As increasing numbers of patients don’t speak English as their first language—or at all—the health care field is taking action. Here’s what’s happening and how you can become involved.
Imagine if you were in a hospital in a country where no one spoke English. Being in a strange hospital or other health care facility can be scary enough, but if you had no idea what was going on, it would make you more stressed—possibly making your health worse. You would feel incredibly vulnerable, as not knowing what was happening to you or if the workers could help you would be terrifying.
There was a time in the United States when that could happen. Although it shouldn’t happen, legally, anymore, as Allison Squires, PhD, RN, FAAN, explains, there is still a need for more bilingual nurses. “All health care facilities are required by law—including the Civil Rights Act and updated regulations in the Affordable Care Act—to provide patients who do not speak English with an interpreter,” says Squires, an associate professor at the New York University Rory Meyers College of Nursing. “The interpreter can be an in-person interpreter or a telephone or video interpreter to meet the requirements of the law.”
According to Squires, the increase in patients who haven’t developed English skills comes from two situations: the post-WWII legacy in which U.S. citizens came here as immigrants, and the most recent wave of immigration, which has matched or surpassed the immigration numbers of the early 20th century. “According to the Pew Research Center, one in five households in the U.S. speaks a language other than English at home. More communities are also becoming refugee resettlement cities across the U.S., which means increasing linguistic diversity in places that have historically only had English speakers,” says Squires. “The demand for nurses who speak another language is at an all-time high.”
Location, Location, Location
While all the sources whom we interviewed agree that Spanish is the most prevalent second language needed for patients, they also say that other languages are vital as well, depending on your region of the country. “Spanish is the priority language nationally. Other languages depend on where you live and who is migrating there,” says Squires. “For example, in the New York City and New England regions, there are now large numbers of Russian speakers. These individuals often come from former Soviet Union states where Russian was the official language. Other parts of the country, like Texas and Louisiana, have large numbers of Vietnamese speakers who came to the U.S. as refugees or immigrants. Other than Spanish, language demand is often specific to a local health care service area.”
“Spanish is the language in highest demand, particularly in Texas, California, Florida, and Illinois. In California, bilingual skills are needed for Spanish, Chinese, Vietnamese, and Russian,” says Terry Mort, who is manager of talent acquisition for VITAS Healthcare, the nation’s leading provider of end-of-life care. In the 14 states and the District of Columbia in which they provide care, VITAS Healthcare has also found the need for Mandarin, Cantonese, Tagalog, Hmong, Korean, and Creole.
“We constantly have to look at demographics of the communities we serve and pay attention to how they’re changing over time,” explains Mort. “Take California as an example. At one time, South Central Los Angeles was primarily an African American community, whereas today it’s predominately Hispanic. And as our services move into outlying areas of Los Angeles County, our needs change again because we encounter more families that are Filipino, Asian American, or Hispanic American.”
Currently, in South Florida, several VITAS hospice teams are solely Spanish speaking to appropriately serve their patients’ and community’s needs. “In California, a trilingual nurse—someone who speaks English, Spanish, and other language—would be in high demand,” says Mort.
Although particular languages may be needed to serve certain populations, there are also instances in which unexpected languages may also be required. For example, when there was a recent influx of patients from Puerto Rico at the University of Maryland Baltimore Washington Medical Center who needed health care after Hurricane Maria, there were more Spanish-speaking patients, says Edith Lopez Dobbins, RN. Dobbins is a JET Nurse, which stands for Just Excellent Timing and means that she is a full-time nurse who serves as supplemental staff for different nursing units throughout the hospital. As a result, she has noticed an overall increase in patients who speak Hindi and Korean as their first language.
“In the hospice profession particularly, we also have the challenge of end-stage dementia patients, who may revert to their language of origin as their disease progresses. We had a Russian patient who reverted to speaking Russian, but the family indicated he had not conversed in that language for more than 20 years. If that happens, it requires us to update our care plan so that our nurses and staff members can communicate effectively with these patients in a language they understand,” explains Karen Peterson, senior vice president and chief nursing officer for VITAS Healthcare. “The more languages our staff members can speak, the easier our job is.”
Benefits to Being Bilingual
Bilingual nurses on staff help open everyone up to another world as well as another set of patients to care for, says Vivian Carta Sanchez, DNP, ARNP, from Tenet Florida Physician Services. “Nurses who are bilingual can also serve as translators to communicate very important information from physicians who do not speak the language,” says Sanchez.
Squires says that if you work in a hospital, home care, long-term care, or rehabilitation, there are four key times when interpreters are needed—admission, patient education, consent, and discharge. “Using an interpreter during these times can help reduce your patient’s risk for readmission and complications,” explains Squires.
Having a nurse who is bilingual, rather than using a family member to translate, can be crucial. “Let’s say that I take five minutes to explain something in detail to a patient, and the family member who translates what I said to the patient takes about 30 seconds. I can tell that my patient isn’t hearing the same thing that I said—and that’s a risk to the patient, because they’re not getting complete information,” says Peterson. “It’s one of the reasons we prefer not to use family members as translators because they are part of the unit of care and also dealing with psychosocial issues associated with end of life.”
Another advantage to staffing or being a bilingual nurse is that when you are speaking the same language as a patient, the work you are doing will take the same amount of time that it does as when you are talking with an English-speaking patient, says Squires. There’s no need to be concerned about waiting for an interpreter to arrive or to have to deal with any issues that can occur when using an interpreter by phone. In addition, communicating with family members may also be easier. “That being said, as a bilingual nurse, if you are the first language nurse to work with the patient when they access health services—be they in the hospital, home care, or primary care—sometimes you spend more time with them initially because the patient is so happy to have someone who speaks their own language,” states Squires. “You find out all this other stuff that the patient held back because of the language barrier or issues with interpreter services. Another advantage of being a bilingual nurse is that you can quality check video or phone interpretation.”
Speaking to patients in their native language isn’t only about the words; it’s also about their culture. Dobbins says that while they use “language phone-lines” to keep at patients’ bedsides so that they, their families, and the health care workers can communicate—which is certainly helpful—the phones can also make talking more impersonal. “It makes patients and their families uncomfortable—possibly because it’s not just about language, it’s about culture. Most of the time, we use peers in the health care team who speak the same language as the patient for better communication and overall quality of care,” says Dobbins.
“Bilingualism is even more imperative in the hospice profession because there’s a lot of emotion and psychosocial aspects of language surrounding the dying process. Each person might have a different opinion or thought process around the issues related to dying. It’s unique in that people may have difficulty conveying their thoughts and feelings, even in the same language, simply because it’s about death,” explains Peterson. “Some patients or family members can’t even say the word ‘hospice,’ so they find a way not to say it. But when our nurses, families and patients understand each other’s language and cultural nuances, we’re more confident that patients are making the right decisions and receiving the best possible care because everyone understands each other.”
Knowing about patients’ culture has become so important that the Chamberlain University College of Nursing began offering a Hispanic concentration on its Phoenix, AZ campus in May 2016. Pam Fuller, EdD, MN, RN, the Phoenix campus president, states that this concentration doesn’t aim to attract Hispanic nurses, but rather to appeal to nurses who want to care specifically for this culturally diverse group. This concentration is offered to anyone who is enrolled in the university’s pre-licensure BSN program. Because of its ability to logistically provide clinical experiences for students who are enrolled in the Hispanic concentration, the Phoenix campus volunteered to pilot it. “The local hospitals and health care centers currently serve Hispanic patients and families every day, and Chamberlain helps provide nurses and care to these local communities,” says Fuller.
“Providing nursing care requires not just an appropriate educational degree and a license, but also crosses boundaries of human dignity and respect. Many, if not all, hospitals and care centers are challenged to communicate more effectively with their patients, regardless of cultural background. Chamberlain specifically launched the Hispanic concentration based on information from hospitals in our local markets,” explains Fuller. “When a patient is in pain or in need of health care, they tend to revert to what is comfortable to them, culturally. If you are culturally more comfortable with your own language and traditions, if there is someone who can speak—at least a little bit—the language you speak, it makes the care that much more effective and personal.”
“Chamberlain’s Hispanic concentration is not a language program. This concentration exposes students to the Hispanic language and culture and allows for 25% of their clinical experience to be placed with a Hispanic patient. This gives them real-time experience in serving the Hispanic population,” says Fuller. “Any student—regardless of their personal cultural background—may enter this concentration…The goal of the Hispanic concentration is to educate students and expose them to the culture and language of the Hispanic community to provide an improved level of care to this population.”
Attracting Appropriate Personnel
How can facilities go about recruiting bilingual nurses? Squires believes that a combination of actions could help. Nursing schools need to recognize local demand for bilingual services and restructure curricula to help ensure the success of English as a Foreign Language (EFL) students, says Squires. “Even now, EFL students have lower pass rates on the NCLEX-RN exam, and that’s not helping to meet our need for more bilingual nurses. Schools need to change how they teach and support EFL students so they have the same success rates as English speakers,” Squires says.
“Organizations should give bonuses to people who are bilingual to encourage better communication,” says Sanchez.
As for becoming bilingual, Squires says that to achieve the level of fluency to be able to effectively and safely communicate with patients about health issues, nurses would be required to undergo years of study or at least a six-month immersion in a country where the language that they want to learn is spoken. “Having just a few words or phrases can be helpful for recognizing when a patient is in pain or [has] toileting needs, but when it comes to the complex communication needs that go with admission for services, patient education, consent, and discharge, you really need to have what’s called sociolinguistic competence in a language. That’s something that your employer should help you certify or do it on your own to make yourself more marketable,” says Squires.
At the end of the day, being bilingual or having bilingual nurses on staff is all about patients’ safety and comfort. “As a nurse, many of my most rewarding moments have to do with going the extra mile to help a Spanish-speaking family during their hospital stay,” says Dobbins.
A1C, or Hemoglobin A1C (HbA1c), is considered the gold standard for managing diabetes. But what is it?
The cell wall of the erythrocyte is permeable to glucose. Exposed to this glucose, the Hemoglobin molecule becomes “glycated.” The naming convention for HbA1c derives from Hemoglobin type A being separated using cation exchange chromatography. The first fraction, considered the pure Hemoglobin A is designated HbA0. After that comes HbA1a, HbA1b, and then HbA1c respective of their elution. Hemoglobin exposed to a normal level of glucose has an average glycation. As the glucose level rises, so does the fraction of glycated Hemoglobin, in a predictable way.
The average lifespan of a red blood cell is about 120 days before the cell membrane starts showing signs of wear and tear and they get shuttled off to the spleen, liver, and bone marrow for breakdown and recycling. The A1C therefore is a picture of the AVERAGE blood sugar over the previous 2-3 months. As an average, it cannot tell the difference between someone with tightly controlled blood sugar and a person with wildly fluctuating highs and lows. Neither does it identify episodes of hypoglycemia or periods of critically high blood sugar values. It’s great for population management but too crude a tool to manage an individual patient.
In the chart, we see a day in the blood sugar levels of three patients. All three have the same average blood sugar, but patient number 1 and patient number 2 have wildly fluctuating levels throughout the day. Patient 1 spends more time outside of range than inside, but her A1C would be normal.
The A1C coupled with the patient’s daily blood sugar record gives a more complete picture for individual patient management. Other shortcomings in the A1C happen with patients with high or low blood cell turnover. Patients with kidney disease undergoing dialysis have especially high turnover of red blood cells due to the process of filtering the blood. Their A1C would be abnormally low. Cirrhosis of the liver decreases blood cell turnover leading to higher A1C levels. Certain types of anemia and blood disorders as well as some vitamins and medications can affect the accuracy of the A1C. If you hang your hat on the A1C for all your treatment decisions, you will be misled.
So, what is the A1C good for? The American Diabetes Association has the following guidelines to be used in the diagnosis of diabetes:
||What It Means
|Less than 5.7%
||Normal (minimal risk for type 2 diabetes)
|5.7% to 6.4%
||“Prediabetes,” meaning at risk for developing type 2 diabetes
|6.5% or greater
Following it over time allows for risk evaluation for complications arising from diabetes. There’s a strong positive correlation between high A1C numbers and diabetic neuropathy, kidney disease, and eye disease. Diabetic specialists use the daily blood sugar levels to formulate an individual plan for each patient to drive the A1C numbers lower over time.
Understanding the A1C and what it does and does not tell you is important. It’s a great starting point, but not an accurate tool for individualized diabetes care.
Tavonia Ekwegh, DNP, APRN, PHN and CEO of the I-Help Foundation, uses her nursing skills to help struggling communities gain health and wellness equity through access, education, and even the ability to grow their own fruits and vegetables in some urban food deserts.
“I-Help Foundation started with a vision my husband [Timothy Ekwegh] and I had for helping people, hence the name I-Help Foundation,” says Ekwegh. “We started with a focus on the transient population and providing them with homemade meals and hygiene packets every single weekend for three years.” After taking a break to concentrate on her educational pursuits, Ekwegh and her husband found the drive to help people offered a fulfillment they needed.
Ekwegh recently shared some insights about health inequities, starting initiatives, and I-Help’s role in making a difference.
What makes I-Help distinct?
I-Help is distinct in the sense that we are comprised of a team of upstreamists who truly believe that health can be improved by addressing the root causes of social determinants of health. I-Help Foundation works closely with stakeholders on a variety of social injustices and health inequities. Our approach is more at the community level while maintaining our relationship with the local and national health sectors. By working closely with community stakeholders, I-Help Foundation has been provided with insight into health disparities and possible root causes. This insight has led I-Help Foundation to where it is today, with a new mission and vision that focuses on remedying health inequities by taking action on the social determinants of health.
I-Help seems to adapt to the changing health needs of communities. Why is adapting to those changes is so essential to the health of community members?
I-Help Foundation works within communities to both identify and advance solutions that assist in removing stigmas and barriers, and to promote the overall health of the economically and socially disenfranchised. We pride ourselves in building a foundation of knowledge by way of research so that we can better prioritize to the changing needs of the community. On-going community health assessments have proved that the needs and the environment of communities are ever-changing and social determinants can either assist or prove to be a barrier to an entire community trying to make healthier decisions.
Are some communities at a health disadvantage? How does I-Help work with community partners to change the outcome or implement programs or activities that will begin the process of improvement?
I-Help Foundation believes that some communities are at a health disadvantage for copious reasons such as social, economic, political, and logistical reasons. I-Help Foundation is committed to addressing the root causes of health disparities by working in collaboration with communities. We empower the community stakeholders such as young people and adults to advocate for their health and identify needed changes in their neighborhoods. Then we help develop and support the community’s vision of health by cultivating partnerships to deliver unique and customized programs and services that are empathetic and inclusive.
Can you please give an example of an I-Help success story of which you are most proud?
I-Help Foundation is most proud of our Farm up 4 Health, which is an urban farming program geared toward teaching young people in economically disenfranchised communities how to farm and cultivate sustainable organic non-GMO fruits and vegetables. We do this by providing them an opportunity to gain a practical farming experience by working on an urban farm every weekend. We accomplish this by providing them with the necessary equipment, seeds to grow, and harvest crops year after year.
I-Help Foundation Farm up 4 Health provides communities access to organic and healthy fruits and vegetables in otherwise inaccessible neighborhoods. In certain communities where food deserts are prevalent, these community gardens provide a nutritional avenue for families. Communities learn how to grow fresh fruits and vegetables, some of which are new to their palate, while mentors provide information about healthy eating.
What made you decide on nursing as a career choice?
I was introduced to nursing at a very tender age by way of my mother who is a registered nurse. I watched my mother’s career trajectory from nursing assistant to becoming a registered nurse later on in life. Some of my most profound memories of nursing came from going to work with my mom when she worked at a nursing home and a physician’s office. I can recall interacting and forming relationships and bonds with many of her patients. I remember one elderly patient that I fell in love with at the nursing home; she was probably in her late 80s or 90s, she had no family and my presence brought her so much joy. Although I was not allowed in the patient’s room, I would sneak and visit her, read her books and provide her companionship for the time I was there. From that moment on, I knew I wanted to meet the physiological and psychosocial needs of individuals. I believe nursing is my calling, and even in the capacity of president and CEO of a non-profit organization, I can still exemplify the tenets of nursing.
What is your personal goal as a nurse?
My personal goal as a nurse is to become a game changer for my profession and generations to follow. I would like to see I-Help continue to improve and advocate for the overall pursuit of health and wellness for our communities.
What makes health equality so important to communities on a micro level but then also as a sign of national wellness?
Health equality is a fundamental human right that is paramount to communities being able to thrive on both a micro and macro level. Without health equality, we will continue to see disproportionate levels of disease, poverty, and limited access to healthcare and public services. The health and wealth of a nation is also contingent upon the ability and willfulness to provide equitable access to healthcare for all.
Kyana Brathwaite, founder and CEO of KB CALS- Caring Advocacy & Liaison Services, worked as a critical care nurse when she hurt her shoulder during a patient transfer.
“Our patient population is getting heavier [and] it is not always realistic to pull colleagues from different areas/departments to help. My true issue was not with the injury—although unfortunate, they do happen—my issue was with how my particular situation was handled after the injury by both management and the entity I worked for,” she explains.
For these reasons, the pain of her injury and the lack of support by management, Brathwaite chose not to stay at the bedside. Would she have stayed had circumstances been different?“Prior to the injury, I was considering staying at the bedside for at least five more years to give me time to plan the direction in which I wanted to take my nursing career.”Although she did plan to continue her career eventually, she would have given solid years to suffering bedside nursing specialties.
In fact, many nurses run from the bedside as soon as possible because conditions are so deplorable. They look for jobs in advanced practice, teaching, and other non-bedside related areas of nursing, while the number of nurses taking care of the most critical patients continues to dwindle.
Here are four reasons nurses leave the bedside and some ideas as to how to make them stay.
1. New Grad Education
New grads can go into a bedside job and not know exactly what they are in for. In nursing school, clinicals usually don’t go beyond two to three patients per student so they are not exactly exposed to the real-life rigors and stresses that come with the life of a bedside life—and cultural shock is a very real phenomenon.
“Nursing students are constantly told by faculty, peers, mentors, and experienced nurses what bedside nursing is ‘really like,’ says Greg Eagerton, DNP, RN, an associate professor at the University of Alabama at Birmingham School of Nursing. “However, it is like the first time we ride the bike by ourselves…The same is true for new nurses; their hands are held throughout their training and then the day comes when they are ‘alone’ and it’s a little frightening. They now have the sole responsibility for their patient’s care, their patient’s life—and that can be daunting. It’s also the reason we always encourage team support from their mentors, their more experienced peers, and from all members of the health care team, including physicians, therapists, support staff, etc.”
Although this is true, new grads often express intense dislike of their new role as a bedside nurse, and they immediately want to move to another branch of the profession. Is it that the nurse is not prepared or that the job is simply too difficult? It certainly sounds like management is trying to accommodate new nurses, but a quick search of internet nurse boards will reveal new nurses in despair. Perhaps more intensive job shadowing will allow new grads to see what bedside nurses do. Perhaps more realistic teaching would also go a long way toward helping them. Whatever the answer, new grads are a special population that needs attention—though it already gets quite a bit—to keep them safe and happy at the bedside.
2. Staffing Ratios
Another issue that chases nurses from the bedside is poor staffing ratios. It can be overwhelming for one nurse to have eight to ten patients to themselves. Not only is it unsafe, it is also stressful, and many nurses would rather find a new job than to put their licenses and their mental health on the line like that. For this reason, staffing ratios are important to consider when examining the loss of bedside nurses.
“I do not feel staffing ratios is the main driving factor,” argues Ken Shanahan, MSN, RN, CCRN-K, clinical nursing director at Tufts Medical Center. “One of the main reasons I feel this way is because the only state with staffing ratios is California and yet they have the most nurse strikes. These strikes are actually increasing dramatically and are something we will need to address as a profession. The work environment is the most important factor and number of nurses or ratios is only a component of the working environment. There are many other components that we are not hitting the mark on that would help create a healthy work environment.”
Although a large portion of nurses would disagree with Shanahan’s opinion on the importance of staffing ratios, he does have a point: they are not all that is involved here. Getting the floors better staffed is only one part of the puzzle, but addressing pressing issues such as horizontal violence is needed, too. Everyone knows about staffing ratios, but few realize they are only one prop to hold up a very large house meant to keep nurses at the bedside.
3. Compassion Fatigue and Burnout
Compassion fatigue and burnout are the psychological components that keep nurses from staying at the bedside. The two are closely related but are not the same. Burnout, in short, is frustration with the situation and is typified by anger. Compassion fatigue is an exhaustion of the ability to extend oneself emotionally anymore and is typified by depression. Please note, these are very simple definitions and they are not exhaustive. Both of these conditions can occur together, and neither is pleasant. Nurses have had their lives broken over these issues, and no one wants to go through that. How, then, do we solve this problem?
“Burnout and compassion fatigue are concerns for direct care providers in all professions,” explains Eagerton. He suggests the following measures to help support staff:
- Leaders should be visible and approachable.
- Work schedules should allow adequate time off between shifts.
- Adequate breaks should be provided during the work shift so that staff have down time.
- Schedule time for staff to have discussions about what stressors they are experiencing that may lead to burnout and fatigue.
- Create opportunities for staff to be involved in activities that allow them to do things that are not direct patient care but have meaning to them, such as committee membership, attending professional conferences, and so on.
- Have resources available for nursing staff in addition to their managers to discuss their stressors, such as chaplains, mental health professionals, and counselors.
- Have dedicated space(s) on or near the units where they work where they can have some quiet time or time to eat their meal or have their break without interruption.
With these ideas in place, nurses can have a better shot at overcoming compassion fatigue and burnout. When these are not a factor or are a mitigated factor, the more a nurse can feel happier staying at the bedside.
Nursing is definitely a contact sport, as stories like Brathwaite’s prove. Transferring patients is getting more and more difficult with increased body weights. In addition, various specialties are more susceptible to transfer related injury. For instance, operating room nurses are at great risk because they must move patients who are unconscious and essentially dead weight. However, that doesn’t make your typical bedside nurse any less at risk. Moving and lifting are just as much a part of the job, and mechanical equipment is usually not available to help.
“There is only one of you, [and] there will always be more patients,” says Nick Angelis, CRNA, MSN, author of How to Succeed in Anesthesia School (And RN, PA, or Med School) and cofounder of BEHAVE Wellness.“If no one is available to perform a task safely with you, don’t do it. Hospitals always push putting the patients first, but you’re a danger to patients if you give and give until your weekly schedule must also include time for massage and chiropractor appointments. Flu vaccines, unsafe equipment, dangerous staff ratios, risk of physical harm from unruly patients because hospital security resembles nursing home patients—these all require putting yourself first.”
It really does come down to this: Nurses need to learn how to put themselves first. If you can’t lift that 300-pound patient, then don’t even try, no matter how much it needs to be done. Similarly, hospitals need to make allowances for nurse injuries. Providing mechanical lifts, better security, and education about safety could go a long way towards protecting nurses and keeping them at the bedside.
In the end, the question of keeping nurses at the bedside is definitely multifactorial—and controversial. Patients have been cared for all this time with the methods we’ve been using, so why change? The reason to change is that the nursing shortage is real, and it isn’t what you think. It isn’t a lack of trained nurses. It is a lack of trained nurses willing to work. If we can make the bedside more appealing to these nurses who have run for cover, perhaps the nursing shortage wouldn’t really exist at all.
Health care quality and patient safety are not dependent upon a singular factor. Rather than addressing the system and its processes in a methodical, incremental fashion, the current model focuses improvement in a single area, rather than addressing the system as a whole—this is where the industry is failing. Organizations are seeing functions such as patient safety, provider safety, patient experience and satisfaction, utilization and others, rather than an intricate web with the patient and direct care providers at the center.
In health care, quality improvement is seen as the domain of clinical staff. Look at the profiles of people in quality improvement roles, and you will see most are RNs, MDs, or DOs, thus sending the message that the onus of quality improvement is on the clinical staff alone. This prevailing attitude is sabotaging the ongoing efforts to improve quality and ultimately impacting patient safety and experience.
What the typical health care approach to quality improvement (QI) fails to consider is that health care is a system made of disparate processes. Processes that feed into multiple areas and functions, far beyond direct patient care. It is an intricate web, that gets results. Whether good or bad, systems will always have the result that they are intended to and confining quality to the domain of clinical staff and their leaders is a huge failing that many organizations are still perpetuating.
The rigidity of roles in health care have created siloed efforts of improvement. Yes, there are state and regulatory compliance issues around licensure and scope of practice, but some of the restrictions in improvement work has been self-imposed by outdated attitudes and practices that no longer reflect the quickly changing field of health care. This impacts communication and can result in harm to our patients.
As health care continues to adapt Lean and Six Sigma into its QI practices, the industry is falling into the trap of only using Lean tools, but not following the spirit of a Lean culture. A Lean culture empowers everyone to work across departments and functions, make changes to improve quality, and add value to our patients. Risk is inherent with change, but with Lean, blame is never assigned—mistakes are seen as learning opportunities. Whether or not an organization uses this methodology, the mind shifts that must occur are imperative to improving care and having a true culture around continuous improvement. Thirty years ago, the New England Journal of Medicine ran a piece called “Sounding Board.” In it, the author describes two cultures: one that is punitive toward mistakes (Bad Apples), and the other is collaborative, with management acting as coaches who encourages honest dialogue about errors, with staff feeling supported to learn from them. The second was far more effective than the first. Why, after thirty years, is health care is still struggling to adapt continuous improvement?
Today marks Post Traumatic Stress Disorder (PTSD) Awareness Day to educate the public about a condition that can strike anyone. PTSD, an often-misunderstood ailment, is treatable but can have lasting impacts if people don’t recognize it in themselves or in others.
Nick Benas QMHC and Michelle Hart LICSW are authors of Mental Health Emergencies, a book that examines how anyone, but particularly medical and emergency professionals or those in roles such as teaching or human resources, can respond to a mental health crisis including post traumatic stress disorder. Providing the proper response and supports can open up the patient to a wide range of effective and needed treatment without the stigma they often feel in their daily lives.
Michelle Hart answered a few questions from Minority Nurse to help promote understanding of this condition, its causes, its treatments, and the sensitivity needed to help people who have it.
Please tell me how PTSD develops. Does it impact all ages?
PTSD develops after an exposure to real or perceived threat and/or witnessing or experiencing a traumatic event. Vicarious trauma can occur by listening to another’s detailed account of a traumatic event. It can impact all ages and babies have been born with high levels of cortisol, which is an indication of PTSD, after having a parent while in utero experience PTSD. The level of a person’s resiliency is a factor whether or not the effect of a trauma will eventually lead to PTSD.
Is there effective treatment for PTSD?
The most effective researched based therapeutic approach to PTSD is Dialectical Behavioral Therapy, DBT. However, many aspects of Cognitive Behavioral Therapy (CBT) have been proven to reduce symptomology.
How can nurses recognize signs of PTSD in patients or in those close to them?
One of the most common signs of PTSD is derealization or depersonalization. Examples of this include the following:
- The inability to experience a range of natural occurring emotions
- Lagging mind/body connection
- A person who is injured who does not experience pain in accordance with the level of injury
- A flat affect of emotions, not able to cry or laugh when situationally appropriate
- A person who stares off into space when discussing an event or appears to be re-experiencing the event when telling story
- Heightened awareness or hyper-vigilance in a safe environment
- Sleep disturbance, either not able to sleep or frequent nightmares, is a common occurrence with individuals experiencing PTSD
Finally, if a person actually states they feel traumatized they should be acknowledged in any event. It is usually not a major event that happens, but it can be small events over a period of time as well. Listen to a person when they are reporting the above stated symptoms.
How can nurses help someone with PTSD? In an emergency? In a non-emergency?
Being self aware is the major point of helping someone in an emergency with PTSD. Other important ways to help include the following and this all holds true for emergency and non-emergency situations. :
- Move with intention and do not make sudden movements.
- Explain and paraphrase what is happening during the emergency.
- Listen to an individual and do not argue.
- Allow a person to speak without interruption.
- Do not ask for details that do not matter.
- It is not effective to relive or retell the event as a matter of helping someone.
- Keep your voice calm and do not become over animated.
- Ask the person what they might need to feel safe for that moment.
- Keep the person safe and do not allow them to be alone in the midst of a panic attack associated with PTSD.
What are some common misconceptions about PTSD?
The biggest misconception of PTSD is that you have to be involved with something major. PTSD is individualized and can be compounded by many factors. The event which leads to the PTSD diagnosis might not be the overall cause. Bear in mind that negative childhood experiences can factor into a person who experiences PTSD. Certainly we hear about the large scale events which cause a person to experience PTSD, but never rule out a person experiencing PTSD based upon ones own thoughts of how traumatic an event was for them.
What gives those with PTSD hope?
PTSD is a treatable ailment. Most clinics have a variety of specialists who can help with PTSD. Help a person understand that the emotions and the things they are experiencing are real for them. Allow them to understand they are not alone and help them give a name to what they are experiencing. There are effective treatments available to help with the treatment and lessen the symptoms of PTSD. Have local resources available to give to patients and/or help them get in contact with assistance.
How can nurses spread that message?
The best way to help everyone is to DESTIGMATIZE PTSD. It is not an us-or-them diagnosis. Everyone in their lifetime will experience an event that could possibly cause PTSD. Allow others to have their own experiences without personal bias. We are not here to judge, just allow others to heal.