As nurse practitioners, learning to communicate with pediatrics patients determines success in patient care. When children are communicated with in a way they are able to understand, they are more cooperative with treatments and less anxious about procedures, often to the astonishment of parents. As a pediatric nurse practitioner, parents often would ask for advice about how to talk with their children about stressful life events such as divorce, military deployment of a parent, or a change of schools, to name a few. In these situations, parents would require education and support while they navigated through these stressful events with their children. Parents are now in the midst of the COVID-19 pandemic that impacts every aspect of family functioning and life.
Children account for 8.8% of all COVID-19 cases in the U.S., have milder symptoms, and a lower mortality rate as compared to adults, according to the CDC. However, the psychosocial impacts of the disease from the death of a loved one, extended separation from parents due to quarantine or hospitalization, and the impact of mitigation efforts such as school/daycare closure, parental job loss, and social isolation can lead to long-lasting psychological effects on children. Studies have indicated that prolonged separation from parents, isolation, and quarantine can lead to a post-traumatic stress disorder, anxiety, and depression in children well after the period of isolation and quarantine have ended. However, studies have indicated that the impact of natural disasters, terminal illness, and national emergencies on children can be mitigated when they are given accurate, honest information communicated in a way that they can understand. Nurse practitioners can learn from these events and apply communication strategies used in the above situations to the pandemic. Therefore, what can nurse practitioners do to support parents as they try to communicate with their children about the COVID-19 virus?
Nurse practitioners can encourage parents to talk to their children about the difficulties that arise from the COVID-19 and its impact. Parents may think they are protecting their children by not talking to them about the disease, but research shows that even children as young as two years of age are aware of the changes around them. It is important that adults communicate in simple terms, taking into account the child’s age and level of understanding. As children’s understanding of the world changes as they develop, it is essential for adults to understand children’s comprehension of illness and causality. Very young children do not have an understanding of cause and effect and believe that thoughts, wishes, or unrelated actions can cause external events. As a result, children may blame themselves or perceive that the illness is punishment for bad behavior. Therefore, listening to what children believe about COVID-19 transmission is essential; providing children with an accurate explanation that is meaningful to them will ensure that they do not feel unnecessarily frightened or guilty. It is essential that communication guidelines are developed to aid in communication about the disease. The American Academy of Pediatrics recommends the development of and the distribution of developmentally appropriate guidelines and materials to help parents communicate clearly and honestly about COVID-19 with their child. Currently, the Centers for Disease Control and Prevention (2019), Unicef (2020), and the World Health Organization (2020) all have online resources available to parents to assist them with communicating with their child about COVID-19. In addition, an interactive multilingual book called #COVIBOOK has been developed to explain COVID-19 to children. Nurse practitioners can ensure that parents have these resources available and provide time during office or telemedicine visits to answer questions or concerns about the disease.
Nurse practitioners can implement palliative care communication principles to assist parents in communicating with their children about the disease. Weaver and Wiener (2020) have suggested that principles of palliative care communication principles could be applied to assist parents with communicating with children about some of the difficult situations that can arise from COVID-19 such as the death of a grandparent or a child’s isolation from family due to quarantine. Palliative care principles of communication are grounded in honesty and trust, self-compassion, safety, sensitivity and intuition, connection, preparedness, community building, death as part of life cycles, and legacy. In this model, children are given accurate information delivered in a way that is sensitive to the maturity, developmental level of the child, family environment, and the influence of external factors such as social media. The palliative care model of communication is child-centered, supportive of the changes the child is experiencing, and responsive to the child’s needs. Principles of palliative care communication have been effective in providing comfort to parents and children in dealing with terminal illness. Applying these principles of communication to children impacted by COVID-19 may mitigate its effects. However, more research is needed to provide evidence that palliative care principles of communication are effective in providing comfort to children and families impacted by the COVID-19 virus.
Nurse practitioners provide time spent educating parents about communication strategies about COVID-19. Telemedicine visits can be a means by which nurse practitioners can provide education and support to parents. However, nurse practitioner telemedicine services are not consistently reimbursed by private insurance or Medicaid Payment redesigns are needed to ensure nurse practitioners are reimbursed for telemedicine visits related to talking to parents about COVID-19 related communication strategies for their children.
There are currently 74 million children in the U.S. being impacted by COVID-19. Knowing that the impacts of the virus can have long-term psychological sequelae on children’s well-being, nurse practitioners need to be provided the tools necessary to support parents through the pandemic. Communicating with children about COVID-19 needs to be a priority and resources, research, and money are needed to support this endeavor.
In research released late this summer, Brad N. Greenwood, PhD, the lead author of “Physician-patient racial concordance and disparities in birthing mortality for newborns,” concluded that when Black newborns had care from a Black pediatrician, their mortality rate was decreased by half when compared to white babies.
Dr. Greenwood, an associate professor at George Mason University School of Business, took time to answer questions about this research.
Did you determine why Black babies have a better chance of survival?
I want to emphasize how cautious we need to be about speculating about the “why” question, because it is speculative. This is secondary data, so nailing down the exact mechanism is difficult, even if we do see the effect get larger in some places (hospitals that deliver more Black newborns) and smaller in others (Black newborns without comorbidities). But there are several possible explanations:
- We want to be careful not to pathologize Black newborns, but there is evidence that Black newborns can be more medically challenging to treat due to social risk factors and cumulative racial and socioeconomic disadvantages of Black pregnant women. As a result, it may be that Black physicians are more aware and attuned to these challenges than white physicians.
- Issues of spontaneous racial bias, which research does suggest manifest towards both adults and children, could also be at play. As a result, it is conceivable that the newborns are treated differently.
- There may also be challenges accessing preferred caretakers for Black mothers, or an inefficient process of allocating physicians at the hospital level.
- There is evidence in the literature that racial concordance increases trust and communication between patients and providers. While the newborn obviously won’t be speaking to the pediatrician, the mother may be, and this might have an effect.
All of these are possible, so we want to be very careful about the interpretation, since we cannot come down firmly on one mechanism or another. Likely, it is a mix of all these things and potentially more. What we do know is that the effect is persistent under a lot of conditions and gets bigger when Black newborns are born in hospitals which deliver many Black babies. This at least suggests part of the explanation may be institutional.
Your findings state that it doesn’t matter if the birth mothers share the same race as the physician. So if a white mom gives birth to a Black baby, the chances of the baby surviving are increased here as well if the doctor is Black?
When we are investigating the mother, the physician changes from being the pediatrician to being the obstetrician (the two physicians are almost always different). There is no spillover examination where we look at the effect of the mother’s physician on the newborn.
Why the effect doesn’t manifest for mothers is also speculative. While absence of evidence is not evidence of absence, it could simply be that maternal mortality is an order of magnitude lower than newborn mortality. It is also possible that there is no effect of concordance in these situations.
According to the Association of American Medical Colleges (AAMC) in 2018, 5% of all physicians identified as Black. If there are so few Black physicians overall, what will need to happen so that babies of color get the care they need to survive? What do your results mean for the care of newborn babies of color now and in the future? How can your study’s results impact the health care system for the better? How can health care workers prevent this disparity from occurring? If they can’t on their own, what needs to happen?
I will answer these all together as they seem to be related. The speculative nature of the mechanism, to me, highlights that more research is needed to understand the precise dynamics behind the finding. Specifically:
- whether physician race serves as a proxy for differences in physician practice behavior,
- if so, which practices, and
- what actions can be taken by policy makers, administrators, and physicians to ensure that all newborns receive optimal care.
The work, in my mind, is a starting point. It identifies an issue that is a real problem and provides some paths forward. But a lot of work remains to understand the issue in its entirety.
More directly to your question, I also think the work underscores the need to continue the diversification of the medical workforce. Inasmuch as research suggests stereotyping and implicit bias contribute to racial disparities in health outcomes, I think the work also highlights the need for hospitals and other care organizations to invest in efforts to reduce such biases and explore their connection to institutional racism. But the effort doesn’t simply rest on the shoulders of hospital administrators. Reducing racial disparities in newborn mortality also requires raising awareness among physicians, nurses, and other health care actors about the prevalence of these disparities, furthering diversity initiatives, and revisiting the organizational routines in low performing hospitals in order to determine why these effects persist.
What is key is that we identify high performing physicians, teams, and acute care centers, identify what makes them higher performing, and then promulgate that information to lower performing locations.
What else should our readers know?
There is one thing I think bears specific note. One conclusion we have heard is that this means Black newborns should immediately be funneled to Black physicians. There are three critical flaws with this logic:
- The disproportionately white physician workforce makes this untenable because there are too few Black physicians to service the entire population (5% of practitioners vs 13% of the population). This would mean the market is functionally underserved as you highlight above.
- It avoids the foundational concern of resolving the disparities in care offered by white physicians. This would mean that even if improvements are made there is still the chance that a newborn would not receive sufficient care in an emergency situation.
- Physician performance varies widely among physicians of both races. There are tremendous physicians of both races, and there are underperforming physicians of both races too. So it isn’t really an effective selection criteria.
What we have is a situation where structural issues are causing babies to die. I don’t think any of the members of the coauthor team would claim this is a function of malice on the part of physicians. But if we are going to solve the problem, we first need to acknowledge that disparities of care exist. Once we do that, we can start to fix them.
I’m doing laundry at a wash & fold in front of the house boats of Sausalito. Reminder: buy more scrubs. I’m one mile from from the hotel. Three minutes by car, 10 minutes by bicycle. The views are great. The weather is awesome. I could live here easy. Not on a house boat though.
They have a problem with the mating calls of some kind of small mud fish whose population has exploded. I guess it sounds terrible, like hammers on the hull all night long. Nature.
The hotel is a popular national chain brand in Mill Valley, gateway to Mount Tamalpais, and Muir Woods. It’s just north of San Francisco. I can just barely see Coit Tower. I’m maybe an hour and a half from my home so the commute would be brutal. The state is picking up the hotel tab thanks to a program authorized by the governor. It’s been a godsend.
The hotel is using the pandemic money to remodel. The room is nice, but there are sawzalls and hammers and loud Mariachi music playing during the day. At least I’m hardly ever there. They don’t clean the rooms as often because of the pandemic, but you can get fresh towels and coffee pods at the front desk any time.
The job is tedious, but not difficult. Basically, you make rounds on the prison population two times daily trying to root out COVID patients and separate them. I get there at 5:30 AM. There is a line to get through the gate. I have to sign four different log books in four different areas plus clock in with a time card.
We got a great tour of the prison on day one. The thing I remember the most is when the nurse educator guiding us said, “To everyone else they are prisoners, to us they are patients…all of them.” This dichotomy in mandates between prison staff and medical staff has allowed me to put the job neatly into my bailiwick. Nursing is nursing. The rest of it is for prison staff to handle.
The whole prison is on lock down. It’s quiet in the yards. It’s been grim. However there is hope. The numbers are improving. On my first day, there were over 1,300 patients in isolation. Two weeks later, the number is half of that. Everyone wears a mask. Infection control is taken seriously. Teams of nurses go out twice daily to assess the inmates. Other teams are doing COVID testing. Every staff member gets tested once per week. Cautiously, things are returning to a semblance of normalcy, whatever that means in a prison.
We pair up—an RN and an LVN—and grab our shoulder bag. Inside the bag is an IR thermometer, a pulse oximeter, a BP cuff, disposable PPE, alcohol wipes…sundries. When we get to our assigned area we put on the PPE and each team gets their own guard to keep them safe. “Don’t step into the cell, don’t put your face in front of the food port, don’t walk close to the cells…” Helpful advice and a sober reminder of the overlapping existence of prisoner and patient.
I’ve given careful thought to the nature of the job, the nature of crime and punishment, and the morally ambiguous task of providing competent health care to people who have committed terrible crimes. Thankfully, I’ve never followed crime stories. Having worked in the ER for many years, I’ve dealt exclusively with the aftermath of crime and the amelioration of its physical consequences…as best as can be done anyway. I have no curiosity about death row inmates. I can honestly say that I leave that at the door and look at each person strictly through the lens of health care. Having said that, I can tell from even the most cursory interactions with some of the patients that there are some seriously disturbed people within these walls. I’m happy to move along to lower level offenders.
From the ground, I can say the efforts to control the spread of COVID within the prison have been very successful. Again, I’m just the tip of the spear so the big picture is a little out of my view. But just judging from the numbers of patients I assess daily, things are improving very quickly. I guess that’s the benefit of working within a closed system…it was also that closed system that allowed the virus to spread so quickly in the first place, so there’s that. Wearing masks, social distancing, testing, contact tracing, quarantining…they have brought the cases of infection down so quickly that it’s possible that the job will end early. I’ll be sorry to leave. The pay is…generous.
The best part of the experience has been meeting new friends. Travel nurses are go-getters. I’ve met nurses from all over the world on this assignment. We share a common bond and have moved together from trepidation to confidence in this new role. We share stories in the break room and compare notes on our experience. Several nurses are staying in the same hotel that I am. It’s a great way to meet friends in our new socially isolated world. I hope that I have met lifelong friends here as I have on other contracts. The staff at the prison have been nothing but welcoming, same for my agency. A good experience from top to bottom.
The good news…or bad news depending on how you look at it, is that other prisons are experiencing similar outbreaks and will need COVID crisis teams to come in. There are already jobs being posted for other prisons in California. Susanville, San Lois Obispo, are two that I’ve seen. If you are interested in making some quick money, and are willing to shoulder some risk, I encourage you to contact a recruiter. The turnaround time for me was three days between first contact and clocking in. Be ready to move quickly. Have your documents together. The free hotel program is still in effect so your housing is covered. Stay safe out there.
Community health centers have taken on a big role in the nation’s healthcare as the COVID-19 pandemic has continued to impact the nation. Nurses who work in these centers find their skills in high demand.
According to the National Association of Community Health Centers (NACHC), federally funded centers provide essential access to primary care for people who may not be able to access it through traditional means. Whether there are barriers from language, income, lack of insurance, or transportation, these centrally located health centers remove many of those barriers to care.
Access to healthcare is especially important right now, as the coronavirus is having a devastating impact on communities that are predominantly of people of color and immigrants, and where people live in densely populated neighborhoods and homes. Many of these communities also have a high number of essential workers who must be out in the community daily—increasing the risks to their health and that of those around them. Some community centers provide care for rural areas, where there’s little access to healthcare, but still a high need. The Rural Health Information Hub offers a toolkit for healthcare workers in these areas.
The NACHC states that with the effective preventative care and emergency care, community health centers are able to divert people away from the emergency departments which may be their only viable healthcare option. In addition to healthcare, community health centers also offer or coordinate much needed services such as translation or interpreter services, transportation, and the case management of complex issues and conditions.
Staff also act as excellent community advocates and work to explain, distribute, and educate patients on health conditions, treatment options, home care, and disease management. By doing this, patients and their families can have better outcomes as they know how to manage all aspects of their health. Patients learn about any conditions or symptoms through education provided with a focus of culturally competent healthy practices and behaviors that will work for them.
As an affordable and viable option for approximately 29 million people in the United States, the nearly 1,400 community health center organizations nationwide provide a place where residents go for healthcare delivered by a staff that understands the specific details of their community and how those details can impact their health. Some states have organizations devoted to community healthcare, such as the Massachusetts League of Community Health Centers, that offer more information, resources, and history of these vital centers.
Nurses interested in a career working in community health can find out more through the American Public Health Association, an advocate for providing high-quality and effective public health options. A healthy community allows residents many more options, and community health centers help provide that lifeline.
From pregnancy and neonatal care to addiction or heart disease, community health nurses will see it all in their practices. It’s an excellent role for those who are committed to both lifelong learning and the foundation of a healthy community that is focused on equity.
August is National Breastfeeding Month and is a good time for nurses to offer support and resources for families who want to make breastfeeding part of their lives.
According to the United States Breastfeeding Committee, “83 percent of U.S. infants receive breast milk at birth, only 25 percent are still exclusively breastfed at six months of age.” And while the benefits of breastfeeding are widely touted by the American Academy of Pediatrics and other organizations, not every family has equal access to resources or has a supportive environment in which breastfeeding can be sustained.
This month calls attention to the disparities that exist and can help families who choose breastfeeding to have better opportunities for education, support, and resources.
On August 27, from 11:30 am to 1 pm EDT, BirthNet will host the lunchtime discussion, Celebrating Black Breastfeeding and How Doulas Can Help. The panel discussion will address using doulas to help families through some of the challenges they find, especially during the times when COVID-19 can bring even more barriers to finding support when they need it.
Most babies and mothers reap health benefits associated with breastfeeding. According to the American Academy of Pediatrics those include some infant and childhood protection against:
- respiratory tract infection
- necrotizing enterocolitis
- otitis media
- urinary tract infection
- late-onset sepsis in preterm infants
- type 1 and type 2 diabetes
- lymphoma, leukemia, and Hodgkins disease
- childhood overweight and obesity
Mothers also find benefits include a faster uterine recovery, decreased bleeding, faster postpartum weight loss, and some risk reduction of ovarian and breast cancer.
Nurses can continue to offer support to moms who are beginning the process or those who want to continue and are having a hard time doing so. While breastfeeding is a natural method of feeding, it isn’t always easy. Frustration, pain, and exhaustion can derail even the most determined parent. But supportive care—from a nurse, a friend, family member, or a professional—can make the path to continue a little easier. When parents find reliable and effective advice, emotional support, and encouragement, they may be more inclined to continue.
As a nurse, even if you aren’t an ob/gyn specialist, you can help support families who want to breastfeed by helping them find resources within your organization. General supportive conversation if they are finding breastfeeding more challenging than they realized or guiding them toward breast pumps, pillows, nursing clothing, salves, or support groups can sometimes be all that’s needed.
As a professional, you can also advocate for breastfeeding rights including workplace rights for working parents, equal access to resources and support, and general acceptance of breastfeeding.
The Healthy Newborn Network offers a Breastfeeding Advocacy Toolkit that offers ideas on everything from funding to workplace policies aimed at making breastfeeding easier and more sustainable for many different lifestyles and scenarios.
Celebrate and support families this week during National Breastfeeding Month.
On April 3, 2020, the Centers for Disease Control (CDC) made a statement encouraging all Americans to wear cloth face coverings upon leaving their homes. In response, Black men have expressed their concern about such a recommendation. Their concern is based in that wearing masks could expose them to racial profiling and harassment from law enforcement officers. An example of such concern can be seen in the Twitter posting of Aaron Thomas, a Black man living in Ohio: “I don’t feel safe wearing a handkerchief or something else that isn’t CLEARLY a protective mask covering my face to the store because I am a Black man living in this world. I want to stay alive but I also want to stay alive.” Such a tweet has been reposted more than 18,000 times since its original posting. Based on his statement, Thomas has decided to not wear a mask so that he can “stay alive.”
This concern has not been unwarranted. A month before the CDC provided its recommendation, two Black men posted a video of themselves on YouTube being escorted out of a Walmart in Wood River, Illinois by a police officer for allegedly “wearing surgical masks.” One of the men stated that: “[The policeman] followed us from outside, told us that we cannot wear masks. This police officer just put us out for wearing masks and trying to stay safe.” The chief of the Wood River police, Brad Wells, stated later in a news release that the police officer in the video “incorrectly” told such men that a city law prohibited the wearing of masks. Chief Wells went on to state: “This statement was incorrect and should not have been made. The city does not have such an ordinance prohibiting the wearing of a mask. In fact, I support the wearing of nonsurgical mask or face covering when in public during the COVID-19 pandemic period.” As a result of the two men filling a complaint, Chief Wells told The Washington Post that an internal investigation of the incident has begun with the assistance of the local NAACP branch.
Georgia Senator, Nikema Williams, wrote a letter to the state’s governor urging him to temporarily suspend the mask laws. She explains why in her letter, stating that her husband, who is African American, 6’3”, and weighs 300 pounds: “was telling [her] how uncomfortable it was to wear a mask in stores because folks get intimidated and look at him like he’s up to no good.”
Black men have also experienced racial profiling when not wearing a mask. In April of 2020, a video from Philadelphia filmed a Black man being removed with force by four police officers one day after the city’s transportation authority required all riders of buses, trolleys, and trains to wear face coverings. After the incident, the transportation authority made an announcement deeming face coverings no longer required for riders.
Therefore, it has been found that both Black men who follow and do not follow the CDC recommendation to wear a face covering have experienced episodes of harassment. Blacks are already at an increased risk of contracting the virus, but now Black men in particular are faced with the dilemma to wear a mask to save their lives from either racial profiling or the raging COVID-19 pandemic.
Like several senators, the NAACP has also made a statement urging states to indefinitely stop their mask laws. Marc Banks, the NAACP’s national press secretary, stated: “No person should be fearful of engaging in lifesaving measures due to racialism.”
Melanye Price is a political science professor at Texas’ Prairie View A&M University. She tells The New York Times that the well-intentioned recommendation to wear masks or bandanas actually can put African Americans at greater risk of racial profiling. According to Kevin Gaines, a professor of civil rights and social justice at the University of Virginia, Black men are already being profiled by the police on a regular basis, but wearing masks heightens such risks of profiling. The initial assumption is not made that Black men are wearing masks to protect themselves and those around them from the threat of the virus. However, in contrast, it is assumed that they are engaging in some type of ill will like stealing or other crimes.
As a result of the risks of racial profiling, some Black men have changed their style of dress in an effort to appear less threatening. STAT correspondent Usha Lee McFarling reports that Black men have attempted to “tone down their appearance to lower suspicion.” Examples of such “toning down” comes in the form of wearing college T-shirts and “dressing like prospects, not suspects.” This has even been found in their choice of mask colors and patterns, choosing floral prints or plain white masks over others.
Vickie Mays, a professor of heath policy and management at UCLA, has been attempting to track situations in which Black men wearing masks have suffered harassment. Mays tells STAT that Black men should wear masks despite the risk of racial profiling in order to, foremost, protect their health. However, she suggests that such masks not be dark in color or “ominous looking.” Instead, she suggests they be bright in color or have traditional African prints. Mays also urges health officials to swiftly procure professionally-made masks for Black communities just as they would any other commodity like food or water as this population has been reportedly experiencing greater rates of COVID-19 infection than non-minority groups.