From Public Health Advisor to Congressional Candidate: An Interview with Lauren Underwood

From Public Health Advisor to Congressional Candidate: An Interview with Lauren Underwood

Last issue’s health policy column highlighted nursing’s increased engagement in the public policy arena. To continue this conversation, this column highlights a registered nurse running for Congress to help champion access to affordable health care. Yes, Lauren Underwood, MSN/MPH, RN, of Naperville, Illinois is running for Congress to represent the 14th Congressional District of Illinois.

Her Journey to Pursuing an Elected Position

Underwood is steadfast and fiercely committed to helping shape policies and programs focused on ensuring that everyone has access to affordable health care. She is a registered nurse who received her BSN from the University of Michigan and her MSN/MPH from Johns Hopkins University. Her nursing experiences include service as a health policy advisor, research fellow, senior director, and research nurse at the National Institutes of Health Clinical Center. Her passion for public policy was heightened while serving as a health policy advisor in the Office of the Secretary at the Health and Human Services in Washington, DC initially under the leadership of Secretary Kathleen Sebelius followed by the leadership of Secretary Sylvia Burwell. In this capacity, Underwood worked on private insurance reform, summary of insurance benefits, health care quality in the Medicare program, the Agency for Health care Research and Quality, and preventive services (free screenings, immunizations, and contraceptive coverage) for four and a half years from 2010-2014.

Lauren Underwood

Lauren Underwood, MSN/MPH, RN
Democratic Candidate for Congress, 14th Congressional District of Illinois

Tell us about working for the Obama administration.

Got a call the week that Mr. [Thomas Eric] Duncan was in the hospital in Dallas with ­Ebola asking if I would be willing to join the President’s team to help with disaster response, so I transferred over to ASPR, the Assistant Secretary for Preparedness and Response, at HHS. We worked on emerging infectious diseases (e.g., Ebola, Zika Virus, Middle East Respiratory Syndrome virus, or MERS), we also did national disasters (e.g., wildfires, hurricanes, floods) and then bioterror (small pox, anthrax) and worked with drug companies to develop vaccines, treatments, and diagnostics. I stayed in the administration until the very end, the last day. And so, when the election happened in 2016 we were working on the water crisis in Flint. I was surprised, and I thought that Hillary Clinton’s team was going to win and that we were going to hand off our work on health reform and on Flint to people who cared and wanted to continue the process. And then we got the Trump team who made it very clear they wanted to do away with health care coverage. And that’s not why I went into nursing or why I did this work. So, I knew I could stay in government and help them do that. I wanted to continue the work and so I came back home to Illinois because Illinois is a state that expanded Medicaid. I got a job working for a Medicaid managed care company in Chicago as the Senior Director for Strategy and Regulatory Affairs for a company called Next Level Health.

Are you still there?

I left my job about six weeks ago. The primary campaign was about eight months. I worked full time six and a half months; you know you have to do that. I am a young person, not someone of particular means or whatever, so it was necessary. And then it was like “Lauren, you could really win if you put your time and energy into the campaign.” And so that was an easy choice to transfer to full time.

So, you are now devoting full time to the campaign?

Yes.

This reflects your journey. Describe in a few words what really made you run for an elected position.

I am going to tell you a story. Last spring when I returned home, I went to congressman Randy Hultgren’s one and only public event. It was a moderated event hosted by the League of Women Voters. And during that evening, he made a promise and said that he was only going to support a version of Obamacare repeal that allowed people with preexisting conditions to keep their coverage. That’s important to me as a nurse. I also know how critical it is for people with chronic illness to have access to medications and procedures that they need. Obviously, I worked to implement the Affordable Care Act so I read the law and I know that it works. I know that we can fix what does not work. We do not have to throw the whole thing away. Like so many Americans, I have a preexisting condition myself. I have a heart condition, SVT (supraventricular tachycardia), and it is well controlled. As you know, it is a preexisting condition, so I would not be able to get coverage under these repeal scenarios. And so, when the congressman made that promise I believed him.

And then a week to ten days later he went and voted for the American Health Care Act, which is a version of repeal that did the opposite. It made it cost prohibitive for people like me to get coverage. And so, I was upset not at the vote itself, but because he did not have the integrity to be honest the one time he stood before our community. That’s not what a representative is supposed to do. A representative is supposed to be transparent, accessible, and honest. And we deserve better. I said, “you know what, it’s on! I’m running” and launched my campaign in August and just won the primary on March 20th. I was in a field of seven—the only woman running against six men—and I won 57% of the vote.

Were you the only African American?

Yes.

I know you are concerned about overall access to care and have a deep commitment to utilizing your expertise and experience while working in the Obama administration.

I believe that health care is the number one issue in this election across the country and in our district, and we need a solution to make health care more affordable for American families. It is not enough for families to rake together money for their premiums and have an insurance card in their pockets and cannot afford the coverage.

I believe that a lot of the conversation in the last several years has been political in nature and undoing President Obama’s legacy and not on at all focused on trying to lower costs and make health care accessible for American families. That’s my objective! I want to work on drug prices. I want to work on this opioid drug crisis so that loved ones can get the treatment that they so desperately need. And so, I believe there is a lot of value in having a nurse at the negotiation tables when we are making these decisions and passing policies that will transform our health care system. I am excited about the opportunity to be a leading voice on Capitol Hill on these important issues.

What do you think are the most pressing issues impacting nursing and health care?

Affordability. Any program that is starved of resources will fail. The ACA has been intentionally sabotaged and as a result, we see extraordinary high premiums that are unaffordable for most families. That is not how the program was designed to work and so I think there are technical fixes we can do to make the program more affordable. We can do things like negotiate drug prices, it can be done, we need to take a strong position on this opioid drug addiction crisis. We need to implement reforms like how we pay for rehab and how we award funds to municipalities in order to create a pathway for lasting change. And then there are opportunities to expand coverage so we will have fewer uninsured Americans. What we are seeing now in order to resuscitate it takes 2-3 doses of Narcan because the drugs are so strong. Municipalities who have received Narcan grants are running out of Narcan. A Narcan only solution is not a solution. Law enforcement only solution is not a solution. Addiction is an illness and we need to treat it as such. We need to send people to treatment so they can have a shot at recovery. We could have an evidence-based policy solution. We know treatment can be effective.

What do you think is the most pressing issue affecting nursing today?

I think there are a few things. The high cost of our education. We have not really seen increases in funding. What we have seen are marginal increases or flat funding. I think that this is unacceptable, in particular in the context of what we are seeing in higher education more broadly. And not just at the federal level. In higher education, many states have reduced putting money into public education, shifting the responsibility to families and individuals and with that coupled with flat funding for nursing education we are seeing a generation of nursing students with significant debt. And that is going to be a barrier, I believe, to our profession being able to grow. Right now, we have an economic situation where we are not seeing the shortage that we saw ten years ago. But it’s very easy to get back to that point if the economics of going into nursing shifts when you graduate from a BSN program with $100,000 in debt and are limited in your initial salary. Loan repayment programs are not that plentiful as they used to be. The economics of it makes it tough. Because we are talking about middle class folks who are not able to take on that debt. And when it is becoming increasingly attractive to become an APRN, that is all debt to be able to get the master’s to become a nurse practitioner or a nurse midwife. We are going to need some serious advocacy and a plan to deal with the cost of our education.

What are your thoughts about safe staffing?

It is so interesting. Safe staffing has been a legislative priority for decades. We have not been able to pass these bills. I think the approach needs to be more balanced with safe staffing committees in these hospitals. Moving away from these ratios and having hospitals have safe staffing committees that would take into consideration the circumstances that facilities and the region when staffing levels. On these committees, nurses would serve so a legislative body is not dictating it. I think that this is an appropriate approach coupled with compelling Medicare participating facilities to set staffing levels and monitor outcomes.

When elected, what would you do to go about helping to ensure equitable access to health care?

That’s like the question! For me, equitable access to health care allows everyone to get health care. Health care is a human right. Human rights have been fundamental to my nursing practice. It is written in our Code of Ethics—this idea that everyone should have health care—and I think our policies should reflect that. For me, that includes fixing the Affordable Care Act to ensure affordable coverage; and making sure we have clinics, hospitals, and facilities in communities so that the burden is not on low-income people or people with transportation challenges or resource limitations so that people are able to get the care and services they need. We have so much innovation, technology, and so many improvements now in a way we are able to provide care whether it’s telemedicine or individualized health care. It is a shame if all of that innovation and all of those improvements are seen in resource communities. We need to be focused in these conversations about reform and transforming our system to ensure that it is serving everyone—rural, urban, low income, and elderly.

What advice would you give to aspiring policy advocates who may be considering a run for public office?

Your country needs you! There are too few nurses in policy positions. Seek a County Board position. The County Board supervises the local Department of Health. Run for state legislator, they address scope of practice issues. Run for Congress! There are many opportunities to serve and lead. Step forward!

Microaggressions in the Nursing Classroom Environment

Microaggressions in the Nursing Classroom Environment

One of the hottest topics amongst nurse educators today is finding strategies to promote safe learning in the classroom environment. According to the American Association of Colleges of Nursing (AACN), it is estimated that over 73% of “nontraditional” students are studying in undergraduate nursing programs. The term “nontraditional” refers to all students who meet the following criteria: over the age of 25, ethnic minority groups, speaks English as a second language, a male, has dependent children, has a general equivalency diploma (GED), required to take remedial courses, and students who commute to the college campus. Nurse educators have a responsibility to ensure that all of their nursing students are learning in a safe environment.

For instance, microaggression is something that nurse educators must address in order to promote a safe classroom environment. Microaggressions are subtle, verbal and nonverbal snubs, insults, putdowns, and condescending messages directed towards people of color, women, the LGBTQ population, people with disabilities, and any other marginalized group. These insults are often automatic and unconscious in nature, according to Derald Wing Sue, PhD, author of Microaggression in Everyday Life: Race, Gender, and Sexual Orientation. Microaggression can cause a person to question themselves regardless of whether the microaggression occurred or not because they were unsure if they were just being oversensitive to the offense or if the perpetrator really intended to harm them with what they said. Microaggressions are usually committed by “well-intentioned folks” who are unaware of the hidden message that is being transferred.

Types of Microaggression

Microaggressions are similar to carbon monoxide—“invisible, but potentially lethal”—­continuous exposure to these types of interactions “can be a sort of death by a thousand cuts to the victim,” says Sue. He further outlines three themes in three ­microaggression ­categories. The three themes are: racial, gender, and sexual orientation. The themes appear to occur in three different forms of microaggression: microassaults, microinsults, and microinvalidations.

Microassaults. Also known as “old-fashioned racism,” microassaults are conscious verbal or nonverbal attacks meant to hurt, oppress, or discriminate against the marginalized groups. This can range from telling racial jokes, name-calling, or isolating a student base on their racial, sexual, or gender identity. For instance, a student may deliberately refer to an Asian classmate as an Oriental. (Hidden message: You are not a true American. You are a perpetual foreigner in your own country.) Another example of a microassault is a teacher asking an African American male student, “Are you a first-time generation ­college student?” (Hidden message: African American males usually do not go to college.) Microassaults leave the students feeling unwanted, uncomfortable, and invisible.

Microinsults. A microinsult is an unconscious and unintentional discriminatory action against one’s identity. For instance, a teacher not asking a transgender student what pronoun to use when addressing the student (Hidden message: You are not acknowledging my identity.) Another example of microinsult is a teacher calling on an Asian student to come to the blackboard to work out a drug calculation problem. (Hidden message: All Asians are supposed to be good at math.) Or a student jokingly making the comment “that’s so gay.” (Hidden message: Being gay is associated with negative and undesirable characteristics.) A microinsult can also be nonverbal. For instance, when a white professor fails to call on the African American students in the classroom. (Hidden message: People of color contributions are unimportant.) Microinsults can have a far-fetching negative impact on a student, and they can affect a student’s ­motivation and commitment as well as mental health.

Microinvalidations. Microinvalidations are unconscious ­communications or environmental cues that faintly exclude, negate, or nullify the psychological thoughts, feelings, or experiential reality of a person’s identity. One example of microinvalidation is a student asking an Asian student, “Where are you from? You speak perfect English.” The Asian student replying, “I was born and raised in Florida.” (Hidden message: You are not American.) Or when a teacher continues to mispronounce the name of a student even after the student has repeatedly corrected the teacher. (Hidden message: I am not willing to learn how to pronounce a non-English based name.) Or a white science professor asking the male nursing students, “Why are you going into a nursing? It’s a female profession.” (Hidden message: ­Nursing is not “a real man’s job.”) Or the classic case of a white student telling her black roommate, “I don’t see color. There is only one race: the human race.” The color blindness offense is one of the most frequently delivered microinvalidations. Another example of microinvalidation is a student who unconsciously opens the door for a classmate who is in a wheelchair. (Hidden message: You are not able to independently take care of yourself.) The student should wait for the student in the wheelchair to ask for help if she or he needs it. Microinvalidation is one of the most harmful forms of microaggression because it leaves the victim feeling ashamed and asking themselves “Am I being oversensitive or paranoid?”

How to Address Microaggressions in the Classroom

Professors and students are the most common perpetrators of microaggressions in the nursing classroom environment. In the course of interaction, the professor or student may say something that offends a student intentionally or unintentionally. Since microaggressions are usually invisible to the ­perpetrator and may seem to have reasonable alternative explanations, the student may be left feeling uneasy and questioning themselves about what the implied message was.

Microaggression is processed in five different phases, Sue says. Phase one is the incident (verbal, nonverbal, or environmental). The perpetrator intentionally or unintentionally commits the offense. Phase two is the receiver’s perception of the offense. For instance, the receiver may ask themselves, “Was I just discriminated against?” or “Did she say what I think she said?” Phase three is the receiver’s immediate response to the offense. The receiver may respond by taking a defensive stand. Phase four is the receiver’s interpretation of the meaning of the offense. They may even ask themselves, “Should I say something?” or “If I say something it may make it worse.” Phase five is the consequence that may happen to the receiver of the offense. For instance, students may lose confidence in their ability to ­complete the course. Microaggressions can cause psychological consequences on the students over time, such as anxiety, depression, helplessness, and loss of drive, which can impede the student’s academic performance.

Therefore, the first step to addressing microaggression in the classroom environment is to acknowledge that it exists, says Jared Edwards, PhD, a psychology professor at Southwestern Oklahoma State University. Nurse educators need to get to know their students. You should be aware of their campus cultural environment and the specific challenges that your students from different backgrounds may face. Do not dismiss the classroom experience of microaggressions as “isolated” incidents. You should work with your students to create a safe classroom atmosphere by establishing solid ground rules and classroom expectations. You can incorporate open classroom discussions about microaggressions into your courses. For instance, have students conduct a group presentation on the impact of microaggressions in a classroom environment. This will promote teambuilding skills and communication and writing skills as well as help create awareness surrounding the common occurrences of microaggressions. Nurse educators need to be aware of what programs (e.g., student counseling center, ­disability services) are available on their campus so they can refer students who may need help dealing with the psychological consequences of microaggressions.

Nurse educators must be prepared to teach and advocate for culturally diverse students in a multicultural classroom setting. Additionally, they can show they value their students in many ways. For instance, taking the time to learn how to properly pronounce every student’s name can show the students that you value the student’s identity.

The Link Between Cultural Communication, Hospital Safety, and Desired Outcomes

The Link Between Cultural Communication, Hospital Safety, and Desired Outcomes

A clinician sees a Somali patient with a primary complaint of back pain and, following an exam, prescribes a traditional course of western medical action. The patient, however, is reluctant to act on the medical advice because he thinks his back pain is caused by a bad relationship with his parents or guilt over something he did. “It is always good (for clinicians) to have some knowledge about their patient’s culture, to know who they are dealing with,” says Fozia Abrar, MD, of Minneapolis. “It might cost time and money, but you save more money by not getting a misdiagnosis, by improving quality of care.”

Suffering from bacterial gastritis, a Somali woman in Minnesota visits several providers but does not take the medication they prescribe. When met with a smile and a greeting in her native language by Dr. Abrar, the patient complies with the same treatment recommended by the previous ­providers—Dr. Abrar successfully ­persuaded the patient to fill a prescription and take the medication because of her ­knowledge of the patient’s culture. This situation is not new or unique—medical ­anthropologist and psychiatrist Arthur ­Kleinman, MD, has spent 30 years championing cultural issues in ­medicine. He says a great body of evidence shows culture does matter in clinical care.

Every cultural group has traditional health beliefs that shape members’ perspectives about wellness. The increasingly diverse, twenty-first-century patient population requires clear communication and practitioner awareness of patient health perspectives in order to significantly impact patient satisfaction, safety, compliance, and outcomes.

Organizational Culture, Patient Satisfaction, and Safety

Organizational culture informs every worker whether patient satisfaction is a key value. By influencing employee behavior and how ­employees are treated, ­culture drives employee effectiveness, safety, and whether employees take advantage of opportunities as they arise. Organizations that dedicate additional employee resources to patient safety signal to employees that both employee effectiveness and patient safety are high ­priority. In other words, organizational values and beliefs guide employee commitment to patient and worker satisfaction. According to the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture: 2016 User Comparative Database ­Report, patient safety improved more at hospitals where they increased employment of staff who reported ­incidents, ­compared to hospitals that did not expand the number of employees who ­reported incidents.

At Atrius Health, a Massachusetts ambulatory care provider with 36 locations, staff can report safety events while updating existing electronic health records (EHRs). This reporting mechanism has increased the number of reported events, and as many as 30% of events reported monthly come in through the EHR tool, according to Ailish Wilkie, patient safety and risk ­management ­director for Atrius Health.

In other words, employee ­accountability shapes ­workplace and organizational culture.

Patient Culture, Provider Culture

In addition to the effect workplace culture has on patient satisfaction and employee competency, two additional areas of culture impact health care effectiveness. Both a patient’s cultural background and the provider’s scientific/medical culture inform patient and provider wellness perspectives. If patient compliance with the treatment plan is the goal, providers need to understand the patient’s cultural identity.

By the same token, patients need to know that their perspectives are respected. Few health care ­observational ­studies have reported ­sufficient information to support the claim of provider bias, but a 2006 study published in the Journal of General Internal ­Medicine reported that most internal medicine residents gain cross-cultural skills through informal training, and most stated that delivery of high-quality, cross-cultural care was important but were skeptical about the expectation of learning every little detail about all cultures. Barriers to ­cross-­cultural care included lack of time, not knowing enough about the religion or ethnic group of the patient they were caring for, and/or dealing with belief systems which are ­different than their own.

A 2000 study in Social ­Science and Medicine found that physicians rated ­minority patients more negatively than White patients; the study also reported that physicians viewed minorities as non-compliant and more likely to engage in risky health behaviors. Clearly, providers need reliable resources to add to their understanding of the patient’s perspective.

A 2017 survey of 111 health care providers revealed where providers currently turn to access cultural training and information, and what types of information providers need when they are unsure/unaware of the patient’s cultural profile and its implications for treatment decisions, patient compliance, and safety outcomes. The survey found that providers want more data on their patients’ use of nontraditional medicine; their faith beliefs; and who the health care decision-makers are.

Diversity and Disparities

An increase in racial and ethnic minority health ­professionals provides greater opportunity for minority ­patients to see a practitioner who speaks their primary language or is from their own racial or ethnic background. This can improve the quality of communication, patient safety, satisfaction, compliance, and outcomes. In addition to ­increasing the diversity of practitioners, hospitals are working to improve hiring diversity, employee cultural awareness, and organizational culture.

In 2015, The Health Research & Educational Trust (HRET) commissioned a ­national survey of hospitals and health systems to quantify the actions they are ­taking to ­promote diversity in leadership and ­governance, and reduce health care ­disparities. Data for this project were ­collected through a national survey mailed to the CEOs of 6,338 U.S. registered hospitals. The response rate was 17.1%, with the sample generally ­representative of all hospitals.

Minorities represent a ­reported 32% of patients in hospitals that responded to the survey, and 37% of the U.S. population, according to other national surveys. In contrast, the HRET survey data show that minorities represent only 14% of hospital board membership, 14% of executive leadership positions, and 15% of first- and mid-level positions.

As a sign of progress, though, nearly half of hospitals surveyed had a plan to ­recruit and retain a diverse workforce matching their ­patient population. Further, 42% said they implemented a program to find diverse ­employees in the organization worthy of promotion.

Cultural Data Collection

The HRET data show that 98% of hospitals are collecting patient data on race. Additionally, other areas of data collection included ethnicity (95%) and first language (94%). But, the percentage of hospitals that correlated the impact these factors have to the delivery of care was a mere 18%. Remarkably, in 2011 only 20% of hospitals analyzed clinical quality indicators by race and ethnicity to identify patterns, whereas 14% looked at hospital readmissions, and 8% analyzed medical errors.

A serious flaw in the HRET survey was zero data collected on hospital patient national origin. The report listed myriad reasons why hospitals might be failing to meaningfully use the data, such as fearing potential liability issues after publicly acknowledging disparities in care, concerns about the public relations backlash, and a lack of knowledge in developing clinical programs that would reduce or eliminate inequalities. Plus, some hospitals noted the lack of a “diversity champion” on their staff to help lead the effort.

Hospitals seem to be making progress in educating staff on diversity, with 80% providing cultural competence training during orientation and 79% offering continuing education opportunities on cultural competency, according to the survey.

What’s Next?

Hospitals have begun to include leadership goals ­designed to reduce care disparities by implementing ­diversity initiatives such as: allocating adequate resources to ensure cultural competency/diversity initiatives are sustainable; ­incorporating diversity ­management into budget ­planning and ­implementation process; increasing hospital board diversity to reflect that of its patient population; board members demonstrating completion of diversity training; developing plans specifically to increase ethnic, racial, and cultural diversity of executive and mid-level management teams; and executive compensation tied to diversity goals.

Beyond the C-suite, hospitals are developing diversity plans with initiatives that include diversity goals in hiring manager performance expectations; implementation of programs to identify diverse, talented employees within the organization for promotion; documented plans to recruit and retain a diverse workforce that reflects the organization’s patient population; required employee attendance at ­diversity training; hospital collaboration with other health care organizations to improve health care workforce training and educational programs in the communities served; and education of all clinical staff during orientation about how to address unique cultural and linguistic factors affecting the care of diverse patients and communities.

This increased implementation of appropriate health care and adherence to effective diversity and cultural education programs at every level of health care will ultimately result in improved patient ­satisfaction, compliance, hospital safety, and patient health outcomes.

Adapting to Different Work Cultures

Adapting to Different Work Cultures

Our health care system ­today has made tremendous progress in providing care to ­individuals and families. Change is good, but as the health care industry rapidly responds to emerging trends, markets, and ­opportunities, how staff nurses respond to different kinds of work ­culture is important, particularly when work culture highly ­impacts a nurse’s job function.

Work culture is made up of the norms, values, and beliefs that characterize an organization. Several factors, including management, workplace practices, policies and philosophies, ­employees and their interactions, ­leadership, expectations, rewards or ­recognitions, communications, transparency, and ­support within an ­organization, can influence work ­culture. Work culture,which can make or break a workplace, is powerful. It can ­inspire health care employees to be more productive and positive at work, or it can make them feel undervalued and frustrated. Thus, it plays a crucial role in shaping ­behaviors in ­organizations.

Your Work Culture

Ask yourself the following:

  • What is the culture like in your workplace?
  • Do staff naturally unite and collaborate?
  • Are the leadership and ­executive teams available and transparent?
  • What values and principles does your organization ­express?

Sometimes, you might say “it’s challenging.” Defining work culture can be difficult; nevertheless, it is fundamental to good (or poor) practice. Work culture is not often discussed, but clearly, nurses can be ­negatively or positively ­influenced by their work ­culture.

Work culture in nursing is critical to job satisfaction, nurse retention, and patient outcomes. A toxic work culture can lead to increased sick days, stress-related symptoms, and nurse turnover. It also plays a large role in the ability to provide quality nursing care. Work culture can impact everything from the safety of patients to job satisfaction. If yours is negative and discouraging, you cannot just wait for it to change. The first thing you must realize is that it might not change at all without you taking some kind of action.

Understanding your work culture is key to developing practice that aims to improve care. Although a positive work culture is mostly created from the top down, it often happens from the bottom up. Nurses should not undervalue the power of their work culture. Understanding work culture as a learning environment is ­related to how nurses choose to engage in their workplace and how the workplace normalizes their involvement in activities and interpersonal relations. Nurses can take inspired action, engage in networks, and initiate work culture change. This is not a simple task, but nurses can utilize their own personal power and create cultural transformation in their workplace. Keep in mind that work culture can—and will—change and evolve over time. The first approach is to define and evaluate your work culture—both what it is now and what it should be in the future.

Every workplace has its own work culture. Most of this is unspoken, but a lot can be learned from an employee handbook or company policy. Observation, assessment, and communication are key ­approaches to help you ­uncover your work culture. These key approaches can also be utilized by someone who has unique developmental and ­socialization needs, such as new graduate nurses, international nurses, student nurses, and nurses who are undergoing role status changes or transitioning to a new area. No matter what your status is, here are five ways to help you thrive in your work culture.

  • Watch and learn. Give yourself some time to understand the reasons behind workplace behavior and you will be much more successful in understanding the causes. Observe how things are done. Take notes. Keep track. Building relationships with people in your workplace and connecting with someone on your team who has a good understanding of how the workplace culture works can help you better ­understand and avoid making a mistake.
  • Don’t be afraid to ask questions. You don’t need to know everything. Questions are a great way to clear up differences and get to know people. Also, be sure to ask for help whenever you need it. Asking for assistance or an explanation should not be considered a sign of weakness.
  • Remain motivated at work. Nurse burnout is real, so it is important to recognize the impacts you make on your patients and workplace every day. Focus on yourself and how you can be a positive influence.
  • Be transparent. Let your ­coworkers know about your background and your career goals. Don’t hesitate to share your ideas and let your team and supervisor know what other skills you have to offer.
  • Acknowledge your mistakes. Apologize and laugh it off. Keep your sense of humor and learn from every mistake you make.

Developing the skills and ability to understand and communicate effectively with all your coworkers (including your supervisor) is critical to your success in your own career, as well as the success of your organization. These skills are not innate; they require practice, but anyone can develop these skills. Adapting to a new work culture is an ongoing process. Once you have the skills, you can work more effectively with different groups of people and adjust easily to working in different cultures throughout your career.

East Meets West in the Bathroom

East Meets West in the Bathroom

A patient needed assistance in the bathroom.  An elderly, obese, female with Lupus affecting her legs and hips needed help transferring from her electric wheelchair and some assistance with hygiene and buttoning her pants. It’s something I’ve done a million times and I didn’t think twice about it. What happened later made me think about the differences in cultures between India and the United States and how to approach these differences when they come up with someone in the workplace.

After the job was completed and the patient gone, the episode came up in conversation between the patient’s doctor, who is from India, and myself. While she didn’t exactly dress me down, she was very firm that clinic nurses were not supposed to help patients in the bathroom. She gave me several reasons:

“The patient takes care of herself at home. Why do you need to do it here?”

“If the patient has a caregiver at home, where is the caregiver now?”

“What if you get injured, who is going to take care of you?”

“If you help her in the bathroom this time, she will expect help every time she comes.”

I thought about this conversation for a long time. Without a doubt, I was correct to help the patient. This I know. It’s required by the nursing oath, and it’s required by my own moral code. Why did this doctor see things so differently?

Indian society is rigidly stratified by religious and socioeconomic class. At the bottom are the untouchables who work with waste. This stratification was formalized during British rule with some 60,000 different classifications. With this in mind, I realized that my doctor was actually trying to protect me from performing work outside my caste, which would be degrading to me. From my point of view, all people are created equally. As a nurse, when someone asks for help, I don’t have to decide if that person is worthy of my help or if performing a task is outside of what is permitted by my caste. I just do it.

From the doctor’s point of view, I was performing a task outside of what is permitted by my caste and performing it for a person who is of lower status than myself. I was breaking social norms, degrading myself, and degrading the clinic and other nurses whom she expected would not perform such duties. After doing some thinking, I can now appreciate her point of view, but it is not my point of view. The tricky part is how to address it in the future in a culturally sensitive manner. I don’t want to insult my doctor. She is in a position of power over me. I don’t want to break my nursing oath or my personal moral code to always offer assistance when someone asks. In this case, I’ve decided to simply not bring it up again. I will continue to perform my nursing duties as I always have without mentioning it. I will respect my doctor’s culture by simply avoiding the subject in the future. In a perfect world where I’m king, I would explain to the doctor my point of view and expect her to change her point of view to suit my own. However, the world is not perfect, and I’m not king. So respect, cultural sensitivity, and work relationships will win out over my personal feelings.

Successfully Integrating International Nurses into Your Staff

Successfully Integrating International Nurses into Your Staff

Eight nurse leaders from across the country gathered to participate at the Avant Healthcare Professionals CNO Roundtable to share their thoughts on the challenges, solutions, and opportunities that they face.

Benefits of Diversity

Diversity in staffing is known to produce higher quality work and increase productivity, overall. More importantly, diversity makes your recruitment and retention efforts easier, according to a Glassdoor study. Two-thirds of the respondents in the study said that a diverse workforce is an important factor when evaluating companies and job offers. The Glassdoor study also found that 57% of people surveyed think their company should be doing more to increase diversity in its workforce.

For health care staffing, diversity is highly desired as it has a direct impact on care delivery. International health care professionals are more equipped to care for minority patients as they understand diverse backgrounds and can better communicate bedside shift reports to them, according to an American Nurses Association study.

In this article, Avant Healthcare Professionals Founder and CEO Shari Dingle Costantini and Vice President of Clinical Operations Jennifer David asked CNOs how they successfully integrate international RNs into their staff. Below are the suggestions.

Address Staff and Peers

It’s essential to inform your staff that an international nurse will be joining the team. Take the chance to educate your staff on the nurse’s culture and background pre-arrival of the new nurse.

Some countries’ medical terms do not translate accurately in English. Procedures may also vary depending on the country, so educating your staff on the clinical differences is a must. Your staff will be understanding and more willing to help when they are aware of these differences.

Assigning an ethnically diverse preceptor for the new nurse is also very helpful in the onboarding process. If this is the first international nurse on your staff, designate nurse leader support for the international nurse so that they have a “go to person” to depend on when needed.

“We have had a lot of success with international nurses as part of our staffing solution. Understanding what environment these nurses come from and then acclimating them to our environment has been key for our retention program. Our other international nurses also help with that transition in prefacing them.”
– Caroline Stewart, CNO, Citrus Memorial Hospital

Address Patients

The patient experience is the most important aspect of care. Hospital leadership should encourage unit managers and charge nurses to educate patients and the patients’ families on their international nurse’s education, preparation, and experience. Therefore, it’s crucial that the patient understands that they are receiving the best care they can get no matter who their nurse is.

Eliminating patients’ requests in nurse changes will reinforce that the international nurse is a part of the team and will make the patient feel more comfortable about their care.

Address the Community

Whether you live in a diverse community or not, discussing the need for international nurses is important. Reach out to key influencers in the community such as the mayor, the Chamber of Commerce, the Rotary Club, local reporters, etc. Inform them of the nursing shortage and explain how international nurses bring value to the community. The goal is to have political backing for a care environment that welcomes diversity.

One of our partners at Great Plains Regional Medical Center met with the mayor and the school board to introduce diversity education to the North Platte, NE community. These meetings serve as a catalyst to successfully integrate internationals into the hospital as well as the community.

Most importantly, the school board should be aware of international families in the community and be prepared on how to integrate these students pre-arrival. Bullying can be an issue in grade schools, which is why the school board should be involved in these meetings.

Overall Goal

Involving your staff, patients, and the community in diversity education serves to create a welcoming home for international nurses and internationals, in general. These nurses are looking to be a part of the community as permanent residents. The overall goal is to improve patient care with a staff that better represents the population. Diversifying your community can start with the health care system. Considering international nurses at your hospital is a great start.

About Avant Healthcare Professionals

Avant Healthcare Professionals (AvantHealthcare.com) is the premier staffing specialist for internationally educated registered nurses, physical therapists and occupational therapists. Avant helps clients improve the continuity of their care, fill hard-to-find specialties, and increase patient satisfaction, revenue and HCAHPS scores. Avant is a Joint Commission accredited staffing agency and founding member of the American Association of International Healthcare Recruitment (AAIHR).


Originally published on February 7, 2018 at AvantHealthcare.com