It Takes a Village: Nurses Work to Provide Culturally Competent LGBTQ Care

It Takes a Village: Nurses Work to Provide Culturally Competent LGBTQ Care

As a gay man, Austin Nation, PhD, RN, PHN, understands the health care barriers faced by many lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. As a nurse and educator, he’s working to increase awareness and address the health disparities that continue to exist in the LGBTQ community.

An assistant professor of nursing at California State University, Fullerton (CSUF), Nation lived through the 1980s AIDS crisis, and has worked with many patients in the HIV/AIDS community. While he acknowledges an HIV diagnosis is no longer a death sentence thanks to increased funding and better treatment, Nation has also seen how young gay black and Latino men continue to be disproportionately affected by HIV/AIDS. The Centers for Disease Control and Prevention (CDC) report that 1 in 2 black men and 1 in 4 Latino men will be diagnosed with HIV during their lifetime.

“We’re not reaching all of the people we need to reach,” Nation says. “In order to get to zero new HIV infections, we need to figure out how to engage these populations.”

While treatments have transformed HIV into a chronic but manageable illness, many people are not aware of how prevention efforts that use antiretroviral treatment, and pre-exposure prophylaxis (PReP), an HIV-medication that when taken consistently, can lower the risk of getting infected by more than 90%. Despite being widely available, the CDC notes that while two-thirds of the people who could benefit from PrEP are black or Latino, they account for the smallest amount of prescriptions to date.

To that end, Nation has worked to address the tenuous relationship many people of color and members of the LGBTQ community have with the health care system. Statistics from the Kaiser Family Foundation show that LGBTQ patients often face challenges and barriers in accessing health services including stigma, discrimination, the provision of substandard care, and outright denial of care because of their sexual orientation or gender identity.

“I’ve led LGBTQ cultural competency trainings to teach nurses and nursing students how to provide inclusive services and care for LGBTQ patients,” Nation says. “By knowing whether a patient is gay, lesbian, transgender, straight, or bisexual, and how to best communicate, nurses can identify potential health disparities and care for their patients more effectively.”

On the CSUF campus, Nation has also been a part of the university’s Faculty Noon Time Talks, discussing health care disparities within the African American community. In addition, he is working with faith leaders to adopt a more inclusive environment for LGBTQ individuals who may be reluctant to come out and subsequently don’t receive HIV testing or prevention counseling.

“I also teach a public health course at CSUF where we discuss vulnerable patient populations including the LGBTQ community,” Nation says. “I try to integrate real-world experiences into the course curriculum.”

Nation believes that all nurses can help to achieve diversity and meaningful inclusion, whether they are part of the LGBTQ community or an ally. “Have a voice and be an advocate,” he says. “One person can make a difference.”

Navigating Cancer Care with LGBTQ Patients

As an oncology nurse and LGBTQ advocate, Megan Ober, RN, MS, BSN, OCN, a case manager at the Palliative Care Clinic at the UC Davis Comprehensive Cancer Center in Davis, California, often finds herself bridging the gap between providers and LGBTQ patients.

“Many health care providers work under the assumption that all patients are heterosexual,” says Ober. “It’s important to create a welcoming environment for LGBTQ patients in order to educate them on cancer risk factors and ensure they receive preventative screenings.”

Ober says LGBTQ patients often feel they are being judged and are reluctant to share their sexual orientation or gender identity out of fear of being turned away from health care providers. This distrust can lead to some LGBTQ not seeing a doctor regularly for check-ups and screenings, delaying diagnoses and not receiving information on treatments that might help either their physical or emotional health.

Over the years, Ober has given presentations to staff on LGBTQ disparities in cancer care and risk factors that lead to greater cancer incidence and later-stage diagnoses. These disparities include:

  • Anal cancer. It’s rare in the general population, but 34 times more prevalent in gay men.
  • Cancer screenings. According to the American Cancer Society, lesbians and bisexual women get less routine health screenings than other women including breast, colon, and cervical cancer screening tests.
  • Breast cancer. Lesbian women have higher rates for breast cancer including nulliparity (never having given birth), alcohol and tobacco use, and obesity.
  • Cervical cancer in transgender men. Since most transgender men retain their cervixes, they are also at risk of cervical cancer but are much less likely to obtain Pap smears and regular cancer screenings.

 

Resources to Bring Better Care to LGBTQ Patients

For nurses who want to educate themselves further about LGBTQ health topics, the following information can help:

  • Lavender Health has held virtual coffee hours for nurses working with LGBTQ populations. Their website offers events, resources, and more to help both providers and members of the LGBTQ community promote wellness.
  • The National Resource Center on LGBT Aging offers cultural competency training for staff at nursing homes and others who care for seniors. They also have downloadable guides on creating an inclusive environment for LGBTQ seniors.
  • The U.S. Department of Health and Human Services offers a free downloadable guide, Top Health Issues for LGBT Populations Information and Resource Kit.
  • On a national level, organizations such as the National Alliance of State and Territorial AIDS Directors (NASTAD) has partnered with the Health Resources and Services Administration’s HIV/AIDS Bureau (HRSA-HAB) to launch HisHealth.org, a free online tool that helps nurses and other medical staff learn how to engage HIV-positive young black LGBTQ patients and young black transgender patients by taking a whole-health approach to wellness.
  • Organizations such as the Human Rights Campaign and their Healthcare Equality Index can help with training and best practices such as making changes to electronic medical records and hospital paperwork to incorporate sexual orientation and gender identity and criteria that hospitals can use to become Equality Leaders.
  • The National LGBT Health Education Center has a free downloadable guide, “Providing Inclusive Services and Care for LGBT People: A Guide for Health Care Staff.” The guide discusses using preferred pronouns and preferred names, understanding diversity and fluidity of expression, making LGBTQ patients feel comfortable, common health issues among the LGBTQ population, and much more.

While it can be difficult for nurses to begin a conversation about a patient’s sexuality and sexual health, Ober says it’s important for providers to ask in order to care appropriately for LGBTQ patients.

“Rather than assuming all patients are heterosexual, I recommend nurses introduce themselves and ask a patient how they would like to be addressed, their chosen name, and their preferred pronoun,” Ober says. “There’s a great training video on YouTube called ‘To Treat Me You Have to Know Who I Am’ that showcases a mandatory employee training program that was launched for health care providers in New York.”

Ober also cautions against assuming the personal info on a patient’s chart is correct. Often, people who are transgender may identify as a different gender than the one listed on their electronic medical record.

“Rather than greeting a patient with a title such as Mr. or Ms., I encourage nurses to ask patients how they would like to be addressed,” Ober says. “Shifting from a heteronormative model to one that is more inclusive acknowledges that patients and families aren’t all the same. The woman sitting by your patient’s bedside may be her wife, rather than her sister or friend.”

Nurses Lead the Way with Change

Caitlin Stover, PhD, RN, chair of the national Gay and Lesbian Medical Association (GLMA) Nursing group says both nurses who identify as LGBTQ and those who are allies can work to create an inclusive environment for LGBTQ patients.

“I’m an ally that joined GLMA and now I’m chair of the organization,” Stover says. “There are so many resources out there that can help nurses become better patient advocates and deliver culturally sensitive care to LGBTQ patients.”

Stover says while many nurses across the country are doing great work in creating an inclusive environment in their hospital units and establishing trust and rapport with LGBTQ patients, there are still many nurses and providers who have not received education on LGBTQ health issues.

“It’s important for nurses to strip themselves of preconceived notions, judgements, and assumptions,” Stover says. “Our job is to provide the best possible care, regardless of a patient’s age, ethnicity, gender, or sexual orientation.”

She cites the Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients downloadable PDF created by GLMA as a good starting point for nurses who are seeking advice on how to communicate with LGBTQ patients using sensitive language. The document also includes guidelines for forms, patient-provider discussions, and more.

Continued Education Leads to Better Health Outcomes

Learning about LGBTQ patients isn’t a topic that is always covered in nursing school. A national survey conducted in 2014 found that 43% of nursing faculty who taught in bachelor’s degree programs across the United States reported limited or somewhat limited knowledge of LGBTQ health. Between 23-63% of respondents indicated either never or seldom teaching LGBTQ health, although a majority of respondents felt LGBTQ health should be integrated into the nursing courses they teach.

In 2013, Columbia University Medical Center in New York launched the LGBT Health Initiative, based at the Division of Gender, Sexuality, and Health at the New York State Psychiatric Institute and the Columbia University Department of Psychiatry in association with the Columbia University School of Nursing. The goal of the initiative is to bring together research, clinical care, education, and policy to fight stigma and improve the health of the LGBTQ community.

Janejira J. Chaiyasit, DNP, AGNP-C, an assistant professor at Columbia University School of Nursing and a nurse practitioner at ColumbiaDoctors Primary Care Nurse Practitioner Group, says students at the Columbia School of Nursing receive training on LGBTQ cultural competency as part of their studies.

“We highlight the unique health disparities, risks, and health needs of the LGBTQ patient population to increase awareness, so that our future providers and care takers will offer appropriate care and ask the right questions,” Chaiyasit says.

At Columbia, Chaiyasit has seen how promoting inclusivity and culturally competent care has led to better patient care and health outcomes, and how training staff and students adequately prepares them to care for LGBTQ patients.

“If a patient doesn’t feel comfortable, how can we expect them to divulge their personal health concerns to us, and, in return, enable us to give them the best care?” Chaiyasit says.

And despite progress that has been made nationally, Chaiyasit says there’s a continued need for nurses to learn about the differing health needs of the LGBTQ community.

“LGBTQ patients have a lot of health disparities and changing the preconceptions of health care delivery for this community is a way to close the gaps—reducing ER visits, reducing the time to access health care for medical and psychosocial issues, and increasing the rate of preventative health screenings,” Chaiyasit says. “For example, many health care professionals are unaware of the health needs for trans patients, specifically these patients’ needs for transition-specific hormone therapy care and maintenance to achieve the desired gender features. This is really important as it impacts physical and mental health as a whole.”

In addition to nurses becoming more aware of gender-neutral language, many hospitals have begun customizing their patient intake forms to ensure they are LGBTQ-inclusive.

“At Columbia, we piloted intake form questions, which were ultimately implemented across the Nurse Practice Group, that allow patients to select, or even write in, their preferred gender identity pronouns,” Chaiyasit says. “A complete patient history helps to ensure each patient gets the care and services they need.”

The Power of a Brain Dump: How to Untangle Your Mind

The Power of a Brain Dump: How to Untangle Your Mind

As you probably already know, a cluttered home can lead to alarming levels of anxiety, stress, and feeling overwhelmed. Professional organizers encourage us to clean off a cluttered desk because it decreases productivity. And decluttering the physical environment is a crucial practice for running a well-kept and smoothly operating life.

But, your closet is not the only thing you need to declutter!

You need a way to untangle your messy mind, because nursing is a stressful occupation and nurse burnout is a real thing. A simple “brain dump” is the best decluttering tool for that job. What’s a brain dump? Merriam-Webster defines it as “the act or an instance of comprehensively and uncritically expressing and recording one’s thoughts and ideas (as on a particular topic).”

Here’s why you need to do a brain dump at the start of the new year.

When your thoughts, priorities, and plans are disorganized, it can send you into a state of overwhelm that’s hard to climb out of. New Year’s is the perfect time to declutter your mind and gain some fresh ideas to set new goals and plan new projects in 2019. Like most nurses, you probably have loads to do and as weeks and months pass, your to-do list continues to grow. Your brain is like a computer, and can only store or process so much information before it slows to a crawl or freezes altogether. You may have experienced a human version of the dreaded computer spinning wheel or slow loading progress bar. It may have been a case of mental brain fog (confusion), or total brain freeze (panic!), or a brain on an endless loop of obsessive thought. But there is a way to speed up your own “operating system” when you’re faced with a mile long list of priorities and tasks.

Here’s how to do a brain dump, quickly and easily.

The technique is as simple as taking a notebook and a pen and writing down everything that’s clogging up your mental space. Allow all your thoughts, feelings, tasks, and notions to spill out onto the page, where you can see them. Write quickly and freely. Don’t worry about grammar, spelling, or punctuation. If you like, you can set a timer for 15 or 30 minutes and write as fast as you can to beat the alarm. You might wind up with a page or two, or if you have a lot on your mind, ten pages worth of material.

Here’s what to write about when you do a brain dump.

You can choose a general writing prompt, like “The most important things that happened to me in 2018.” Or you can make a long list of routine to-do’s that are weighing you down. Or vent your feelings of frustration or rage in scrawled red ink. Feel free to explore at length in a rambling, stream of consciousness style,  how you feel about your life in a private shorthand that only you can read. The trick is to treat the process like psychotherapy and spill out your thoughts and feelings without censoring them. Let your subconscious mind have its say and give your conscious mind (the nice, orderly, good citizen) a well-earned break.

Phew! You should feel much better now that you’ve untangled your mind and cleared some space for fresh inspiration.

Here’s to a happy and healthy New Year for all you superhero nurses out there!

Preventing Nurse Burnout

Preventing Nurse Burnout

Working as a nurse can be tough. Because they are so focused on patients, they may not see when they’re experiencing burnout—and that can lead to problems with themselves or with being able to properly care for patients.

But there are ways to recognize it and to counteract it. Sarah A. Delgado, MSN, RN, ACNP, a Clinical Practice Specialist with the American Association of Critical-Care Nurses says that there are ways to identify burnout as well as ways of coping with it.

What are some tips for nurses so that they can prevent burnout?

 The first step with burnout is to recognize when it’s happening. Some signs of burnout include:

  • Feeling that you have to drag yourself to work, and that tasks at work take more energy than you can muster
  • Feeling irritable, critical, or cynical with coworkers
  • Having physical symptoms such as headaches or stomach pains or trouble sleeping

Nurses may try to dismiss these symptoms, especially in the busyness of the holidays, because they feel compelled to power through, no matter what. The truth is that recognizing and addressing burnout can actually be energizing; just realizing that you deserve to feel better is the first step toward positive change.

Coworkers can help each other call attention to burnout. If you notice someone is struggling, it may be worthwhile to check in and ask how they are doing. Burnout can be a team problem if it is pervasive on a unit because it’s hard to come to work when the people you work with are dissatisfied, short tempered, or unable to sense the value of their work. So recognizing the symptoms and checking in with colleagues is an essential strategy.

Burnout is a complex phenomenon and while there are self-care actions that nurses can take to address it, factors in the work environment contribute to burnout. Worry that patient care is compromised by an inadequate staffing mix, feeling that administrators are not responsive to clinical issues, and poor communication among health care team members are examples of issues in the work environment that can led to the mental, physical, and emotional exhaustion of burnout.

Issues in the work environment are not insurmountable but a single member of the environment cannot address all of these issues alone. If you are a nurse working in an unhealthy work environment that contributes to burnout, maybe create a New Year’s resolution to talk to your colleagues about it. If you find that they share your feelings, there may be factors beyond your control contributing to the problem.

Consider forming a group and seeking support from management to identify specific steps toward a healthy work environment. The American Association for Critical Care Nurses has resources including the AACN Standards for Establishing and Sustaining Healthy Work Environments and an online assessment tool that units can use to evaluate their environment and identify ways to make it healthier.

What are the best action steps they can to take?

There is some evidence that mediation and mindfulness practices can significantly reduce anxiety and worry. There are resources online and applications to help learn these techniques. The National Academy of Medicine provides a list of resources.

Attending to the basics—sleep, exercise, and nutrition—also helps with the physical, mental, and emotional exhaustion of burnout. Sometimes, it is easier to advise others on self-care than to take the time to do it for ourselves. The American Nurses Association initiative Healthy Nurse, Healthy Nation provides a structure for nurses to think about their own self-care and develop healthy habits.

When you find yourself feeling relaxed and rested, think back to what you were doing at that time. Were you talking to a friend, exercising, drawing, spending time with family, reading a novel, or watching a movie? Being deliberate in engaging in the activities that bring joy can reduce the stress of burnout.

What kind of self-care should they do?

I think a key antidote to burnout is satisfaction in your work. There are some shifts that are so frustrating and so exhausting! Then there are also moments when you comfort a frightened family member, catch a change in a patient’s condition, or hear “thank you” from a colleague—moments when you know your actions have a positive impact on someone else. Those moments are priceless. Keep a log or a journal by your bed or create a note in your phone with a list of your priceless moments as a nurse, and take time to re-visit them from time to time. The way you felt in those moments is as real and as powerful as the negative emotions.

What else do they need to be aware of?

Leaders and organizations in health care are increasingly taking action on the issue of burnout. As mentioned, the ANA launched the Healthy Nurse, Healthy Nation project. The Critical Care Societies Collaborative, a collection of four professional organizations, also identified burnout as a priority issue. Information and videos from their summit on this topic can be found here. Finally, the National Academy of Medicine created an online resource, the Clinician Well-Being Knowledge Hub, that offers individual and system level strategies to combat burnout. I think this website can be validating; it is important to recognize that you are not alone in feeling burnout as a member of the health care workforce.

Ensuring Equitable Access to Safe and Clean Water Through Advocacy and Legislative Action

Ensuring Equitable Access to Safe and Clean Water Through Advocacy and Legislative Action

Recollections of the Flint water crisis are still vivid in the minds of many Americans. Responses to this crisis in the winter of 2014 needed to be swift and comprehensive. And while it may be hard to believe that access to clean, adequate, and equitable water in America remains at risk, advocates for environmental justice call for continued vigilance in ensuring access to safe and clean water. In this column, we discuss the need to ensure equitable access to this life sustaining resource through advocacy and legislative action with Katie Huffling, RN, MS, CNM, who is the executive director of the Alliance of Nurses for Healthy Environments.

Katie Huffling, RN, MS, CNM

Ms. Huffling, tell me a bit about yourself and how you became involved in addressing environmental health issues?

I trained as a nurse-midwife at the University of Maryland School of Nursing. While there, I had the great fortune to meet Barbara Sattler and Brenda Afzal. They were leading the only environmental health center at a school of nursing in the country. Through their mentorship, I learned about the many ways that environmental toxicants could affect reproductive health and the health of the growing fetus. It is an area that many of us received little or no content on in nursing school, yet they can have significant negative health impacts across the lifespan. I became very passionate about environmental health issues and when the opportunity arose to work on this full time with the Alliance of Nurses for Healthy Environments, I jumped at the chance! We are the only national nursing organization focusing solely on the intersection of health and the environment. I now work with nurses and nursing organizations around the country on a number of environmental health issues such as climate change, clean air and water, toxic chemicals, and inclusion of environmental health into nursing curriculum.

Can you give me an example of an environmental health issue that is affecting health right now?

Clean water is one of the greatest public health advancements of the 20th century. As nurses, we recognize clean water is essential to health and a basic human right. It is also essential for providing nursing care. Nurses rely on water to wash their hands, give newborns their first baths, and is essential for the clean linens utilized throughout health care.

Here in the United States we have an expectation that when we turn on the tap clean, healthy water is going to come out. Unfortunately, for many throughout the country this is not the case. Every year, millions of Americans experience waterborne illnesses. Waterborne illnesses are caused by a variety of sources, including waterborne pathogens such as viruses or bacteria, human or animal waste, heavy metals such as lead or arsenic, or industrial pollutants. Certain populations may also be more likely to be exposed to unsafe drinking water, including low-income populations and some communities of color.

I know you have been a champion for environmental justice for some time now. What are some key legislative priorities with regard to clean and safe water?

To address a number of urgent clean water issues, the U.S. Environmental Protection Agency (EPA) proposed an update to the Clean Water Act, originally passed in 1972. The Clean Water Act needed to be updated due to the great expansion of knowledge regarding upstream sources of pollution. Researchers now understand how important protecting headwaters and other upstream water sources are to clean water downstream. There was also confusion concerning which waters were protected by the Clean Water Act. This followed two Supreme Court Decisions in 2001 and 2006, directly impacting the drinking water for 1 in 3 Americans.

In 2015, the EPA and the Army Corps of Engineers finalized the Clean Water Rule (CWR). This rule was only finalized after an intensive stakeholder process in which they held over 400 meetings and received over 1 million comments, 87% of which were in favor of the rule. The Clean Water Rule clarifies which “waters of the US” will be regulated under the Clean Water Act. These include traditional navigable waters, tributaries, a small number of waters that have a significant nexus to traditional navigable waters, interstate waters, or territorial seas, and also exempts certain waters such as puddles, ornamental ponds and rain gardens, and continues certain farm exemptions.

After the rule was finalized, a number of plaintiffs sued the EPA. The rule was suspended by the Sixth Circuit court until the outcome of these suits. This stay was overruled in February 2018. During this time the Trump Administration announced they were going to suspend the rule until 2020. This suspension was overruled by the courts in August and the CWR must now be enforced in 26 states.

The issues that the CWR addresses are very important to environmental justice communities. If the rule is repealed, low-income communities and communities of color—who already face disproportionate exposures from other environmental hazards—may be most impacted. These communities, along with rural communities, are more likely to have poor infrastructure that is not able to handle contaminants in the water. These communities also may not have the resources to upgrade their water systems. They may also be more likely to rely on well water that can be more susceptible to pollution from upstream sources.

Turning to implications for nursing, why and how can nurses get involved in addressing this issue?

The EPA has announced they plan to permanently repeal the CWR; however, this repeal has not been finalized yet. If they repeal this rule, the drinking water for over 117 million Americans could be negatively impacted. Once this official announcement occurs, the nursing voicing will be crucial to protecting this vital public health regulation. There are many ways nurses can be active in this policy arena:

  • Watch the new webinar from the Alliance of Nurses for Healthy Environments for one-hour free CE that reviews the CWR and provides opportunities for action (https://envirn.org/the-clean-water-rule).
  • Sign this petition to Acting Administrator Wheeler asking to him to keep the CWR in place.
  • Call your Senators and Congress people and ask them to support the CWR.
  • Engage your professional nursing organizations—write a newsletter article and ask them to write a letter to Acting Administrator Wheeler or to Congress. As the most trusted profession, when our nursing organizations actively engage on issues such as clean water, Congress listens.

The most vulnerable among us are harmed by dirty water. By actively engaging on clean water issues, nurses can help policymakers and the public make the connection that clean water is essential to health.

Are there additional resources we should be aware of?

The American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies (which is available online here).

The Alliance frequently offers webinars (many with free CE) on a variety of environmental health topics. We’re free to join and if you sign up for our newsletter you will be notified of upcoming webinars and opportunities for action. To learn more, visit https://envirn.org.

Recognizing Depression in Your Patients

Recognizing Depression in Your Patients

While the holiday season can be a lot of fun, it can also be a time that makes a lot of people become depressed. Whether it’s because they’ve lost family or friends, they’re experiencing rough times, or they are in the hospital and/or are ill, it can make many sad.

There’s a difference between regular sadness and depression, though. And it’s important to be able to recognize if your patients are experiencing depression. According to Sharon R. Kowalchuk, RN, DPN, Director of Nursing at Silver Hill Hospital (an academic affiliate of the Yale University School of Medicine, Department of Psychiatry), nurses can recognize symptoms of depression in their patients. “In any setting, patients may come to our attention with reports of loss of energy, anxiety, aches and pains, headache, insomnia, changes in appetite, or a significant weight loss or gain in a short period of time. These symptoms are not necessarily signs of depression, but they call for further exploration,” says Kowalchuk.

What are the specific signs that you can recognize as being those of depression? “It is easiest to recognize depression when the patient reports feeling sad, empty, hopeless, having difficulty enjoying usually pleasurable activities or sex. The more subtle signs may be irritability, restlessness, becoming more cranky than usual, having difficulty keeping up with everyday routines, or focusing on TV or reading. Expressing feelings of pessimism, guilt about one’s life, thinking a lot about losses or failures, believing things will not get better—these are more concerning symptoms,” explains Kowalchuk. As difficult as it might be, she says, “You will need to ask if they have thought about suicide.”

If you recognize these signs in patients, it’s important to get more information about any action they may have taken to prepare for suicide. “A key question is whether they have attempted suicide or began a suicide attempt that was interrupted by another person—or they stopped of their own volition,” says Kowalchuk. She adds that these questions are outlined in the Columbia-Suicide Severity Rating Scale (C-SSRS), a protocol that uses simple, plain language questions that anyone can ask to assess risk.

Depending on the level of risk or the particular setting, says Kowalchuk, the nurse caring for this patient may need to refer him or her to a mental health professional.

“Holidays are times that bring up life events, feelings of loss or loneliness, placing all of us at risk. The consequence of undetected depression is death by suicide,” she says. “According to the suicide experts at The Lighthouse Project, ‘Just ask, you can save a life.’”

8 Most Common Christmas-Related ER Visits

8 Most Common Christmas-Related ER Visits

’Tis the season to be jolly, and to have your festive follies land you in the emergency room. Holiday cheer can dissolve into tears after any number of seasonal accidents around Christmas time, from falling while hanging lights to cutting yourself with a knife while cooking. Below, we’ve rounded up eight major reasons for the seasonal injuries that often happen in the last few days of December. If you’re working in the ER on or around Christmas Day, keep these causes in mind as you put on your holiday scrubs.

Wrapping and Unwrapping Gifts

As mundane as these tasks seem, wrapping and unwrapping gifts is a major cause of injury around Christmas—and there’s a huge spike in cases on Christmas Day in particular. Knives, scissors, and box cutters can easily slip, resulting in lacerations. Even those awful hard clamshell plastic cases can pose a risk if you catch your skin on a jagged edge. Wrapping gifts can also result in lacerations and even major paper cuts if people aren’t careful. If this sounds silly to you, just wait until you work Christmas morning in the ER and watch the patients come through the door.

Decorating the House

Deck the halls with boughs of holly, but just be sure not to injure yourself in the process. Decorations pose all sorts of dangers. You can shock yourself while putting up lights, fall while hanging a garland over a door, or cut yourself on a broken ornament or figurine. In particular, children can get into a lot of trouble around decorations, such as swallowing small ornaments, hurting themselves on heavy stocking holders, and tripping over ground-level decorations. Keep that in mind when you’re decorating your house, or while you’re treating a patient who injured himself or herself doing these very things.

Hanging the Lights

Hanging lights inside or outside may be a time-honored tradition, but it’s also a dangerous one. Like decorating the house, hanging Christmas lights comes with all sorts of hazards. There’s the obvious risk of falling off a ladder or roof, resulting in bruises, broken bones, and/or a concussion. But you can also throw out your back while reaching up high or blow out your knee while climbing a ladder. Plus, there’s always the chance of cutting yourself on a broken bulb or shocking yourself with electricity when you plug in the lights. Around Christmas time, you may find yourself wishing your patients had simply put some battery-powered candles in the window and left it at that.

Trimming the Tree

Trimming a Christmas tree holds all the dangers of putting up decorations and hanging Christmas lights, all at once. If you manage not to throw out your back or pull a muscle while getting the tree into the house and setting it up in the stand, there’s still the possibility of falling off the ladder while you drape the lights or put on the tree topper. Of course, you can shock yourself while plugging in the lights as well. If you get through that unscathed, there’s still the chance that you will cut yourself on a busted ornament or lightbulb or trip on the tree skirt. Trimming a tree is all fun and games, until it isn’t.

Getting the Flu

Okay, so the flu isn’t related to Christmas directly, but December does fall right within the window for flu season. (The extended flu season for 2017-2018 lasted all the way from November to March and was the worst outbreak in the U.S. in almost a decade.) Flu viruses will already be circulating by Christmas, and the stress and travel of the holiday can wear down people’s immune systems, making them more prone to contracting the flu. Expect to see severe cases of the flu starting in November and continuing through the rest of the winter holidays, including Christmas—and be sure to encourage any healthy patients you see to get the vaccine!

Cooking the Food

Cooking that delicious Christmas dinner can also prove harmful to your health. Knife lacerations are a common injury around the holidays, as cooks are often distracted while chopping and inexperienced chefs find themselves pressed into cutting vegetables. Burns also happen often due to splattered oil or gravy, as well as brushing up against a hot pan or stovetop burner unknowingly. Less common are full-on cooking fires, which are thankfully more rare but more serious when they do occur. Come Christmas, you’ll probably find yourself patching up more than one overambitious chef, so brush up on your burn and wound care skills.

Eating the Food

You’ve managed to get through cooking all the food without burning or lacerating yourself, so you’re home scot-free, right? Wrong. Food poisoning can happen during holidays due to undercooked meat–which harbors salmonella–or any dishes left at room temperature for too long, which allows nasty bacteria to grow. There’s a high likelihood you’ll see patients with nausea, vomiting, diarrhea, abdominal cramps, and/or fever, all classic signs of food poisoning. You might also get some cases of more mild gastrointestinal distress (“mild” being relative) with symptoms such as severe gas, bloating, constipation, and abdominal pain. Traditional Christmas dishes are full of fats, oils, sugars, spices, and other irritants, and many people overindulge on the holiday, leading to seriously upset stomachs.

Drinking Too Much

Just as many people overindulge in food over the holidays, so they also overindulge in alcohol. While alcohol-related incidents are a bit more common on New Year’s Eve, many people also imbibe to excess during other winter holidays, including Christmas. Drunk driving is obviously a major concern, but plenty of other minor mishaps can result from drunkenness, such as slips, falls, and injuries caused by sluggish reflexes.

While some of these resulting injuries might not be so different from ER visits the other 11 months out of the year, it helps to know the possible cases that might walk through the door, especially if you’ve never worked a holiday shift in the ER before. Keep these eight injuries in mind as you treat patients, and consider rewarding yourself with a nice Christmas gift, such as sturdy nursing shoes or a new stethoscope once you get through the craziness of holiday injury season.