Educating About Health Equity

Educating About Health Equity

Nursing has always held health equity as a critical value in many ways. Nurses strive to deliver the best care to all patients, independent of socioeconomic status, gender, race, or other factors.

Health equity arguably gets even more attention than in the past. And that attention also occurs in nursing schools, where nurses are presented with the concept of health equity.

In this article, we examine how various schools teach health equity. But first, let’s define the term.

educating-about-health-equity

“Fair and Just Opportunity”

Health equity, according to the Centers for Disease Control and Prevention (CDC), “is the state in which everyone has a fair and just opportunity to attain their highest level of health.” Educator Jessica Alicea-Planas, PhD, MPH, RN, of the Egan School of Nursing and Health Studies at Fairfield University in Fairfield, Connecticut, echoes that sentiment, defining health equity as “ensuring that everyone has an opportunity to live whatever they feel their healthiest life should be.”

“Equity should mean that people have the opportunity to get what they need when they need it,” notes Alicea-Planas, associate professor of nursing at Egan and practicing nurse at a community health center in Bridgeport, CT. “That’s something that has historically been lacking for certain communities within our healthcare system.”

Health equity means that “everyone has the ability and opportunity to be healthy and to access healthcare to help them maintain health,” says Latina Brooks, PhD, CNP, FAANP, associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Brooks also directs the MSN and DNP programs at Frances Payne.

Beyond Accessibility

The CDC notes that achieving health equity requires ongoing efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.

Health equity isn’t just about access to healthcare, notes Elaine Foster, PhD, MSN, RN, vice president of nursing, Education Affiliates. It can also relate to whether a diabetic patient, for instance, knows what to get checked. “I think sometimes we’ve put a very narrow description on health equity, and I think if you were to flesh it out, it goes beyond that accessibility,” Foster notes.

“You can even take health equity that next step and say, Do you have an advocate or do you have someone who knows to push the envelope?” says Foster. “We have to be active participants in our healthcare these days to get what we need.”

Besides accessing resources, health equity involves “understanding how to navigate our healthcare system,” says Alicea-Planas. “It is understanding the information that’s being provided to us by healthcare providers and being able to use it for patients to do well on their health and wellness journey.”

Teaching Equity

At various schools, health equity is integrated throughout the course of study. For instance, at Adelphi University College of Nursing and Public Health, Long Island, New York, health equity is threaded throughout the undergraduate and graduate curriculum in various courses, notes Deborah Hunt, PhD, RN, Dr. Betty L. Forest dean and professor. For example, in the school’s community health course, there is a focus on vulnerable and underserved populations. In the childbearing course, Hunt notes, there is a focus on health disparities and maternal and infant mortality.

Foster notes that health equity is threaded into the curriculum at the 21 nursing schools within the Education Affiliates system. Likewise, at Frances Payne Bolton, health equity is integrated into courses. However, Brooks notes that some courses go more in-depth, such as discussing health equity in vulnerable populations.

At Egan, introductory courses talk a lot about health equity and social determinants of health, notes Alicea-Planas, as do clinical courses. “I think a big part of understanding health equity is also understanding social determinants of health,” says Alicea-Planas. “I am super excited that now in the nursing curriculum, we have lots of conversations around those social determinants of health and how they influence people’s ability to attain their highest level of health.”

The Takeaways

One crucial learning that Alicea-Planas hopes students take away is that for students who haven’t been exposed to many people from different backgrounds, it’s essential “to understand how historically our healthcare system has treated certain communities of color. That factors into people’s feelings about how doctors or nurses treat them, influencing their ability to seek care.”

Alicea-Planas notes that students wanting to explore the topic of implicit bias can take a test on the Project Implicit website. In addition, the Kirwan Institute for the Study of Race and Ethnicity at The Ohio State University offers online modules on implicit bias.

Foster hopes that students learn that no matter what the patient’s background, “Everyone is entitled to good, nonjudgmental care within the healthcare system.” Students must learn “not to impose our beliefs, our judgment on someone. Because until we get rid of that type of judgment, we will never overcome issues with health equity because we’ve got to first check our beliefs and opinions at the door and say I’m going to give the best care possible to these patients.”

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SWAT RNs: Supporting Bedside Leaders with Clinical Judgment

SWAT RNs: Supporting Bedside Leaders with Clinical Judgment

SWAT RNs serve as expert consultants and mentors to nurses working as bedside leaders in various clinical settings. With clinical practice experience of five or more years in the areas of critical care, emergency nursing, and flight nursing, these nurses enjoy the adrenaline rush that comes with quickly assessing patients at risk for condition deterioration.

SWAT RN Role

The role of the Specialized Workforce for Acute Transport Registered Nurse (SWAT RN) has evolved in national healthcare organizations. Early detection of patients experiencing physical decline is the hallmark of the SWAT RN role. Having identified an early condition decline, bedside nurse leaders working in various clinical settings collaboratively work with SWAT RNs to promptly stabilize and prevent patient injury and death. 

Susan Dresser, Cynthia Teel, and Jill Peltzer, in their 2023 article entitled, Frontline Nurses’ Clinical Judgment in Recognizing, Understanding, and Responding to Patient Deterioration: A Qualitative Study, noted that nurses who work at the bedside are essential in the recognition of patients’ decline and initiating contact with the SWAT RN. Hence, the SWAT RN is a nursing role that is instrumental in the promotion of the nursing process and the National Council of State Boards of Nursing’s 2019 Clinical Judgment Measurement Model within the acute care setting, as they work collaboratively with bedside nurse leaders to facilitate positive patient outcomes.

A Hypothetical Case Study

The following hypothetical case study provides an opportunity to explore the SWAT RN role and examine how this role collaborates with bedside leaders to improve patient outcomes.

Case Presentation

Bernard Salzo is a 38-year-old male employed as a carpenter and painter. Unable to sleep and experiencing restlessness accompanied by shortness of breath for the last two days, Mr. Salzo presents to the emergency department (ED) at 3:00 a.m. with difficulty breathing. The triage nurse obtains his vital signs: blood pressure 134/82 mm Hg, respirations 30 breaths per minute, heart rate 102 bpm, temperature 99.8 F, and oxygen saturation on room air, 94%. The patient appears anxious and restless, requiring redirection as the triage nurse processes him. The patient states, “I have not been sleeping that well. I kind of feel discombobulated.”

History and Assessment 

Mr. Salzo’s medical history is significant for childhood asthma and hypertension. His hypertension is managed with an ACE Inhibitor, Lisinopril 15 mg PO daily, and diuretic Furosemide 10 mg PO daily. Prescribed Montelukast sodium 10 mg PO once daily and a Proventil HFA inhaler twice daily and as needed for asthmatic symptoms. Mr. Salzo’s asthma has been stable for the past ten years. Mr. Salzo is a nonsmoker and abstains from alcohol.

Mr. Salzo is triaged, assessed by an ED nurse, examined by an ED provider, and admitted to a Medical-Surgical Unit. The nurse in the Medical-Surgical Unit suspects worsening respiratory distress, noticing that Mr. Salzo has become increasingly anxious and is moving about restlessly in bed during the admission assessment. Oxygen therapy via nasal cannula 2 L O2 is placed on the patient, and the nurse contacts the SWAT RN, who arrives in less than 5 minutes.

The SWAT RN provides a rapid assessment of the patient and reports their findings to the patient’s healthcare provider and bedside nurse leader.

  • Alert and anxious, use of accessory muscles of respiration, respiratory distress
  • RR- 32 breaths per minute and labored, BP- 143/88 mm Hg, T- 100.3 F (temporal), oxygen saturation- 90% on room air (sitting)
  • Peak flow- 185

HEENT, Skin, Neck

  • No bruits, nor thyromegaly or adenopathy
  • Bilateral tearing of the eyes noted with conjunctivae that are edematous and inflamed
  • Pharynx with clear postnasal drainage; nasal mucosa edematous with clear discharge
  • Fundi without lesions
  • Skin is supple, diaphoretic, pink, and flushed

Lungs

  • No egophony or fine crackles (rales); scattered coarse crackles present
  • Expiratory phase is prolonged with wheezes auscultated bilaterally
  • Diaphragm percusses low in the posterior chest with 2 cm; chest expansion is limited

Cardiac

  • No clicks or gallops
  • Tachycardia, regular
  • Notable slight systolic ejection murmur (SEM) at the left lower sternal border (LLSB) without radiation

Abdomen, Extremities, Neurologic

  • Capillary refill at 3 seconds, no clubbing, no edema; extremities clammy
  • Bowel sounds present, no hyperactivity; abdomen non distended
  • Liver percusses 2.5 cm below the right costal margin, but overall size 8 cm, no tenderness or masses
  • Cranial nerves intact; DTR 2 + and symmetric; sensory intact; strength 5/5 throughout

Preliminary Laboratory Results

  • pH- 7.48; PaO2- 70; PaCO2- 33 mm Hg
  • HCT- 33.0% and HgB- 7.2 g/dL
  • WBC- 7,680
  • PLTS- 246,000

Bedside Nurse Leader and SWAT RN Collaboration

The SWAT RN maintains closed-loop communication with the bedside nurse leader assigned as the primary care nurse for Mr. Salzo. The bedside nurse leader and SWAT RN discuss the patient’s time of initial decline, treatment approaches that were effective, and next steps. The SWAT nurse respectfully acknowledges the bedside nurse’s prior knowledge about the patient’s health history and recent health status change while modeling clinical judgment in managing the clinical case scenario.

General Outcome

Mr. Salzo complains of chest tightness. Intravenous access via Mr. Salzo’s right arm in the cephalic vein was secured. The bedside nurse leader inquires about potential allergen exposure and the use of methylprednisolone (Solu-Medrol) intravenously. The SWAT RN and team decided to assess the patient’s response to a bronchodilator. The SWAT RN administers Albuterol nebulizer treatments. An electrocardiogram (ECG) reveals sinus tachycardia (Figure 2.). The elevated white blood cell count (WBC) is suggestive of infection. A chest x-ray shows a large area of opacity in the right lung. A sputum sample is obtained and sent for culture and sensitivity. Blood cultures were obtained as well.

Admitted to the Medical-Surgical Unit with the primary diagnosis of asthma exacerbation and pneumonia, Mr. Salzo starts the intravenous (IV) antibiotic ceftriaxone (Rocephin) 1 gm twice daily. On day 2 of antibiotic therapy, a repeat chest x-ray reveals the presence of a mass in the right lung. Further diagnostic tests reveal that the mass is a malignant neoplasm. Mr. Salzo was diagnosed with lung cancer adenocarcinoma.

Education

The unknown or atypical presentations are the driving factors in bedside nurse leaders utilizing clinical judgment in the decision-making process to ramp patient assessment to the level of consultation before rapid patient deterioration occurs. Mr. Salzo’s diagnostic presentation appeared typical for asthma. However, his elevated WBCs suggested infection was present. The resolving pneumonia treated with IV antibiotic therapy revealed a malignant tumor mass, adenocarcinoma.

Adenocarcinomas typically proliferate within the cells that line the alveoli. According to the Centers for Disease Control and Prevention (CDC), in 2022, 50% to 60% of lung cancers were diagnosed in patients with no smoking history. The CDC noted in 2022 that 10% to 20% of nonsmoker cancers are squamous cell carcinomas and 6% to 8% small cell lung cancers. The CDC also noted that risk factors associated with lung cancer include family history, pipe smoking, cigarette and cigar smoking, beta-carotene supplements in heavy smokers, human immunodeficiency virus (HIV), and environmental risk factors. Mr. Salzo’s dual occupation as a carpenter and painter, both environmental risk factors, likely placed him at risk for the development of lung cancer. Wood dust can be inhaled and enter the airway and lung tissues, causing scarring and irritation. The paint contains benzene solvents that, inhaled, can lead to oral and lung cancers.

The National Council of State Boards of Nursing Clinical Judgment Measurement Model provides the nursing profession with a roadmap for enhancing critical thinking, clinical decision-making, and clinical judgment within the clinical setting. SWAT RNs, because of their advanced clinical practice experience and knowledge, effectively role model closed-loop communication and evidenced-based practice clinical interventions and provide clinical expertise “in live-time” to bedside nurse leaders during emergent patient cases.

Conclusion

Mr. Salzo, transferred to an oncology unit, begins cancer treatment. The bedside nurse leader provides him with education about his new diagnosis. His clinical presentation to the ED for an asthmatic exacerbation and the combined efforts of all healthcare team members have contributed to Mr. Salzo’s diagnosis and current implementation of treatment for lung cancer. The early involvement of SWAT RNs is instrumental in supporting bedside nurse leaders (and nurses in other settings) with the provision of rapid assessments and necessary diagnostics in ensuring the consistent delivery of evidence-based practice care for patients entering healthcare systems. In the 2020 article, Using Benner’s Model of Clinical Competency to Promote Leadership, Barry Quinn discusses the novice to expert level nurse in clinical practice. Because the SWAT RN is an expert level nurse, their role is essential in developing leadership and competency of bedside nurse leaders in recognizing patients with rapidly declining physiological problems. Hence, SWAT RNs’ roles are beneficial in promoting clinical judgment in bedside leaders at all practice levels (e.g., novice to expert).

How Nurses Can Spot and Support Patients Suffering from Lipedema

How Nurses Can Spot and Support Patients Suffering from Lipedema

Despite being first identified in medical literature in the 1940s and impacting 5-12% of women annually, medical professionals rarely diagnose Lipedema due to the lack of training and awareness to recognize the disease.

Nurses have the most face time with patients, so nurses must understand what Lipedema is and how to recognize the signs.

We spoke with Ana Pozzoli, PT, CLT, National Lymphedema Network expert clinician, about how nurses can play a pivotal role in helping women receive care and treatment for Lipedema. What follows is our interview, edited for length and clarity.

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Ana Pozzoli is a licensed physical therapist and certified lymphedema therapist with over thirty years of experience in orthopedics and lymphatic disorders. The focus of her work is a mix of orthopedics and mostly lymphatic disorders. She and her husband own Omnitherapy Center, LLC.

What is Lipedema?

Lipedema is a chronic medical condition involving loose connective tissue. Lipedema is characterized by symmetric enlargement of the legs due to deposits of fat beneath the skin. It is predominantly diagnosed in women. The cause of Lipedema is unknown; however, there is evidence of hormonal and hereditary influences. It is identified by increased nodular and fibrotic adipose tissue in the gynoid areas, the buttocks, hips, thighs, lower abdomen, and limbs. Many believe these changes start at different hormonal stages in a female’s life, such as puberty, pregnancy, pre-menopause, and menopause. It is a common condition but underrecognized. The hallmark of Lipedema is tissue inflammation. This often painful medical condition usually worsens gradually. Few physicians recognize the constellation of signs and symptoms to diagnose it properly.

How many people suffer from this condition? Are they generally women?

Though comprehensive epidemiology data is lacking, Lipedema impacts 5-12% of women.

What is the prognosis for women with lipedema?

With a Lipedema diagnosis, it is believed the different hormonal stages of a female’s life can worsen the condition. It is a gradual worsening of the adiposity in the legs, though some individuals develop Lipedema that stabilizes. In the early stages of Lipedema, most females have a normal appearance above their waist. The upper extremities, chest, torso, and abdomen can also enlarge. Physicians underrecognize it; if left untreated, it can progress, causing mobility and disability issues.

Why is it rarely diagnosed or misdiagnosed? 

Lipedema was first diagnosed in the 1940s at the Mayo Clinic by Allen and Hines. The pathophysiology of Lipedema needs to be better understood and routinely included in medical school curricula. There is currently no specific test to identify Lipedema. Imaging studies like ultrasound, MRI, lymphoscintigraphy, and lymphangiogram may be helpful, although test results may appear normal in the earlier stages.

The medical community often confuses lipedema with obesity and lymphedema. Other similar disorders are Lipohypertrophy (no pain and edema), Chronic venous insufficiency, and other idiopathic edemas. Misdiagnosis in patients with Lipedema is concerning, as it can delay appropriate management of the condition and allow the progression of the condition.

What are the physical signs and symptoms and genetic markers for diagnosing Lipedema? 

Lipedema signs and symptoms vary from person to person, including abnormal adiposity in both legs, extending from buttocks to ankles. These may include the tendency to bruise easily, pain sensation in the legs, having knee (Genu) valgus, smaller waist in relation to the hips, hypermobility of the joints, pes planus, cuff sign at the ankles, and is generally resistant to dietary and exercise interventions. General fatigue and physical impairment are often observed. There is swelling with symmetrical enlargement of the lower limbs due to abnormal adiposity. Some manifestations to watch for may indicate weight loss has been non-respondent to exercise; elevation does not tend to help; absent or minor pitting edema; vascular fragility; tenderness in the affected areas; and negative stemmer signs. 

Many clinicians and patients reference Stages of Lipedema. You can read more about staging here. For more comprehensive guidelines on diagnosis, you can reference the Standard of Care.

What are the treatment options available for Lipedema?

There is no one effective treatment approach for treating Lipedema. Management to prevent progression and alleviate symptoms is the therapy goal. Current guidelines recommend conservative therapies such as specialized compression garments and manual lymphatic drainage (MLD).

  • Manual lymphatic drainage targets the extra fluid retention of the extremities in the later stages. It also helps with reducing pain sensation.
  • Compression therapy helps support the tissue and prevent increased fluid retention. The compression is selected according to the lipedema type and location in the body. It can be in leggings, Bolero for arms, Knee Highs, capri, and shorts. Flat knit or micro-massage materials tend to support the tender tissue where the adiposity is present. Circular knit garments tend to bind on the tissue and create more discomfort. In the later stages, bandaging may be applicable in their treatments. Each patient needs to be assessed individually for garment selection. A pneumatic compression device(pump) can be beneficial in self-management.
  • Exercises should also be individual to the patient’s needs. The focus should be on posture, strength, mobility, balance, joint hypermobility, and gait. Some tools that are implemented are aqua therapy, vibration plates, and exercise equipment. Some of the techniques used as exercise can range from yoga, tai chi, swimming, and Pilates. Exercise should not be aggressive because it may cause the body to produce inflammatory hormones during performance of, such as cortisol.
  • Skin care is critical at all stages of lipedema. Many patients consider dry brushing and moisturizing the skin as essential. The best way to care for the skin is to hydrate from within. Drinking water is vital.
  • Nutrition suggestions vary but can play a significant role in the inflammatory condition of Lipedema. Understanding the anti-inflammatory way of eating can be a part of self-management. Remember that the FDA does not test supplements, so there is no way to know possible side effects. Most diuretics do not help alleviate the swelling of Lipedema. Liposuction can be valuable for some people to manage pain and improve mobility. However, research is still evolving on the effectiveness of surgery. Surgeons have different approaches; there must be clear research to recommend one approach over another. We encourage you to research, and your decision should be made in partnership with a qualified medical professional.

How can Nurses communicate information about the disease with patients? 

Nurses can be a liaison in the care of a Lipedema patient. Many times, nurses are the first practitioner to see the patient. By recognizing the signs and symptoms, a differential diagnosis may be made instead of labeling the patient as obese. Since nurses are in direct communication with the physicians or the specialist in the medical team, noticing and documenting the criteria that classify the patient as Lipedema will initiate a dialogue about the patient’s condition.

What general facts and advice should nurses know about lipedema to help their patients?

The fact is that Lipedema is an actual chronic condition of loose connective tissue. If the patient fits the criteria profile, the patient should not be diagnosed as obese based solely on BMI.

Another fact is that Lipedema predominantly affects women.

There is an actual asymmetrical body composition, a smaller trunk compared to the lower portion of the body. The feet and hands are usually spared.

Lipedema is progressive if left untreated, and is common but misdiagnosed and underrecognized. This condition carries psychological morbidity.

Look for signs and symptoms if you think the patient may display Lipedema. Be compassionate with the patient, and do not judge. Guide the patient to the proper resources, such as the Lipedema Foundation.

What role do nurses play in helping patients (women) receive care and treatment for this ailment?

Nurses play a critical role in showing an understanding of the signs and symptoms that are involved in the diagnosis of Lipedema.

Discuss with your patients that there is help for them to manage the condition’s progression.

Show compassion when the patient tells you they have tried many things and that nothing works for them.

In addition, nurses are also health care providers who can become certified lymphedema therapists by the many certification institutions.

What can nurses do to help patients with this condition? 

Once Lipedema has been identified, reassure your patient that it’s not their fault that their body looks different.

Early recognition and functional limitations can enhance the ability of the patient to make lifestyle changes to improve the quality of life.

Guide the patients in the right direction with proper recommendations to the health care practitioners equipped to treat them.

Where can nurses go to become educated about lipedema?

References

  1. Amanda Oakley. Lipedema. DermNet NZ. 2008;http://dermnetnz.org/dermal-infiltrative/lipoedema.html(http:dermnetnz.org/dermal-infiltrative/lipoedema.html).
  2. Herbst KL, Kahn LA, Iker E, Ehrlich C, Wright T, McHutchison L, Schwartz J, Sleigh M, Donahue PM, Lisson KH, Faris T, Miller J, Lontok E, Schwartz MS, Dean SM, Bartholomew JR, Armour P, Correa-Perez M, Pennings N, Wallace EL, Larson E. Standard of care for lipedema in the United States. Phlebology. 2021 Dec;36(10):779-796. doi: 10.1177/02683555211015887. Epub 2021 May 28. PMID: 34049453; PMCID: PMC8652358.
  3. Bonetti G, Herbst KL, Dhuli K, Kiani AK, Michelini S, Michelini S, Ceccarini MR, Michelini S, Ricci M, Cestari M, Codini M, Beccari T, Bellinato F, Gisondi P, Bertelli M. Dietary supplements for lipedema. J Prev Med Hyg. 2022 Oct 17;63(2 Suppl 3):E169-E173. doi: 10.15167/2421-4248/jpmh2022.63.2S3.2758. PMID: 36479502; PMCID: PMC9710418.
  4. Okhovat JP, Alavi A. Lipedema: A Review of the Literature. Int J Low Extrem Wounds. 2015 Sep;14(3):262-7. doi: 10.1177/1534734614554284. Epub 2014 Oct 17. PMID: 25326446.
  5. Warren Peled A, Kappos EA. Lipedema: diagnostic and management challenges. Int J Womens Health. 2016 Aug 11;8:389-95. doi: 10.2147/IJWH.S106227. PMID: 27570465; PMCID: PMC4986968.
The Howley Foundation’s $12 Million Gift to Double Number of Nurse Scholars at Cleveland Clinic

The Howley Foundation’s $12 Million Gift to Double Number of Nurse Scholars at Cleveland Clinic

Cleveland Clinic has received a gift of more than $12 million from The Howley Foundation to double the number of nurse scholars at Cleveland Clinic beginning in fall 2023.

In recognition of this new generous gift and the Foundation’s cumulative support, all programs within the ASPIRE initiative at Cleveland Clinic will be renamed to honor the Howley name, including the Howley ASPIRE Nurse Scholars Program.

The nursing program is for local high school and college students and seeks to increase diversity in healthcare, address opportunity gaps and reduce health disparities in the community.

“It’s essential that we diversify the pipeline of our future healthcare workforce, including nurses, to better represent our patients and the communities we serve,” says Tom Mihaljevic, M.D., CEO and President of Cleveland Clinic and the holder of the Morton L. Mandel CEO Chair. “We are grateful for the Howley’s continued support and passion for increasing diversity and equity in our next generation of caregivers.”

The gift will allow the nurse scholars program to double enrollment annually to approximately 50 students from Cleveland-area high schools.

Students enter the program as high school juniors and are taught an innovative curriculum that explores the nursing profession, socialization, and integration into healthcare. High school graduates then can earn a scholarship to pursue a bachelor of science degree in nursing from the Breen School of Nursing and Health Professions at Ursuline College.

Students work as patient care nursing assistants at Cleveland Clinic during the summer after high school graduation and throughout their college careers. They then can return to work as registered nurses at a Cleveland Clinic facility after college graduation and licensure.

“We feel strongly that a quality education is the best way to address social inequality and promote economic mobility,” says Nick Howley, chairman of The Howley Foundation and executive chairman and founder of Transdigm Group Inc. “We want students to be able to complete their nursing degrees poised for success.”

Launched in 2017, the program was the brainchild of Kelly Hancock, DNP, Chief Caregiver Officer of Cleveland Clinic, and the holder of the Rich Family Chief Caregiver Chair, and Lorie and Nick Howley. It has been sustained by The Howley Foundation’s generosity, which has committed more than 20 million dollars to date, and other donors, such as Beth E. Mooney and the KeyBank Foundation.

“We remain committed to cultivating a workplace that embraces diversity, inclusion and equity to better serve our patients,” says Dr. Hancock. “The Howley ASPIRE Program serves as a key element in supporting these efforts. This generous gift allows us to offer this wonderful opportunity to more nurse scholars in Northeast Ohio and increases public awareness about the vital role our nurses have in delivering high-quality healthcare.”

In December 2022, the nurse scholars program celebrated its first five graduates who are now employed as full-time registered nurses at Cleveland Clinic. More than 15 students are expected to graduate from Ursuline College with nursing degrees by 2024.

The Howley ASPIRE Program also offers additional pathways for other healthcare careers, including respiratory therapy, surgical technology, and sterile processing.

Cleveland Clinic is accepting nurse scholar applications from high school juniors through Oct. 1, 2023. To learn more and apply online, visit clevelandclinic.org/ASPIRE.

Hospitals with the Most Vulnerable Maternity Patients Understaffed with Nurses

Hospitals with the Most Vulnerable Maternity Patients Understaffed with Nurses

Hospitals serving more patients at risk for complications during childbirth are less likely to have enough nurses to care for patients during labor, delivery, and recovery, according to a new study in Nursing Outlook.

The findings reveal one of many factors that may contribute to poor maternal health outcomes in the U.S. for the most vulnerable childbearing populations, including Black mothers and those insured by Medicaid.

Nurses play a central role in the 3.6 million births in U.S. hospitals each year. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) issues guidelines on nurse staffing levels for maternity units; its 2010 guidelines call for one nurse to one birthing person during many parts of labor, two nurses at birth, one nurse for each mother-newborn pair during the first few hours after birth, and one nurse for every three pairs of mothers and babies after that period. These same nurse-to-patient ratios were included in the AWHONN nurse staffing standards published in 2022.

Recent data show that patients at high risk for severe maternal complications are more likely to give birth in teaching hospitals and have Medicaid as their insurer. In addition, teaching hospitals—often safety-net hospitals providing a significant amount of care to low-income and uninsured patients—are also more likely to have high volumes of births. In this study, the researchers aimed to determine nurse staffing levels at hospitals with vulnerable maternity patients, using high-birth volume and teaching status as proxies for high-risk patients.

“Patients at risk for serious maternal complications are particularly vulnerable and are likely to need more intensive nursing care based on their medical and psychosocial circumstances,” says Audrey Lyndon, PhD, RN, FAAN, the Vernice D. Ferguson Professor in Health Equity and assistant dean for clinical research at NYU Rory Meyers College of Nursing.

The researchers surveyed 3,471 registered nurses from 271 hospitals across the country. Nurses were asked about staffing levels on their maternity units during labor, delivery, and recovery using AWHONN guidelines. The researchers compared nurses’ responses on staffing with hospital characteristics from the American Hospital Association Annual Survey.

Overall, nurses reported strong adherence to AWHONN staffing guidelines in their hospitals, with more than 80% of respondents saying that their unit frequently or always met the staffing guidelines. Adherence to guidelines was particularly high for specific stages of labor, including a nurse being continuously present at the bedside during second-stage labor (93.3%) and one-on-one care during epidural initiation (84.1%). However, adherence was lower for having a dedicated nurse for postpartum recovery in the two hours right after delivery (71.8%), one-on-one care for mothers with high-risk conditions (72.6%), a nurse dedicated to fetal heart rate monitoring (61.3-77.2%), and one-on-one care during oxytocin administration in labor (54.6%).

Analyzing hospital characteristics, the researchers found that teaching hospitals and hospitals with higher birth volumes, neonatal intensive care units, and higher percentages of births paid by Medicaid were associated with lower staffing guideline adherence—all of which have been shown to serve high-risk maternity patients.

“These gaps in staffing are particularly troubling for our most at-risk patients,” added Lyndon. “Many maternal complications can be prevented or quickly addressed through timely recognition of risk factors and clinical warning signs, and, when issues are identified, the escalation of care and coordination with the care team—but this is only possible when there are enough nurses monitoring patients.”

The researchers note that one possible cause of nurses in these types of hospitals having more patients than recommended may be poor reimbursement from Medicaid for childbirth services.

“Studies show that Medicaid pays hospitals less than half of what commercial insurers pay for a birth. This inequity in reimbursement creates a fiscal challenge in hospitals with a high percentage of maternity patients insured by Medicaid,” says Kathleen Rice Simpson, PhD, RNC, FAAN, a perinatal clinical nurse specialist in St. Louis, MO, and the study’s lead author. “Better funding for teaching and safety-net hospitals caring for high-risk maternity patients could support better nurse staffing.”

In addition, the researchers encourage the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission to consider safe staffing requirements for inpatient maternity care, similar to CMS working to establish minimum staffing regulations for nursing homes to promote patient safety.

ENA-backed Legislation Focuses on Mental Health Treatment in EDs

ENA-backed Legislation Focuses on Mental Health Treatment in EDs

In the U.S, increased diagnoses of mental health issues and insufficient treatment places have resulted in many people turning to emergency departments for help. Unfortunately, this trend causes increased boarding times, ED overcrowding, and challenges for ED staff.

The increase in youth suffering from mental health issues is evident in a CDC survey. Emergency department visits for suspected suicide attempts by youth aged 12 to 17 increased by 39 percent from February through March 2021, compared with the same time in the same period in 2019.

On April 27, Sen. Shelley Moore Capito, R-W.V., introduced the Improving Mental Health Access from the Emergency Department Act (S. 1346). Supporting mental health treatment, decreasing boarding time, and addressing overcrowding are all priority issues for the Emergency Nurses Association. A similar bill is awaiting introduction in the House of Representatives.

“Many of the challenges facing emergency departments today can be directly linked to the need to improve care for behavioral health patients,” says ENA President Terry Foster, MSN, RN, CEN, CPEN, CCRN, TCRN, FAEN. “A lack of resources and treatment options often leaves individuals struggling with their mental health in the ED for extended periods, which leads to overcrowding and, frequently, acts of violence against health care workers.”

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ENA President Terry Foster, MSN, RN, CEN, CPEN, CCRN, TCRN, FAEN

ENA research has shown the average ED stay for mental health patients is 18 hours compared to four hours for all other types of patients.

This proposed legislation would provide resources for EDs through a competitive grant program, allowing them to adopt more collaborative and connected care models to connect behavioral health patients with appropriate resources in their communities. It also aims to increase access to inpatient beds and alternative care settings, which will help alleviate boarding in emergency departments. Recognizing that all EDs are unique, this program would allow each ED to design solutions that will work best for them.

“The passage of this legislation could go a long way in reducing that wait time and providing a significant opportunity to establish a more collaborative approach to comprehensive mental health treatment options,” Foster says.

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