opioid receptor in the brain, but only partially activates it. Then it stays there for a long time, blocking it from opioids, before dissociating. What this means for the addict is that they get enough opioid receptor activation that they don’t get sick from withdrawal. They can function normally with less of the problematic effects of a full agonist like morphine or heroine.
The addition of naloxone, a full opioid antagonist (blocker), keeps the Suboxone pills from being crushed and injected. Though naloxone has a strong effect when given parenterally (by injection), its effect when given by mouth is negligible because it is poorly absorbed sublingually. Suboxone disintegrating tablets are given under the tongue.
So, what is this wonder drug all about? In 2000, federal legislation (Drug Addiction Treatment Act of 2000) made office-based treatment of narcotic addiction with schedule III-V drugs legal. Until then, the only option for addicts was abstinence-based treatment or methadone clinics. The ever-increasing rates of drug overdose deaths in the United States showed this was not working. At first, only MDs specially approved by the Department of Health and Human Services could prescribe medications to treat addiction. In 2016, President Obama signed the Comprehensive Addiction and Recovery Act allowing nurse practitioners and physicians assistants to prescribe schedule III-V drugs for the treatment of addiction. Previously, they could prescribe these medications to treat pain but not to treat addiction.
What does this mean for the addict? For starters, Suboxone and similar drugs are now more widely available. Until recently, the only way for a heroin addict to keep from getting withdrawal sickness was to use more heroine. These patients were considered toxic to regular doctors because their disease lead to ever-increasing doses, seeking medications from multiple providers, decreasing levels of health, and ultimately death. Now that there is an option other than going cold turkey, the addict without some kind of pain diagnosis can get access to health care whereas before they would avoid it because of the stigma of being an addict. Because Suboxone is a partial agonist with high affinity to the μ-opioid receptor, it decreases the ‘high’ if the patient continues to use narcotics causing the patient to lose interest. It offers the benefit of allowing the addict to function in life, decreases the likelihood of death from respiratory depression, and increases the quality of life because there is no need for the addict to ride the wheel of withdrawal—drug seeking, using, running out, and then seeking again to the exclusion of every joy of life.
What happens when a person starts buprenorphine? After a largish battery of tests, the prospective recovering addict will be asked to abstain from narcotics before induction to Suboxone. How long before the first dose the addict has to abstain depends on the person’s addiction. Longer acting drugs like methadone could be 24 hours. Shorter acting drugs like morphine could be as little as six hours. The person should be in the early stages of withdrawal. The reason for this is the “partial” part of partial agonist. The buprenorphine molecule will muscle other narcotics off the receptor site where it was fully activating the receptor. Now, the higher affinity buprenorphine is sitting there doing half the work that the heroine was doing and this leads to symptoms of withdrawal. Giving a person a drug that puts them immediately into withdrawal will turn them off to it completely. You won’t see that person again. Higher success rates are tied with higher levels of symptoms of withdrawal before induction. Now instead of precipitated withdrawal, the person has relief from symptoms of withdrawal even if they are not getting high.
A person who has been successfully inducted to Suboxone therapy will find almost immediate relief. The terrible body aches, muscle pain, abdominal pain, depression, diarrhea, and cravings evaporate. Our patient might just have found a new way to live, free from the constant need to find more narcotics. She can focus on her life instead of her disease. Most of the clinic patients have jobs. They want desperately to be productive members of society for themselves and for their families. Buprenorphine therapy coupled with lifestyle interventions provided by mental health professionals, self-help groups like Narcotics Anonymous, and patient-initiated interventions (like taking a class or going back to school) are part of the success story of a growing number of recovering addicts.
What’s it like to come off Suboxone? Eh, probably a lot like getting off heroine. Same withdrawal profile or pretty close. Patients wanting to get off all narcotics, including Suboxone, can be weaned off gradually depending on their desired treatment goals. Someone facing a jail sentence or travel overseas that needs to detox from opioids quickly may be on a tapered dose of Suboxone for just a few days or weeks. Other people may decide that the burden of staying on Suboxone is worth not having to go through withdrawal and choose to stay on a maintenance dose for the rest of their life. The addiction specialist will help guide the patient through the decision process. Many patients decide to stay on the medication as a hedge against relapse since buprenorphine has a higher affinity for opioid receptors than street drugs. This coupled with the very slow rate of dissociation means that a person would have to stop the buprenorphine well in advance of restarting heroine or other opioid in order to get high.
What does this mean for health care? For one, at least some addicts who eschewed health care in the past can now get treatment for this disease. At some point, most addicts will desire to get off narcotics. Having a real treatment option available instead of a far-away methadone clinic or withdrawal will work to drive these patients into recovery. Another thing is that it’s possible that some of the stigma of addiction will be lifted, at least slowly, as treatment becomes available and success stories become commonplace. As the DEA and FDA work to get a handle on the 70,000 overdose deaths per year by educating doctors and enforcing distribution laws, these drugs will become harder to get. During the 12 months prior to July 2017, overdose deaths fell in 14 states for the first time during the opioid epidemic, according to the Centers for Disease Control and Prevention. In the rest of the nation, at least the numbers have leveled off. Greater access to Narcan (brand name of naloxone, one of the drugs in Suboxone), and more treatment options for addicts will hopefully drive these numbers lower over time. It’s not time to celebrate, but at least there is a glimmer of hope. The priority is to keep addicts alive until they can (or they are ready to) get treatment for their disease.
Nurses have intense experiences that most other health care workers don’t. As a result, they tend to have a great deal of stress. Having friendships with other nurses tends to alleviate it and help in more ways than you might imagine.
Only nurses understand what other nurses truly go through, says nurse practitioner, former attorney, author, and career/lifestyle blogger Meika Mirabelli, JD, MSN, FNP-C, founder of BeautyinaWhiteCoat.com, which helps both health care students and professionals live balanced, successful lives through sharing career and studying tips. Mirabelli knows firsthand how having friendships with other nurses can make a huge difference in the workplace—and how not having them can hurt.
“I have experienced horrible treatment by nurses who were in the field of nursing longer than I have been. During those times, I would have to lock myself in the bathroom to hide and cry. I would count the days until I was done with that job and celebrated when I turned in my resignation,” Mirabelli recalls. But the good has outweighed the bad. “I have also worked with great nurses with whom I still have a bond today. My experience with those wonderful nurses definitely reduced stress and made me a better nurse and a better person. I have thoroughly enjoyed my shifts when I have coworkers that I could call my friends. I also was able to sleep better at night and looked forward to going to work.”
Research has shown that friendships between nurses can reduce stressful situations. A 2016 study published in PLOS ONE found that the “degree of cohesion among friends had a positive impact on the level of job stress experienced by nurses.” The study concluded overall that the “strength and density of such friendship networks were related to job stress. Life information support from their friendship network was the primary positive contributor to control of job stress.”
While it’s important to understand what research has discovered, it’s just as—if not more—crucial for nurses to know how this can help them in real-life situations.
Why Friendships Help
“There will always be bonds and friendships forged when you work with people in close proximity for long periods of time,” says James LaVelle Dickens, DNP, RN, FNP-BC, FAANP, who serves in the U.S. Department of Health and Human Services regional office in Dallas, Texas, as the senior program manager officer for the Office of Minority Health. “Having strong friendships at work is known to reduce stress. A study by Gallup found that people with a best friend at work are seven times more likely to be engaged with their job.”
“I can think of many times when friendships with other Nurse Practitioners (NPs) have made a difference in my life,” says Dickens. “Sometimes, it’s having someone lift our own spirits after we’ve delivered a difficult diagnosis to a patient. Sometimes, it’s offering a younger colleague with coaching to help them be the best professional they can be.”
“Nobody really understands what a nurse does like a nurse, so those relationships provide support, and that support helps bring stress down,” says Benjamin Evans, DD, DNP, RN, APN, PHMCNS-BC, president of the New Jersey State Nurses Association.
Evans explains that what makes nurses so different from other health care professions is that they are with patients more than anyone else. Other health care professionals may come and do a test, treatment, or procedure on a patient, but then they leave. The nurses are the ones who stay behind and help the patients cope with their stress, pain, or fear resulting from these processes or their conditions.
But this is just one example of why nurses have so much stress. Dickens says that other reasons are heavy caseloads, interactions with patients and their family members who may not recognize the significant challenges of their complex health conditions, and dealing with death.
“Oftentimes, the families are more demanding than the patients,” says Evans.
“Every decision a nurse makes affects the health status of their patients,” says Judith Schmidt, RN, MSN, ONC, CCRN, CEO of the New Jersey States Nurses Association. “The public doesn’t realize how stressful these areas can be. If a nurse makes a mistake, it can mean a patient’s life. You have the life-and-death situations with the patients, their families, and the administration.”
“Nurses have the type of job that requires a lot of mental clarity, physical demands, and empathy towards patients and their families,” says Flo Leighton, MS, RN, PMHNP-BC, a board-certified psychiatric nurse practitioner in private practice at Union Square Practice as well as an adjunct faculty member at New York University Rory Meyers College of Nursing.
The difficult work, both physical and mental, is why having friendships is necessary. It’s also great to have others who completely understand you.
Friends “Get” You
Erin Parisi, LMHC, CAP, owner of Erin C. Parisi Counseling & Consulting, LLC, learned about nursing friendships while working as a therapist in a residential treatment setting alongside nurses every day. “My biggest takeaway has been that having friends who are ‘in the trenches’ with you helps manage stress. In nursing, not only are you coping with the system you work in, with a boss/manager you may or may not like, and office politics, but you also have a really specialized knowledge that not everyone has,” says Parisi. “In a system where not everyone you work with is in the same role, you might end up feeling a little more alone in your job. Non-nurses who don’t have the same or similar training may not understand your jokes or fully wrap their heads around your stressors.
“A lot of nurses have a dark sense of humor, which not everyone has an appreciation for. Not only is the friendship of a fellow nurse providing stress relief, but being able to make dark/weird/gross jokes to someone else who will understand and also think it’s funny can reduce stress in a big way,” explains Parisi.
“Sharing a laugh in the midst of a stressful day lowers your blood pressure and helps put everything in perspective,” says Dickens. Having someone else who understands what makes nurses tick and what makes the profession unlike any other serves as the backbone of these types of relationships, he adds. “Having that support network and camaraderie does an NP’s mental health a ton of good.”
Shanna Shafer, RN, BSN, nursing expert, managing editor, and strategic communications manager at BestNursingDegree.com has spent ten years in the nursing field working in everything from home health, hospice, a community health center to vascular access, and in a burn intensive care unit. At the burn unit she says, “Friendships with other nurses blossomed and were essential to my own survival and mental health.” The bonds that nurses develop in various situations are amazing, she adds.
Parisi adds that nurses witness and work on a daily basis with experiences that most people do not. While everyone else in a nurse’s group outside work—non-nurse friends, family, spouses, and significant others—can provide support, they simply can’t connect with nurses like other nurses or coworkers can.
“Given the fact that nurses spend so much time at work—sometimes even more time than at home with loved ones—having friends at work can help make a shift more enjoyable. Nurses who work with you know what the day-to-day struggle looks like on any given shift,” explains Leighton. “The ability to get perspective from a work friend who understands how to handle on-the-job situations builds resilience and normalizes stressful situations. It makes us feel like we’re understood and not alone in the tasks that challenge us.”
Having someone who “gets” you, can reduce stress and make you feel better in various workplace situations. “Research has shown that social health is an importance factor in stress management. Therefore, friendships among nurses could influence rewarding benefits in processing work-related stressors,” says Amy Moreira, LMHC, owner of More MH Counseling, LLC. “The nursing field is a challenging, demanding, and rewarding job with its own characteristics that are, at times, not fully understood by the general public…A nurse who finds friendship with other nurses can benefit from their shared direct experience, allowing themselves to feel better heard and understood—which is an important part of healing in stress management. Potential solutions can be offered from a different perspective with a more solution-focused outcome than advice from other friends and family. Workplace friendships among nurses allows for in-the-moment support and allows for open processing without the need to explain certain contextual aspects.”
Nurses Eat Their Young
There’s the old adage that “Nurses eat their young.” Some more experienced nurses have been known to let the young ones flounder. Nurse.org, though, has a new campaign to dispel this adage called “Nurses support their young.” The campaign is significant because when nurses are friends, the stress of the entire unit, floor, or facility can decrease.
“It’s important for nurses to friend new nurses to allow for effective learning and adjustment on the team, including the patient,” explains Moreira. “Establishing friendships and aiding newer nurses can contribute to a more positive workplace environment and job satisfaction. Friendships between nurses can allow for a more experienced nurse to take on a ‘coaching’ role that enables stress-free learning with laughter, support, and understanding. Working past any frustrations associated with newer nurses lacking knowledge can often be processed when reflecting upon past mishaps in the experienced nurse’s own career.”
“It makes for a healthy work environment when there are coworkers whom you work with whom you can be friends with and discuss difficult issues and challenges that you couldn’t to someone outside the profession,” says Schmidt.
And a healthy workplace will influence other people and environments as well.
The Ripple Effect
When nurses are friends, they aren’t just nice to each other, but they look out for each other. While working as a staff nurse, Leighton developed a core group of nursing friends. “We collectively pitched in to make sure that if someone needed a day off or a last-minute shift coverage, we helped one another. It was an unspoken understanding that we took care of one another,” she recalls.
“While I think that friendship is important in all aspects of our lives, we do know that workplace friendships are tied to higher levels of job satisfaction, engagement in work and performance, as well as overall team cohesion,” says Dickens. “I wholeheartedly believe that a support system at work and in our personal lives is key.”
Nurses who have friends in their workplace can also assist each other during stressful situations by giving each other someone to vent to. “It can put that nurse who is stressed in a better frame of mind. It almost permeates an entire unit if one nurse is stressed and could cause others to become stressed,” he says.
Dickens adds that if a nurse is stressed, patients can sense it in the nurse’s voice and body language. But the opposite is true as well: a happy nurse can make a happy patient.
And sometimes a happy nurse, can just make a happy nurse. That can be essential enough. Nurses who are less stressed because of friendships can have improved mental, emotional, and physical wellness, says Moreira. “Nurses with reduced stress often prioritize self-care, which allows them to give their best selves to others.”
According to the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States. Type 2 diabetes is one of the most commonly occurring chronic diseases, which affects about 90-95% of those diagnosed. According to a 2018 study published in Health and Quality of Life Outcomes, there were over 415 million adults between 20-79 years living with diabetes globally. The American Diabetes Association estimates that over $327 billion is the annual cost of diabetes care in the United States alone.
A serious complication of diabetes is hypoglycemia, a blood sugar level less than 70 mg/dL. Hypoglycemia comes on suddenly and patients display symptoms such as profuse sweating, tremors, irritability, altered mental status, loss of consciousness, among others. Hypoglycemia has several adverse effects including cardiac arrhythmias, seizures, and can be fatal in severe cases. The fear of inadvertent hypoglycemia is among the biggest barriers patients face while working towards glycemic control. Hence, one may conclude that frequent hypoglycemic incidents are disruptive to the normal life, and may result in injury, increased medical costs, loss of wages, and the need for constant monitoring by another person.
Real-time continuous glucose monitoring (CGM) may provide an ideal solution for individuals with a high risk of hypoglycemia. CGM measures glucose levels continuously via a transdermal glucose sensor and sends data to one or more monitoring devices. It is configurable to alert the user and/or designated provider when blood glucose levels are too high or too low. In a 2017 study, David Rodbard, MD, demonstrated that the use of CGMs resulted in significant reduction of hypoglycemia risk and improved patients’ quality of life. Since the invention and subsequent improvement of the quality of monitoring and reporting, CGM systems have become very reliable tools for real-time monitoring of blood glucose and prevention of dangerous hypoglycemia. CGM systems also help reduce health care costs and improve quality of life and productivity of patients.
A Brief Introduction to CGM Systems
The first CGM system hit the market in 1999. Early CGM systems were bogged down with issues related to accuracy, delayed transmission, and patient teaching. Rapid advancements in technology have influenced development of highly accurate, versatile, and user-friendly CGM machines. In 2015, the American Association of Clinical Endocrinologists and American College of Endocrinology included CGM systems into their clinical practice guidelines. Three medical device manufacturers—Abbott Laboratories, Medtronic, and Dexcom Inc.—have emerged as leaders in today’s CGM marketplace at a global level.
CGM’s Role in Preventing Hypoglycemia and Improving Quality of Life
The main idea behind the introduction of CGM systems was to achieve enhanced real-time blood glucose monitoring of diabetic patients and prevention of abnormal glycemic highs and/or lows and its accompanying complications. Multiple studies have successfully demonstrated that diabetic patients are at a risk of undetected hypoglycemia. According to a 2017 study published in Diabetes Technology & Therapeutics, 22% of sudden unexpected deaths in persons under 40 with type 1 diabetes were due to hypoglycemia. The study concluded that using CGM systems helped reduce hypoglycemia and improve glucose control.
Inadequate glycemic control is associated with complications that lead to reduced quality of life, work absenteeism, increased hospitalization, among others. Fear of hypoglycemia and its associated costs may discourage patients from adhering to a treatment plan formulated by their primary care provider. And yet, the Diabetes Technology & Therapeutics study estimated an annual savings of $936-$1,346 per person in hypoglycemia prevention with the use of CGM systems.
A recent randomized controlled trial published in The Journal of Clinical Endocrinology & Metabolism found that type 1 diabetics on real-time CGM systems demonstrated a marked improvement in glycemic control and enhanced of quality of life in the form of reduced incidences of hospitalization, work absenteeism, and lesser fear of hypoglycemia.
Furthermore, recent advances in wireless and data-enabled cellphones have enabled medical technology corporations to improve the functionality and accuracy of CGM systems. Modern CGM systems can now send information to the patient and designated caregivers when the blood glucose levels are too high or too low. CGM systems help promote safety and efficacy of glycemic control for both type 1 and type 2 diabetics and reduces the risk of hypoglycemia significantly.
The benefits of CGM systems are yet to be completely utilized by health care providers and patients due to lack of awareness, suspicion about the safety, efficacy, and cost of these systems. Using CGM systems may lead to long-term financial savings and improved quality of life for patients. It is up to primary care providers to educate patients and families to benefit from available technologies and improve their health.
As a gay man, Austin Nation, PhD, RN, PHN, understands the health care barriers faced by many lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. As a nurse and educator, he’s working to increase awareness and address the health disparities that continue to exist in the LGBTQ community.
An assistant professor of nursing at California State University, Fullerton (CSUF), Nation lived through the 1980s AIDS crisis, and has worked with many patients in the HIV/AIDS community. While he acknowledges an HIV diagnosis is no longer a death sentence thanks to increased funding and better treatment, Nation has also seen how young gay black and Latino men continue to be disproportionately affected by HIV/AIDS. The Centers for Disease Control and Prevention (CDC) report that 1 in 2 black men and 1 in 4 Latino men will be diagnosed with HIV during their lifetime.
“We’re not reaching all of the people we need to reach,” Nation says. “In order to get to zero new HIV infections, we need to figure out how to engage these populations.”
While treatments have transformed HIV into a chronic but manageable illness, many people are not aware of how prevention efforts that use antiretroviral treatment, and pre-exposure prophylaxis (PReP), an HIV-medication that when taken consistently, can lower the risk of getting infected by more than 90%. Despite being widely available, the CDC notes that while two-thirds of the people who could benefit from PrEP are black or Latino, they account for the smallest amount of prescriptions to date.
To that end, Nation has worked to address the tenuous relationship many people of color and members of the LGBTQ community have with the health care system. Statistics from the Kaiser Family Foundation show that LGBTQ patients often face challenges and barriers in accessing health services including stigma, discrimination, the provision of substandard care, and outright denial of care because of their sexual orientation or gender identity.
“I’ve led LGBTQ cultural competency trainings to teach nurses and nursing students how to provide inclusive services and care for LGBTQ patients,” Nation says. “By knowing whether a patient is gay, lesbian, transgender, straight, or bisexual, and how to best communicate, nurses can identify potential health disparities and care for their patients more effectively.”
On the CSUF campus, Nation has also been a part of the university’s Faculty Noon Time Talks, discussing health care disparities within the African American community. In addition, he is working with faith leaders to adopt a more inclusive environment for LGBTQ individuals who may be reluctant to come out and subsequently don’t receive HIV testing or prevention counseling.
“I also teach a public health course at CSUF where we discuss vulnerable patient populations including the LGBTQ community,” Nation says. “I try to integrate real-world experiences into the course curriculum.”
Nation believes that all nurses can help to achieve diversity and meaningful inclusion, whether they are part of the LGBTQ community or an ally. “Have a voice and be an advocate,” he says. “One person can make a difference.”
Navigating Cancer Care with LGBTQ Patients
As an oncology nurse and LGBTQ advocate, Megan Ober, RN, MS, BSN, OCN, a case manager at the Palliative Care Clinic at the UC Davis Comprehensive Cancer Center in Davis, California, often finds herself bridging the gap between providers and LGBTQ patients.
“Many health care providers work under the assumption that all patients are heterosexual,” says Ober. “It’s important to create a welcoming environment for LGBTQ patients in order to educate them on cancer risk factors and ensure they receive preventative screenings.”
Ober says LGBTQ patients often feel they are being judged and are reluctant to share their sexual orientation or gender identity out of fear of being turned away from health care providers. This distrust can lead to some LGBTQ not seeing a doctor regularly for check-ups and screenings, delaying diagnoses and not receiving information on treatments that might help either their physical or emotional health.
Over the years, Ober has given presentations to staff on LGBTQ disparities in cancer care and risk factors that lead to greater cancer incidence and later-stage diagnoses. These disparities include:
- Anal cancer. It’s rare in the general population, but 34 times more prevalent in gay men.
- Cancer screenings. According to the American Cancer Society, lesbians and bisexual women get less routine health screenings than other women including breast, colon, and cervical cancer screening tests.
- Breast cancer. Lesbian women have higher rates for breast cancer including nulliparity (never having given birth), alcohol and tobacco use, and obesity.
- Cervical cancer in transgender men. Since most transgender men retain their cervixes, they are also at risk of cervical cancer but are much less likely to obtain Pap smears and regular cancer screenings.
Resources to Bring Better Care to LGBTQ Patients
For nurses who want to educate themselves further about LGBTQ health topics, the following information can help:
- Lavender Health has held virtual coffee hours for nurses working with LGBTQ populations. Their website offers events, resources, and more to help both providers and members of the LGBTQ community promote wellness.
- The National Resource Center on LGBT Aging offers cultural competency training for staff at nursing homes and others who care for seniors. They also have downloadable guides on creating an inclusive environment for LGBTQ seniors.
- The U.S. Department of Health and Human Services offers a free downloadable guide, Top Health Issues for LGBT Populations Information and Resource Kit.
- On a national level, organizations such as the National Alliance of State and Territorial AIDS Directors (NASTAD) has partnered with the Health Resources and Services Administration’s HIV/AIDS Bureau (HRSA-HAB) to launch HisHealth.org, a free online tool that helps nurses and other medical staff learn how to engage HIV-positive young black LGBTQ patients and young black transgender patients by taking a whole-health approach to wellness.
- Organizations such as the Human Rights Campaign and their Healthcare Equality Index can help with training and best practices such as making changes to electronic medical records and hospital paperwork to incorporate sexual orientation and gender identity and criteria that hospitals can use to become Equality Leaders.
- The National LGBT Health Education Center has a free downloadable guide, “Providing Inclusive Services and Care for LGBT People: A Guide for Health Care Staff.” The guide discusses using preferred pronouns and preferred names, understanding diversity and fluidity of expression, making LGBTQ patients feel comfortable, common health issues among the LGBTQ population, and much more.
While it can be difficult for nurses to begin a conversation about a patient’s sexuality and sexual health, Ober says it’s important for providers to ask in order to care appropriately for LGBTQ patients.
“Rather than assuming all patients are heterosexual, I recommend nurses introduce themselves and ask a patient how they would like to be addressed, their chosen name, and their preferred pronoun,” Ober says. “There’s a great training video on YouTube called ‘To Treat Me You Have to Know Who I Am’ that showcases a mandatory employee training program that was launched for health care providers in New York.”
Ober also cautions against assuming the personal info on a patient’s chart is correct. Often, people who are transgender may identify as a different gender than the one listed on their electronic medical record.
“Rather than greeting a patient with a title such as Mr. or Ms., I encourage nurses to ask patients how they would like to be addressed,” Ober says. “Shifting from a heteronormative model to one that is more inclusive acknowledges that patients and families aren’t all the same. The woman sitting by your patient’s bedside may be her wife, rather than her sister or friend.”
Nurses Lead the Way with Change
Caitlin Stover, PhD, RN, chair of the national Gay and Lesbian Medical Association (GLMA) Nursing group says both nurses who identify as LGBTQ and those who are allies can work to create an inclusive environment for LGBTQ patients.
“I’m an ally that joined GLMA and now I’m chair of the organization,” Stover says. “There are so many resources out there that can help nurses become better patient advocates and deliver culturally sensitive care to LGBTQ patients.”
Stover says while many nurses across the country are doing great work in creating an inclusive environment in their hospital units and establishing trust and rapport with LGBTQ patients, there are still many nurses and providers who have not received education on LGBTQ health issues.
“It’s important for nurses to strip themselves of preconceived notions, judgements, and assumptions,” Stover says. “Our job is to provide the best possible care, regardless of a patient’s age, ethnicity, gender, or sexual orientation.”
She cites the Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients downloadable PDF created by GLMA as a good starting point for nurses who are seeking advice on how to communicate with LGBTQ patients using sensitive language. The document also includes guidelines for forms, patient-provider discussions, and more.
Continued Education Leads to Better Health Outcomes
Learning about LGBTQ patients isn’t a topic that is always covered in nursing school. A national survey conducted in 2014 found that 43% of nursing faculty who taught in bachelor’s degree programs across the United States reported limited or somewhat limited knowledge of LGBTQ health. Between 23-63% of respondents indicated either never or seldom teaching LGBTQ health, although a majority of respondents felt LGBTQ health should be integrated into the nursing courses they teach.
In 2013, Columbia University Medical Center in New York launched the LGBT Health Initiative, based at the Division of Gender, Sexuality, and Health at the New York State Psychiatric Institute and the Columbia University Department of Psychiatry in association with the Columbia University School of Nursing. The goal of the initiative is to bring together research, clinical care, education, and policy to fight stigma and improve the health of the LGBTQ community.
Janejira J. Chaiyasit, DNP, AGNP-C, an assistant professor at Columbia University School of Nursing and a nurse practitioner at ColumbiaDoctors Primary Care Nurse Practitioner Group, says students at the Columbia School of Nursing receive training on LGBTQ cultural competency as part of their studies.
“We highlight the unique health disparities, risks, and health needs of the LGBTQ patient population to increase awareness, so that our future providers and care takers will offer appropriate care and ask the right questions,” Chaiyasit says.
At Columbia, Chaiyasit has seen how promoting inclusivity and culturally competent care has led to better patient care and health outcomes, and how training staff and students adequately prepares them to care for LGBTQ patients.
“If a patient doesn’t feel comfortable, how can we expect them to divulge their personal health concerns to us, and, in return, enable us to give them the best care?” Chaiyasit says.
And despite progress that has been made nationally, Chaiyasit says there’s a continued need for nurses to learn about the differing health needs of the LGBTQ community.
“LGBTQ patients have a lot of health disparities and changing the preconceptions of health care delivery for this community is a way to close the gaps—reducing ER visits, reducing the time to access health care for medical and psychosocial issues, and increasing the rate of preventative health screenings,” Chaiyasit says. “For example, many health care professionals are unaware of the health needs for trans patients, specifically these patients’ needs for transition-specific hormone therapy care and maintenance to achieve the desired gender features. This is really important as it impacts physical and mental health as a whole.”
In addition to nurses becoming more aware of gender-neutral language, many hospitals have begun customizing their patient intake forms to ensure they are LGBTQ-inclusive.
“At Columbia, we piloted intake form questions, which were ultimately implemented across the Nurse Practice Group, that allow patients to select, or even write in, their preferred gender identity pronouns,” Chaiyasit says. “A complete patient history helps to ensure each patient gets the care and services they need.”
“Diabetes is so prevalent in our society, and I feel as though I have a better understanding of my own patients with diabetes,” says Heather Weber, an RN who works in a busy outpatient GI department. She has type 1 diabetes, and she has experienced what it is like working as a nurse with diabetes. “I recently had a GI sickness at work, and as a result, my blood sugar dropped rather quickly after lunch,” she relates. “My coworkers noticed that I was diaphoretic and quickly sat me down, giving me some apple juice to drink. I ended up going home since I was sick with a GI bug, but only once my blood sugar was stable enough to drive. I was grateful for my coworkers’ assistance.”
Since diabetes is such a major problem amongst the population, it only stands to reason that nurses can have diabetes, as well. According to the American Diabetes Association, 30.3 million people in America have diabetes. In addition, 1.25 million adults and children have type 1 diabetes. How can nurses manage their condition? Nurses have a difficult time eating a balanced diet due to skipping meals. They are also on their feet most of the time, putting them at risk for complications of the foot, such as ulcers.
Fortunately, many nurses want to share their experiences to help others navigate the challenge of balancing diabetes and providing excellent patient care. Diabetes educators strive to help all people who have diabetes, and they are an excellent resource for nurses who want to manage their diabetes.
Nurses generally know how to handle their condition. They know diabetes front and back through the job, and they are intelligent professionals who know how to adapt those ideas for themselves.
“I can usually slip away for a few minutes or have a coworker cover for me so that I can test and/or eat a snack,” explains Weber. “When I worked as an ICU nurse doing twelve-hour shifts, I would typically eat snacks to prevent low blood sugars as I did my charting at the nurses’ station.”
Tips like this are invaluable because they are grounded in the actual experience of being a nurse with diabetes.
Fran Damian, MS, RN, NEA-BC, works at Boston Children’s Hospital and is a staff member at Diabetes Training Camp. She has tricks that she uses, as well. “Managing well with diabetes requires good planning and being well prepared with extra supplies all the time,” she says. “I live a healthy lifestyle as much as possible. That includes regular exercise and a well-balanced diet. I feel best when I eat a lot of fruits, vegetables, and lean protein, and I drink a lot of water …. [I] always have glucose tablets on me in case I start feeling low.”
“Our unit was pretty good if we were slammed and did not get lunch,” says Danielle Kreais, MSN, RN, CPNP-PC. She got her diagnosis and learned to cope, all while working a busy OB unit on nights. “The manager ordered lunch meat sandwiches and chips for us. There was another diabetic I worked with and the advice she gave me was to make sure I always had one of those Nature Valley bars in my work bag, in the glove box of my car, and my locker. The peanut butter ones have protein and they are a carb, so it was a great combo if lunch was missed.”
She continues: “She told me for lows to keep those peppermint striped candies [in your pocket] that are soft, and you can chew them. They are enough to bring your sugars up, plus they don’t melt.”
Nurses newly diagnosed with diabetes would do well to carry glucose tablets at all times to prevent low blood sugar. Be sure to tell your manager and your coworkers what’s going on so that they can help you when needed. Snacks and water are essential to good blood sugar control. Don’t forget to use your resources, such as endocrinologists, dieticians, and diabetes educators to plan the right meals and strategies for you to use on the job.
Although tips from nurses can be invaluable, they are nothing like the kind of focused information that can come from a certified diabetes educator (CDE). These are medical professionals who are responsible for teaching all people with diabetes in all situations how to manage their lives and prevent complications.
One such expert is Lucille Hughes, DNP, MSN/Ed, CDE, BC-ADM, FAADE, director of diabetes education at South Nassau Communities Hospital in Oceanside, New York, and treasurer of the American Association of Diabetes Educators. Considering some of the challenges nurses can face when dealing with diabetes on the job, she had tips for some of the most common ones.
Nurses often don’t get the chance to eat during a shift, and this can severely impact blood sugar levels. “When nurses with diabetes find themselves in this situation, planning and being prepared is the best medicine,” says Hughes. “Keeping snacks on hand that are a blend of carbohydrates, protein, and fats can be a tremendous help in these situations.”
“Meal planning is the secret to living with diabetes and being a healthy person,” Hughes continues. “Investing in a good lunch bag (or two) will allow you to plan and pack all the essentials to eating and snacking healthy. Being unprepared and finding yourself at the mercy of a vending machine is not a good situation to be in. It is very unlikely you are going to find a ‘healthy’ lunch or snack option.”
In addition to poor nutrition, nurses also face significant impact to their feet, and this can cause foot related complications for nurses who have diabetes. “First and foremost, investing in a good pair of comfortable shoes is essential for anyone who spends most of their day on their feet,” says Hughes. “Calluses and skin evulsions due to rubbing of a shoe on a toe, heel, or ankle area can be dangerous and yet avoidable.”
Here are six tips that Hughes has on how to find shoes that fit and how to determine if they are a healthy choice:
- When trying on a shoe in the store, make sure it feels comfortable. If it isn’t comfortable, don’t buy it.
- Many think that new shoes require a bit of breaking in and you must endure the associated pain. This is not true. If new shoes start to hurt, immediately remove them and don’t use them again.
- Don’t think that the only shoes you can wear as a nurse with diabetes are unfashionable ones. There are many options for shoes that fit, so do your due diligence and find shoes that will protect your feet.
- In addition to finding the right shoes, foot inspection is vital in protecting your feet. Check them every day. Use a mirror to see the bottoms and sides of your feet. If you notice any redness, cuts, or blisters, see your podiatrist immediately. Take care of small changes immediately before they expand into something unmanageable.
- Podiatrist. Yearly, no exceptions. More often if necessary.
- Finally, any time you see a medical professional, ask them if they will take a look at your feet at your office visit. This could be your primary care doctor, your endocrinologist, or any other specialist you may see—within reason, of course. Many dentists would have trouble with this request. Seriously, though, any professional who looks at your feet could possibly see a problem early enough to stop it. Use these resources.
Nurses spend so much time taking care of others that the self is often forgotten and ignored. Unfortunately, this is unhealthy for any nurse, but particularly troublesome for a nurse with diabetes. Yet, these challenges are not insurmountable, although they may take a little work. Planning your diets and meals are key to ensuring that you will have food on hand for sudden lows. Meal planning can also help you keep your high blood sugar under control. For your feet, planning is again essential. You must find shoes that are comfortable—no questions asked.
Following these steps, nurses with diabetes should be able to function well as nurses—and many are! If you find yourself troubled by mixing diabetes and nursing, let your doctor know. They may be able to refer you to any number of professionals who can help. The most important item, though, is to catch things early and always plan how to confront any challenges.
Recollections of the Flint water crisis are still vivid in the minds of many Americans. Responses to this crisis in the winter of 2014 needed to be swift and comprehensive. And while it may be hard to believe that access to clean, adequate, and equitable water in America remains at risk, advocates for environmental justice call for continued vigilance in ensuring access to safe and clean water. In this column, we discuss the need to ensure equitable access to this life sustaining resource through advocacy and legislative action with Katie Huffling, RN, MS, CNM, who is the executive director of the Alliance of Nurses for Healthy Environments.
Katie Huffling, RN, MS, CNM
Ms. Huffling, tell me a bit about yourself and how you became involved in addressing environmental health issues?
I trained as a nurse-midwife at the University of Maryland School of Nursing. While there, I had the great fortune to meet Barbara Sattler and Brenda Afzal. They were leading the only environmental health center at a school of nursing in the country. Through their mentorship, I learned about the many ways that environmental toxicants could affect reproductive health and the health of the growing fetus. It is an area that many of us received little or no content on in nursing school, yet they can have significant negative health impacts across the lifespan. I became very passionate about environmental health issues and when the opportunity arose to work on this full time with the Alliance of Nurses for Healthy Environments, I jumped at the chance! We are the only national nursing organization focusing solely on the intersection of health and the environment. I now work with nurses and nursing organizations around the country on a number of environmental health issues such as climate change, clean air and water, toxic chemicals, and inclusion of environmental health into nursing curriculum.
Can you give me an example of an environmental health issue that is affecting health right now?
Clean water is one of the greatest public health advancements of the 20th century. As nurses, we recognize clean water is essential to health and a basic human right. It is also essential for providing nursing care. Nurses rely on water to wash their hands, give newborns their first baths, and is essential for the clean linens utilized throughout health care.
Here in the United States we have an expectation that when we turn on the tap clean, healthy water is going to come out. Unfortunately, for many throughout the country this is not the case. Every year, millions of Americans experience waterborne illnesses. Waterborne illnesses are caused by a variety of sources, including waterborne pathogens such as viruses or bacteria, human or animal waste, heavy metals such as lead or arsenic, or industrial pollutants. Certain populations may also be more likely to be exposed to unsafe drinking water, including low-income populations and some communities of color.
I know you have been a champion for environmental justice for some time now. What are some key legislative priorities with regard to clean and safe water?
To address a number of urgent clean water issues, the U.S. Environmental Protection Agency (EPA) proposed an update to the Clean Water Act, originally passed in 1972. The Clean Water Act needed to be updated due to the great expansion of knowledge regarding upstream sources of pollution. Researchers now understand how important protecting headwaters and other upstream water sources are to clean water downstream. There was also confusion concerning which waters were protected by the Clean Water Act. This followed two Supreme Court Decisions in 2001 and 2006, directly impacting the drinking water for 1 in 3 Americans.
In 2015, the EPA and the Army Corps of Engineers finalized the Clean Water Rule (CWR). This rule was only finalized after an intensive stakeholder process in which they held over 400 meetings and received over 1 million comments, 87% of which were in favor of the rule. The Clean Water Rule clarifies which “waters of the US” will be regulated under the Clean Water Act. These include traditional navigable waters, tributaries, a small number of waters that have a significant nexus to traditional navigable waters, interstate waters, or territorial seas, and also exempts certain waters such as puddles, ornamental ponds and rain gardens, and continues certain farm exemptions.
After the rule was finalized, a number of plaintiffs sued the EPA. The rule was suspended by the Sixth Circuit court until the outcome of these suits. This stay was overruled in February 2018. During this time the Trump Administration announced they were going to suspend the rule until 2020. This suspension was overruled by the courts in August and the CWR must now be enforced in 26 states.
The issues that the CWR addresses are very important to environmental justice communities. If the rule is repealed, low-income communities and communities of color—who already face disproportionate exposures from other environmental hazards—may be most impacted. These communities, along with rural communities, are more likely to have poor infrastructure that is not able to handle contaminants in the water. These communities also may not have the resources to upgrade their water systems. They may also be more likely to rely on well water that can be more susceptible to pollution from upstream sources.
Turning to implications for nursing, why and how can nurses get involved in addressing this issue?
The EPA has announced they plan to permanently repeal the CWR; however, this repeal has not been finalized yet. If they repeal this rule, the drinking water for over 117 million Americans could be negatively impacted. Once this official announcement occurs, the nursing voicing will be crucial to protecting this vital public health regulation. There are many ways nurses can be active in this policy arena:
- Watch the new webinar from the Alliance of Nurses for Healthy Environments for one-hour free CE that reviews the CWR and provides opportunities for action (https://envirn.org/the-clean-water-rule).
- Sign this petition to Acting Administrator Wheeler asking to him to keep the CWR in place.
- Call your Senators and Congress people and ask them to support the CWR.
- Engage your professional nursing organizations—write a newsletter article and ask them to write a letter to Acting Administrator Wheeler or to Congress. As the most trusted profession, when our nursing organizations actively engage on issues such as clean water, Congress listens.
The most vulnerable among us are harmed by dirty water. By actively engaging on clean water issues, nurses can help policymakers and the public make the connection that clean water is essential to health.
Are there additional resources we should be aware of?
The American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies (which is available online here).
The Alliance frequently offers webinars (many with free CE) on a variety of environmental health topics. We’re free to join and if you sign up for our newsletter you will be notified of upcoming webinars and opportunities for action. To learn more, visit https://envirn.org.