Inclusion tops the list of many workplace must-haves. But what exactly does inclusion mean?
According to G. Rumay Alexander, EdD, RN, FAAN, clinical professor and director of the Office of Multicultural Affairs at the University of North Carolina at Chapel Hill, when people talk about inclusion they can’t ignore one very important fact – inclusion means something different for each person.
“You have to define terms and explore it and explain it a little more carefully,” says Alexander, who recently moderated the American Nurses Association webinar Diversity Matters: Create an Inclusive Nursing Culture that Leads to Better Outcomes. “A prime example is that people talk about respect. The fact of the matter is that ten different people have ten different definitions of respect.”
How can you begin talking about inclusion?
1. Define It
Nurses excel at critical thinking skills, says Alexander, so sitting down to talk about what inclusion means in your workplace should be the first step.
2. Think About What Inclusion Means to You
“Self-awareness is so key to the work of an inclusive space,” says Alexander. “Understanding and knowing yourself is important. Know what pushes and doesn’t push your buttons.” Use honest self examination of your biases and prejudices so you become aware of them and realize how they could impact your work. Everyone has had different experiences, says Alexander, and each of those can change your outlook. The important work is understanding how that happens and making sure it doesn’t invade your work.
3. Be Willing to Change
When you do some honest reflection, you might realize where you need to make changes. That’s not a bad thing. Almost everyone needs to do something better, so having an open mind and understanding that you are part of a team trying to change takes the personal sting out. Be willing to learn. “Understand that your private decisions have public ramifications,” says Alexander. “You can’t talk your way out of what you behaved your way into.”
4. Change Your Culture
“Culture will trump strategy every time,” says Alexander. If everyone isn’t on board, any changes and any strategies put in place won’t hold. Understanding workplace culture means understanding who shapes the culture and how they interact. “You have to understand culture,” says Alexander. “Culture is the way you approach your work.”
5. Be Patient
“You have to understand when you are changing culture you are dealing with a process and that takes time,” says Alexander. A new environment won’t happen overnight, but it will happen with self reflection, new approaches, and honest and open communication.
Affirmative action has been a hot topic for decades. Since its tumultuous inception almost 50 years ago, affirmative action has been applauded, argued, and scoffed at as an answer to racial inequality.
In 1961, President John F. Kennedy was among the first to use the term “affirmative action” as a method to prevent further racial discrimination despite civil rights laws and, essentially, to temporarily level the playing field. Executive Order 10925 required that government contractors “take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, creed, color, or national origin.”
But it was President Lyndon B. Johnson who developed and enforced it for the first time in 1965 with the passage of Executive Order 11246.
“This is the next and more profound stage of the battle for civil rights,” Johnson said to a Howard University graduating class in 1965. “We seek…not just equality as a right and a theory, but equality as a fact and as a result.”
Since then, the debate over affirmative action has grown more and more contentious and problematic as the public—with divided opinions—have weighed in on a complex issue.
Robert A. Schaeffer, the public education director of
FairTest, the National Center for
Fair & Open Testing, believes that many issues relating to race are highly controversial because critics have been able to define policies as “preferences” rather than “balancing” the playing field.
“Many Americans are convinced that affirmative action creates biases in favor of certain groups,” says Schaeffer. “Particularly in economic tough times, it is not difficult to fan resentment against any plan that seems to advantage [some] while disadvantaging others.”
Schuette v. Coalition to Defend Affirmative Action
In recent months, the battle over affirmative action once again gained momentum in light of the latest Supreme Court rulings. In April, the Supreme Court upheld a constitutional amendment Michigan voters approved in 2006, banning preferential treatment based on race, gender, ethnicity, or national origin in admissions to the state’s public universities.
By a vote of 6 to 2, the court concluded that it was not up to the judges to overturn the 2006 decision by Michigan voters to bar consideration of race when deciding who gets into the state’s universities and made it clear that states are free to prohibit the use of racial considerations in university admissions.
“This case is not about how the debate about racial preferences should be resolved. It is about who may resolve it,” Justice Anthony Kennedy wrote in an opinion joined by Chief Justice John Roberts and Justice Samuel Alito. “There is no authority in the Constitution of the United States or in this court’s precedents for the judiciary to set aside Michigan laws that commit this policy determination to the voters.”
Justice Sonia Sotomayor, on the other hand, blasted the majority, who she said attempts to “sit back and wish away” evidence that racial inequality exists.
“The stark reality is that race still matters,” Sotomayor wrote in her 58-page dissenting opinion joined only by Justice Ruth Bader Ginsburg. “The way to stop discrimination on the basis of race is to speak openly and candidly on the subject of race, and to apply the Constitution with eyes open to the unfortunate effects of centuries of racial discrimination.”
It is unclear how the decision might move other states. Eight states, including Nebraska, Arizona, and Washington, now have bans on affirmative action. The ruling could encourage other states to join the handful that already have such prohibitions, such as California and Florida.
But what’s worrisome to proponents of affirmative action is the precedent that may have been set with the court’s ruling, potentially, further energizing opponents of racial preferences, who have already outlined plans to put Michigan-style constitutional amendments on the ballot in Utah, Ohio, and Missouri.
A survey conducted by ABC News and The Washington Post last year found that 79% of whites and 71% of non-whites oppose the consideration of race and ethnic preferences in college admissions, suggesting that any affirmative action ballot measures are likely to be voted down.
Moving forward, Roger Clegg, president and general counsel of the Center for Equal Opportunity believes that the court’s decision means that colleges in states that have banned racial preferences must follow those laws and other states without bans should reexamine with current plans.
“It also means that colleges in other states must take into account the fact that their continued use of racial preferences, which is unpopular, should consider getting rid of that policy since it may be banned in their states, too,” Clegg adds.
Quite the contrary, says Michael Olivas, director of the Institute for Higher Education Law and Governance at the University of Houston Law Center. “It hurt the choices that Michigan colleges wanted to make, and this violated their academic freedom.”
But it need not be a regressive process, Olivas continues. In Maryland, voters approved resident tuition for the undocumented in a ballot measure, and Colorado voters turned down a Michigan-type measure.
“They are neither good nor bad in and of themselves, except we should not make such important decisions for colleges by this means,” Olivas adds.
The groups that challenged the Michigan affirmative action ban pointed out the basic unfairness of giving preferences in admission to some groups while banning similar treatment of African Americans, Latinos, Native Americans, and women.
“Michigan higher education leaders and most major civil rights groups reinforced our arguments,” says Schaeffer, who provided expert assistance to the groups challenging Michigan’s ban. “However, the judicial system held that voters could impose whatever distinctions they determined to be reasonable.”
Impact on Minority Enrollment
What is not clear is the ruling’s impact on minority enrollment. While the US Supreme Court affirmed Michigan’s constitutional amendment banning race-conscious admissions, states that forbid affirmative action in higher education, like Florida and California, as well as Michigan, have seen a significant drop in the enrollment of black and Hispanic students.
In April 2014, The New York Times published an article examining how minorities have fared in states with affirmative action bans, including California, Florida, and Michigan. At UC Berkeley and UCLA in California, for example, the graphs showed that 49% of the state’s college-aged residents are Hispanic, though only 11% and 17% of freshmen are Hispanic at those two schools, respectively.
In Florida, 27% of the state’s college-aged residents are Hispanic at Florida State and the University of Florida, yet both universities showed that only 18% of their freshmen was Hispanic.
While the decision didn’t address the constitutionality of race-conscious admission policies, Justice Sotomayor cited student-demographic data as proof that the ban, which went into effect in December 2006, has adversely affected minority enrollment and diversity at the University of Michigan (UM) in Ann Arbor.
“A white graduate of a public Michigan university who wishes to pass his historical privilege on to his children may freely lobby the board of that university in favor of an expanded legacy admissions policy,” she wrote. “Whereas a black Michigander who was denied the opportunity to attend that very university cannot lobby the board in favor of a policy that might give his children a chance that he never had and that they might never have absent that policy.”
According to the policy brief, “Restructuring Higher Education Opportunity?: African American Degree Attainment after Michigan’s Ban on Affirmative Action,” which Justice Sotomayor cited in her dissenting opinion, the proportion of African Americans who obtained a bachelor’s degree at UM dropped by about one-third after the ban on race-conscious admissions went into effect.
Additionally, The New York Times article revealed that the enrollment of black freshmen at UM between 2006 and 2011 dropped from 7% to 5%, despite the number of black college-aged persons in Michigan increasing from 16% to 19%.
While Justice Sotomayor argued that the ban on race-conscious admissions might have had a negative effect on the number of minority students who enrolled, it has not necessarily stopped colleges from looking at alternative procedures to maintain and promote diversity.
A 2012 study by The Century Foundation, a nonpartisan group, found that at seven of 10 major schools where racial preferences could not be used, race-neutral alternatives helped maintain or even raise minority representation.
For example, Texas’s Top Ten Percent Rule—which guarantees admission to the University of Texas (or any state-funded university) to any high school senior graduating in the top 10% of his or her class—helps ensure diverse college student bodies. A combination of measures, including affirmative action based on class, increasing financial grants, and de-emphasizing standardized tests are just a few promising race-neutral options that have allowed minority enrollment to return to pre-ban levels.
“From FairTest’s perspectives, all these initiatives are worthy of consideration,” says Schaeffer. “But none fully replace affirmative action as a tool for addressing past and present discrimination.”
Fisher vs. University of Texas at Austin
Last June, the justices had a chance to make another big statement on affirmative action with its decision in Fisher vs. University of Texas at Austin (UT Austin). The case was filed by Abigail Fisher, a young woman from Texas who applied to the university but was rejected. Fisher, who is white, then filed a lawsuit, arguing that she had been a victim of racial discrimination because minority students with less impressive credentials than hers had been admitted.
The Supreme Court did not immediately decide the fate of Fisher. Instead, the justices voted 7-1 to return the case to the lower courts to determine whether the use of race is “necessary” and have “the ultimate burden of demonstrating, before turning to racial classifications, that available, workable race-neutral alternatives do not suffice.”
“Strict scrutiny must not be strict in theory but feeble in fact,” Justice Kennedy wrote. “The reviewing court must ultimately be satisfied that no workable race-neutral alternatives would produce the educational benefits of diversity.”
Only Justice Ginsburg dissented in the decision to send the case back.
“I would not return this case for a second look,” Ginsburg wrote in her dissent. “The University reached the reasonable, good-faith judgment that supposedly race-neutral initiatives were insufficient to achieve, in appropriate measure, the educational benefits of student-body diversity.”
The ruling upheld Gratz v. Bollinger and Grutter v. Bollinger, two cases fundamental in defining universities’ rights to consider race as an admissions factor. Though many argue that the court’s decision preserves the principle that affirmative action is permissible in some circumstances. That, according to Olivas, depends upon the narrow tailoring that the remand requires.
“UT Austin is allowed to use race (by Grutter), and the top ten percent plan—which I helped write—is race-neutral, so Fisher was not harmed. She was simply not admissible,” Olivas argues. “The plan allows in over 50% whites, in a state where whites are only 30% of the [high school] population. It does not harm them, nor does the modest affirmative action policy.”
It can be said both decisions illustrate the court’s skepticism about race-conscious government programs. The Schuette v. Coalition to Defend Affirmative Action ruling alone took five separate opinions totaling 102 pages written over six months—a sign of how divided the court remains on the issue and the role the judiciary should play in protecting racial and ethnic minorities.
To most, the recent Supreme Court’s decision upholding Michigan’s affirmative action ban was far from a shock, but many believe the ruling could symbolize a steady march to the end of the use of race in higher education.
But, for now, the most recent Supreme Court decision only impacts public colleges and universities in the state of Michigan. The voter-approved Constitutional amendment clearly bars them from considering race, gender, ethnicity, or national origin in admissions and related decisions.
“For higher education institutions in other jurisdictions that are not operating under similar bans [some states, such as California, have their own prohibitions], affirmative action policies that comply with the court’s Hopwood [v. Texas] and Grutter decisions remain legally permissible,” says Schaeffer. “However, many who closely observe the Court believe that further restrictions on affirmative action are likely as the result of Fisher and other cases, currently moving through the judicial system.”
Terah Shelton Harris is a freelance writer based in Alabama.
Regardless of the area of clinical expertise or practice setting, there are situations where every nurse can experience stress, and if he or she possesses effective coping skills they are able to overcome the distress before it escalates and causes significant impairment or dysfunction.
While great attention is given to maintaining one’s physical well-being in the health care profession, the importance of the maintaining one’s mental health can be under-recognized or neglected until it is too late. Similar to getting periodic physical health check-ups, the same should apply to one’s mental health.
In the health care profession, nurses can be faced with a myriad of patient cases or crises that can test both their physical and mental endurance and/or stability. It is important for every nurse to be cognizant of the status of his or her mental health, and an evaluation should be performed on an ongoing basis to ensure that one is in good health.
For any nurse engaged in clinical practice, there are five key things that he or she should be aware of as it pertains to their well-being:
1. It is important to periodically assess the status of one’s health.
For example, if one recognizes that they have been experiencing depressive or anxious symptoms for an extended period of time this should serve as an indicator that an issue may exist. Upon identification it is important for a nurse to immediately seek out the aid of a mental health profession to address the issue.
2. Recognize the importance of taking breaks during work to refresh from a particularly taxing or complex patient case.
During the course of any work day, it is important to take breaks to remove oneself from their stressful or high paced work environment to clear their mind.
3. Familiarize yourself with the key warning signs that may signal a mental health crisis.
These may include changes in behavior or thinking, lack of interest in activities that were once found to be pleasurable, or changes in sleeping pattern. These can serve as some of the signs that one’s mental health has been compromised and aid is needed.
4. Keep yourself up to date with the latest developments within the field of mental health.
This is particularly important since it not only affects you but the patients you care for as well. By staying up to date on latest developments within the field of mental health, a nurse is able to immediately identify situations that may have the potential to negatively impact their mental health or their patient’s.
5. Realize that some stress in life is inevitable.
Although the goal is to experience good mental health both on a personal and professional level, there may be a time when there can be a disturbance in one’s mental health, but knowledge, education, and insight can help to address this immediately before it causes impairment.
The International Dyslexia Association describes dyslexia as “a specific learning disability that is neurological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities.” Dyslexia is a condition that does not change in one’s lifetime.
I knew I had dyslexia when I applied to nursing school in 2007. About a decade prior, I received the diagnosis of dyslexia during my unsuccessful attempt to get into graduate school. At age 43, with a daughter in middle school and a supportive husband, I was willing to try a career change again. I succeeded in my prerequisites courses, receiving A’s in Chemistry and Microbiology and a B in Anatomy and Physiology. I thought somehow maybe I “outgrew” being dyslexic. I really knew nothing about what dyslexia was. I knew learning to read was really hard and I got pulled out of reading groups in fourth grade, but I still don’t know very much about it. I knew I did not want reading differently to stop me. I still have so much to learn.
My first try at nursing school was in an accelerated nursing program. The documentation stating my dyslexia diagnosis was more than 10 years old. I attended a community college to complete my prerequisites. The community college was able to accept the documents I had and explained that a university would require updated documentation confirming the condition. To get retested and get current documents would cost approximately $600 to $1,000—an added burden to the cost of tuition and books.
Accommodations for my dyslexia during the accelerated program could not be available because of the outdated status of my documents. Nevertheless, I felt elated because my grades from my prerequisites were high. Fifteen weeks into the accelerated program, I “washed out” and voluntarily withdrew. But, I had a plan. I got retested and got the updated documentation. I also became a Certified Nursing Assistant (CNA). In seven months, I got the call inviting me to join the traditional Bachelor of Science in Nursing (BSN) program. I literally cried with joy. I had another chance.
The tests to assess learning disabilities are not difficult. There were four one-hour sessions, including tests—some written, some verbal, and one involving making shapes with blocks. One test measured my reading speed. I was instructed when to start and, at different times, I was asked to point to where in the article I had read to in the given time. Once the allotted time was completed, I was asked a series of questions to test my comprehension.
Soon after completion of the testing, I enrolled in CNA training. Becoming a CNA significantly contributed to my understanding of many principles I had learned in lecture on the fundamentals of patient care. As a CNA, I was able to learn at the bedside while developing relationships with patients and practicing the skills from both lab and clinicals. Nineteen days after finishing CNA training, I was employed at the location where we completed our clinicals. Having a job as a CNA provided me with the opportunity to make real the theory I had learned in class. The opportunity to work next to real nurses let me watch the lessons you cannot learn through books. My confidence grew as my dedication to complete the BSN degree cemented. Once I returned to the classroom as a student nurse, I was wholly committed to completing the program.
Being back in class gave me the opportunity to fulfill my dream of being a nurse while receiving a variety of accommodations for dyslexia:
Transparencies: Color transparencies over a printed page, which function like sunglasses on a sunny day. The distortion is minimized. This simple fix considerably reduces the strain from reading.
Kerzweil Text-to-Speech Reader: A computer program that changes text into audio. All the computers on campus can utilize Kerzweil, so I bring earphones in order to listen to my tests or texts.
Testing Center: All of my test taking is completed in the test center. An appointment with the test center is scheduled four days prior to each exam. To limit distractions and noise, I test in a room alone.
Time-and-a-Half: My test appointment time is 1.5 times the allotted time in the classroom. So, I go to the testing center early, usually 7:30 a.m. for an 8:00 a.m. test. Rarely do I need the extra time, but the benefit is not having to worry that I might run out of time near the end of the exam. This reassurance really makes a difference, especially when I go back to recheck answers.
There are many parts when I take an exam—it resembles conducting an orchestra. All of the material requires management to maximize my comprehension of the technical questions being asked. There are inputs from four tests simultaneously, so I can receive the information efficiently. There is one test in front of me that I manually mark up, which is covered with a color transparency. This paper test is returned to my instructor. It is a back-up in case there is a computer malfunction.
There are also two tests on the computer. One of the tests on the computer is in the Kerzweil program. This program reads the test to me so I can hear it in my earphones. Kerzweil highlights each sentence in yellow as it is being spoken and each word in that sentence is highlighted in pink.
The second version of the test on the computer is the one that I must complete and submit to the instructor for grading. The final version of the test is the audio in the Kerzweil program. Most of my classmates don’t notice that I am out of class during tests. Usually, when I explain I have a learning disability, the first reaction I get is disbelief since I always participate in class discussions.
It is best for me to prepare for lecture prior to class time. I ask many questions as the material comes up in lecture. To classmates, it might appear that I am really enthusiastic—which I am—but I don’t really have many other options. If I can’t understand a concept from the book, it is easiest to ask during lecture. I am always the most surprised when I get high grades on exams.
During the summer of 2010 between my junior and senior years, I enjoyed participating in an externship. This consisted of fifteen 12-hour shifts, during which I followed a preceptor on the telemetry floor at a major medical center. This externship provided many opportunities for verbal questions and answers—my preferred learning style. My preceptor was incredible. She was open to learn about my learning needs, and we discussed possible precautions to take in order to maximize my performance on the floor.
According to my preceptor, there was no evidence of disability in my performance. I did use a color transparency when there was a lot of material to read and comprehend, but that was the only accommodation I used on the floor. The transparency was also a folder that held materials that I needed, so it blended in discreetly.
Despite research articles in the medical literature raising skepticism about nurses and nursing students with dyslexia, most articles call for the need for more research. There are laws that prohibit discrimination against individuals with disabilities, but application of these laws to nursing students and new nurses with dyslexia is an area that appears vacant. I have not found another group of student nurses that is directly being targeted in this way.
The United Kingdom leads the way in accommodating the needs of dyslexic students. England has a complete, published protocol that details how to best maximize the learning abilities of dyslexic student nurses while ensuring the safety for all. The idea of whether dyslexic student nurses should be allowed to practice in the United Kingdom is never questioned.
Unable to locate a voice from the perspective of dyslexic student nurses, I founded Nursing Students with Dyslexia (NSwD) on www.NursesLounge.com, which is a social networking site geared specifically to nurses and student nurses. Students are able to join NSwD directly at http://community.nurseslounge.com/join/nswd. This page includes research available on assisting student nurses with dyslexia, along with resources and scholarship opportunities.
Someday, I hope to develop a scholarship that encourages student nurses with dyslexia to network together. Maybe by sharing our stories of success we can offer greater insights into the challenges that dyslexic student nurses must overcome. Nursing education is expanding its understanding of how to provide the most successful learning experience for students, including student nurses with dyslexia. I am proud and honored to be a voice as a student nurse who is not letting a disability define or limit me.
Toni Sugg, RN, graduated from Regis University in Denver, Colorado, in May 2011 and received the Nursing Excellence Award for her class. She is currently employed at El Pubelo…an Adolescent Treatment Community, where she cares for kids with a large range of abilities and challenges.
Depending on where they work and their specialties, nurses can earn a range of salaries. Salaries continue to appear to vary by ethnic background as well, but overall, nurses reported in the second annual Minority Nurse salary survey making more this year than they did last year—and more than they did five years ago.
Although nurses reported making higher salaries this year than they reported last year, there are wage gaps by ethnicity that remain to be closed.
In 2013, nurses reported making a median salary of $67,000; this year, they reported earning a bit more, a median $68,000. Still, African American nurses earned a median $60,200 and Hispanic nurses received a median $60,000, while white nurses took home a median $72,000.
To gather all this data, Minority Nurse and Springer Publishing e-mailed a link to an online survey that asked respondents about their jobs, educational backgrounds, and more to better understand their roles as nurses and to determine their current and past salaries.
Some 4,850 nurses from all over the United States responded to the survey questions. The respondents also hailed from a number of specialties, including nurses working in critical care, as certified nurse educators, and in pediatrics, as well as nurses employed at public hospitals, private hospitals, and at colleges or universities.
Some stark differences, though, were noticeable when survey data were broken down by ethnicity. For instance, nurses belonging to different ethnic groups working at similar institutions reported earning different amounts of money. African American nurses working at a public hospital reported earning a median $65,000, as did Asian nurses. Hispanic nurses reported making less, taking home a median $60,000. White nurses, though, said they earned $79,500.
Additionally, nurses belonging to different ethnic groups with similar educational backgrounds also reported salary differences. African American nurses with a bachelor’s degree reported making a median $62,000—similar to the median $60,000 reported by Hispanic nurses—though higher than the median $50,000 received by Asian nurses, but lower than the median $70,000 that white nurses said they made.
At the master’s degree level, the picture is a little different. Asian nurses with master’s degrees commanded the highest salary, a median $80,000, followed by African American nurses, who received a median $76,000. Hispanic nurses, meanwhile, earned a median $74,940, and white nurses with a master’s degree reported making a median $73,000.
Overall, respondents reported earning a higher salary this year than they took home last year and a bit more than they reported earning five years ago. For example, nurses working primarily in patient care reported earning $60,000 this year, $55,000 last year, and $47,000 five years ago, and advanced practice nurses reported making $89,000 this year, $84,000 last year, and $78,000 five years ago.
Though there are still wage gaps to be bridged, nurses reported earning more now than they did just a few years ago.
17.6% of respondents have a PhD or other doctoral-level degree
33.3% work at a college or university
56.2% have been at their current job for five years or longer
65.8% received a raise within the last year
53.5% left their prior job to pursue a better opportunity
41.1% do not expect a raise this year
48.9% are looking to leave their current job in coming years
Top Two Degrees Held by Respondents
MSN, or other master’s-level degree
BSN, or other bachelor’s-level degree
Five Most Common Specialties
Critical care (NICU, PICU, SICU, MICU)
Certified Nurse Educator
Advanced practice nursing
Highest Paid by Employer Type
Health insurance company
College or university
Most Common Benefits Provided
Retirement plan (401(k), 403(b), pension, etc.)
Paid time off
Last summer, The Joint Commission’s culturally and linguistically competent patient-centered communication standards became part of the hospital accreditation process. One year later, what difference are they making?
In 2009, Minority Nurse published a Vital Signs story that asked: “Have you ever wished that hospitals had more of an incentive to provide culturally and linguistically competent patient care?” What prompted that question was The Joint Commission’s announcement that it was developing a set of standards that would incorporate the provision of culturally competent patient-centered care into the national requirements for hospital accreditation.
They’ve been a long time coming, but on July 1, 2012, these new and revised standards for patient-centered communication officially became part of the overall accreditation decision. The standards—which are published in a free downloadable implementation guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals—require health care organizations to, among other things:
- Identify and effectively meet the oral and written communication needs of all patients, including those with limited English proficiency, hearing or visual impairments, and low health literacy;
- Use highly qualified interpreters and translators, rather than untrained individuals, family members, or bilingual staff;
- Document patients’ language and communication needs in their medical records.
Plus, the standards include two provisions designed to create a more equitable environment for lesbian, gay, bisexual, and transgender (LGBT) patients and their loved ones. One requires hospitals to prohibit discrimination based on sexual orientation and expression of gender identity. The other provides equal hospital visitation rights for same-sex domestic partners by allowing “a family member, friend, or other individual to be present with the patient for emotional support during the course of stay.”
As all nurses know, Joint Commission accreditation reviews are something hospitals take seriously. One year later (or two years in the case of the LGBT standards, which took effect in July 2011 to align with the Centers for Medicare & Medicaid Services’ 2011 visitation rights regulations1), what effect have the patient-centered communication standards had? Are they helping hospitals do a better job of serving culturally diverse patients’ needs? And more importantly, are they starting to make any difference in improving minority health outcomes?
Too Soon to Know
The answer is: It’s still too early to tell.
“We’ve been trying to do some analysis of the scoring data and the requirements for improvement that we’ve seen since last July,” says Christina Cordero, PhD, MPH, associate project director, Department of Standards and Survey Methods, at The Joint Commission. “These data have been somewhat limited because of the time frame. But we’re planning to [look at] that information to see how frequently these issues are being scored, what kinds of situations and comments are coming up on survey, and what our surveyors are seeing on-site.”
In the meantime, anecdotal evidence suggests that most hospitals are at least trying to make sure they’re implementing the standards correctly. For instance, says Cordero, who helped develop the patient-centered communication standards and the Roadmap for Hospitals, The Joint Commission has been fielding many questions about how to implement standard RC.02.01.01, EP 28, which requires hospitals to include patients’ race and ethnicity in their medical records.
“Most of these inquiries have focused on what categories and question formats hospitals should use to collect that information from patients,” she explains. “For example, should they ask about race and ethnicity together in one question or in two separate questions? We responded by publishing FAQ documents on our website to help hospitals implement a data collection system that works for them.”
As for identifying areas where improvement may be needed, The Joint Commission’s initial analysis of data from surveyor site visits seems to indicate that hospitals are finding some of the standards harder to comply with than others.
“The one standard that has been coming up most frequently on-site over the last few months is PC.02.01.21, identification of patients’ language and communication needs during the provision of care, treatment, and services,” Cordero reports. “This may mean that hospitals are struggling more with that issue. Our surveyors are looking at not just the documentation of communication needs but what hospitals are doing to identify and address those needs.”
Is It Enough?
Minority health advocates are also keeping an eye on what The Joint Commission’s evaluation of the standards’ early years will reveal.
“I hope there will be a systematic examination of the outcomes and the impact on the quality of patient care,” says Cora Muñoz, PhD, RN, co-author of the book Transcultural Communication in Nursing. “But the fact that there are now two external bodies that require this—the Office of Minority Health [which developed the Culturally and Linguistically Appropriate Services (CLAS) standards in 20002] and now The Joint Commission—is a step in the right direction.”
Hector Vargas, JD, Executive Director of GLMA: Health Professionals Advancing LGBT Equality (formerly the Gay & Lesbian Medical Association) feels that the patient-centered communication standards are “just one piece of a larger picture of progress we’ve seen over the last few years. These standards, the CMS hospital visitation rules, the  Institute of Medicine report [The Health of LGBT People: Building a Foundation for Better Understanding], Healthy People 2020—which for the first time includes specific LGBT health goals—and the Affordable Care Act have all made a difference in how hospitals are addressing the needs of LGBT patients.”
But some transcultural nursing leaders, such as Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CNS, CTN-A, FAAN, President and Founder of Transcultural C.A.R.E. Associates in Cincinnati, argue that simply having culturally sensitive accreditation standards—or even federal government mandates—in place is not enough. Unless these requirements are vigorously enforced, she believes, there’s no guarantee that hospitals will act on them.
Vargas agrees. “The policies are there at the macro level,” he says, “but we really have to rely on the professionals in the hospitals—nurses in particular, but all members of the health care team—to make sure those policies are enforced.”
Nurses as Communication Champions
What can nurses do to help ensure that their institutions are complying with the standards on an ongoing basis—not just when Joint Commission surveyors show up? Muñoz, who is professor emeritus and an adjunct professor at Capital University School of Nursing, asserts that nurses must be leaders in a constant dialogue about the crucial role culturally competent communication plays in planning and delivering the best possible care for every patient.
“When nurses have a patient who needs language assistance, they must demand that the patient gets those [interpretation] services,” Muñoz adds. “As patient advocates, they should not settle for just getting by, or using family members [as interpreters] when it is convenient. That is not acceptable.”
Laura Hein, PhD, RN, an assistant professor at the University of South Carolina College of Nursing and a member of GLMA’s board of directors, gives two reasons why it’s important for nurses to be involved in championing the standards’ LGBT-inclusive provisions. “One is patient protection and advocacy. The other is to protect the rights of their [LGBT] colleagues, whether they themselves are LGBT-identified or not.” However, she cautions, “If they’re working in a state, or a hospital, that is not accepting of LGBT people, it’s a little trickier for them to be an advocate without endangering their own employment.”
Even though the impact of the patient-centered communication standards is still a work in progress, Muñoz emphasizes that progress is the key word. “At least we have the standards now; we didn’t have them before,” she says. “We’re moving forward. I wish we could move faster. But we’re moving.” MN
- U.S. Department of Health and Human Services, “Medicare Finalizes New Rules to Require Equal Visitation Rights for All Hospital Patients,” November 17, 2010, www.hhs.gov/news/press/2010pres/11/20101117a.html, accessed March 26, 2013.
- U.S. Department of Health and Human Services, Office of Minority Health, “National Standards on Culturally and Linguistically Appropriate Services (CLAS),” http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15, accessed March 25, 2013.