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.
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
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.
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
The 2017 clinical excellence conference organized by the National Association of Indian Nurses of America (NAINA) concluded on December 2nd at Houston, Texas. It was for the first time that NAINA as a minority organization ventured to engage in a clinical excellence conference titled “Advancing Health through Excellence in Clinical Practice.” This conference, hosted by the Indian Nurses Association of Greater Houston, Texas (INAGH), was attended by over 200 participants and nurses were provided with 8.91 CEUs by the Southwestern University Hospital, Texas. Participants applauded the organizers for providing an opportunity to network and immerse in a day full of activities that provided thought provoking information to bring back to their own clinical practice.
The APN committee chairperson, Dr. Lydia Albuquerque, set the tone of the conference by welcoming the Houston chapter President Accamma Kallel, MSN, APRN, APN-C, CCRN, president of INAGH and local chapter APN local planning committee chair, to deliver her welcome address. The key note speaker, Melissa Herpel, MSN, APRN, FNP-BC, challenged the participants to embark on pathways to excellence in independent practice as nurse practitioners. As an entrepreneur, she shared success stories of her own business model, how she overcame the challenges that she faced during the process and dared to challenge the participants to go out and start clinics that would provide primary care to the communities. All other speakers delivered their topics of interest and expertise with recent practice guidelines to the participants.
Poster presentations were coordinated by Dr. Letha Joseph, Dr. Solymole Kuruvilla, and Dr. Simi Jesto. Bindu Jacob, BSN, RN (New Jersey) was awarded the first prize, Jessie Kurian, MSN, RN (Dallas) was awarded the second prize, and Dr. Lisa Thomas (Houston) was awarded the third prize. Dr. Rachel Koshy, committee chair of the NAINA Journal, motivated the participants to submit scholarly articles for publication. The NAINA Journal was released by NAINA President, Dr. Jackie Michael. This Journal has been published for the second time with a goal to continue publications at least twice a year.
At this conference, NAINA presented a donation towards the Hurricane Harvey Relief Fund which was accepted by Mr. Zafar Tahir, Houston planning commission representative on behalf of the mayor of Houston. NAINA received a grant from Boston scientific and generous sponsorship from educational and pharmaceutical companies. Our grand sponsor, “APRN world,” an independent educational organization started by Dr. Harila Nair, a nurse practitioner and entrepreneur of Indian origin based in California, needs a special mention for his generous support.
Conference hosting chapter, INAGH, facilitated the Gala night celebration with Bollywood dancing, a grand finale of the Texan dance choreographed by the nurses of Houston chapter, and other entertainment programs. The plenary committee members along with the planning committee were given a standing ovation for conducting an excellent conference which was inspiring, energizing, and remarkable.
The government of Jamaica has asked the United States health sector to cease the poaching of its nurses. “Jamaica Says to Stop Poaching Our Nurses” was a report on National Public Radio earlier this year based on an interview with Mr. James Moss-Solomon, the chairman of the University Hospital of the West Indies in Kingston. He likened the situation to a crisis.
The exodus has forced Jamaican hospitals to reschedule some complex surgeries because of a lack of nursing staff on their floors, according to the report. Moss-Solomon says the United States, Canada, and the United Kingdom are, in his words, “poaching” Jamaica’s most critical nurses. “Specialist nurses is the problem. We have tons of regular nurses,” he told NPR. He was talking about nurses trained to work in such settings as intensive care units, oncology, infectious disease, operating rooms, and emergency rooms. They are the ones being lured away and their English language skills heighten their appeal. “We do very well training our specialist nurses here at a fraction of the cost of what it costs you in the United States or Canada or the UK; so, the issue is an economic one for us,” he explains.
In February, as part of the Jamaica Medical Mission, I discussed this issue with Althea Davis, RN, MHA, as I sat with her in a church hall in the city of Port Maria. For 27 years the mission has served the people of Jamaica under the auspices of the St. James Episcopal Church of Leesburg, Florida. The 55 members of the team represented physicians, dentists, hygienists, optometrists, pharmacists, nurses, physician assistants, and support staff. They came from Los Angeles, Ottawa, New York, San Francisco, Maryland, and Florida.
The team brought state-of-the-art health care to the people of that region for eight days and with tremendous energy and dedication delivered competent care to over 1,700 patients, who for the last 5 years have had their medical records computerized and accessible when the team visits.
Davis, a supervisory public health nurse, serves four health districts. “The nurses are expected to provide service in every aspect of care and are held to a very high standard. In the case of the public health nurse, the Jamaican nurses rank among the best worldwide,” she says.
According to Davis, the training model that Jamaica has followed came out of work done back in the 1970’s and is continuously updated. Over time, specialists have been added in areas such as nutrition, health promotion, information technology, and electronic records management, which is intended to provide a more robust care delivery system and improve patient satisfaction. “Because of training provided, we were well prepared to deal with the Ebola outbreak, and the highly contagious Chikungunya virus,” says Davis.
However, Davis quickly hastened to add that the problem facing the nursing sector is that the profession is “under resourced.”
Davis’ conclusion is an echo of Moss-Solomon’s. The skilled staff are stretched. The referral process for advanced treatment that cannot be handled at the nurses’ level is inadequate at best and unavailable at worst. “It is not just the compensation that influences nurses to leave the island,” Davis says. “It’s also the sense that nurses are not accorded the appreciation for what they do even by health care agencies.”
According to the World Bank, “these shortages have tangible impacts that may compromise the ability of English-speaking [Caribbean] countries to meet their key health care service needs, especially in the areas of disease prevention and care. In addition, the shortage of highly trained nurses reduces the capacity of countries to offer quality health care at a time when Caribbean countries aim to attract businesses, visitors and retirees as an important pillar of growth,” the report states.
In Jamaica, about three out of every four nurses trained have migrated to developed countries. But the Jamaican experience is not unique. In the case of the UK, a recent report by the Royal College of Nursing stated that the nursing workforce has moved from a situation of “net inflow of nurses to a position of net outflow in recent years.” This means that more nurses are moving abroad than are coming to the UK to practice. The main destinations are Australia, Canada, New Zealand, and the United States.
The NPR program stated that Jamaica has been offering free training for nurses to get advanced degrees. The nurses agree to work for three or four years in Jamaica in exchange for the heavily-subsidized education. “But U.S. recruiters,” says Moss-Solomon, “simply pay the fine for contract violation and the nurses fly off to lucrative jobs in the U.S.”
Jamaica’s response to these losses? They are bringing 25 nurses from Cuba to help staff some floors and have plans to recruit nurses from India and the Philippines and have recruited nurses from as far away as Burma/Myanmar.
Increased international recruitment of nurses requires that several policy issues be explicitly addressed. The international debate over the responsibilities of recruiting nations toward countries whose nurses are being recruited, many of which are developing countries, necessitates provision of ethical recruitment guidelines and codes of practice inclusive of possible financial compensation for sending countries in the face of a global nurse shortage.
Keondra Rustan, RN, MSN, PhD(c), visiting assistant professor at Linfield College in Portland, OR, has overcome many challenges in her decade-long career as a nurse and nurse educator. Raised in a single-parent home with limited resources, she discovered how she could channel her interest in science into a nursing career by reaching out to mentors along the way.
Today, she shares her story and offers advice to other minority nursing students and nurses who may face similar challenges in their education and careers.
How long have you been in the nursing field and what has been your career history until now?
I have been a nurse for nine and a half years. I started out working in cardiac health care in Virginia. I did cardiac stepdown, some cath lab work, and I floated to some cardiac ICUs. I then went to the ICU where I learned a great deal and developed some professionalism and leadership traits. I then went on to become an assistant manager of an ICU and IMCU. I finished my master’s degree and became a professor at a private college where I rediscovered simulation and developed a great love for it. I became the simulation lab coordinator and for a time was the interim director of the LPN program, and went on to become the assistant director of the LPN program so that I could make more time for my doctoral schooling.
I am currently working in the dissertation phase of my doctoral program and enjoying my work at Linfield College as a visiting assistant professor working in simulation as lead faculty.
What inspired you to enter the nursing profession?
At first I didn’t want to be a nurse. I went through all of my primary schooling without having the decision of wanting to be a nurse. I wanted to be a scientist at first like those scientists in Jurassic Park.
Later on in high school I decided that I wanted to be a scientist that could help cure diseases and study microbes. However, I lost my grandmother when I was in high school and some of the care that she received wasn’t the best and lacked empathy. I decided that I wanted to help people more directly and show them that they aren’t just a room number but a thriving person who was deserving of care. I wanted to be a person who made a difference in the lives of others.
As nurses we often aren’t remembered individually; but if a patient has less exacerbations and starts feeling better because of your care and the education that you provided, it is very rewarding.
What inspired you to become a nurse educator?
I discovered that I liked teaching by precepting new nurses and nursing students. I enjoyed seeing the potential in them. I loved teaching them how to do things based on evidence and why it was so important for it to be done that way. I wanted to show them how to provide holistic care to patients and help them grow into future leaders.
I also enjoyed telling them stories so they could directly apply the teachings to their practice. Most importantly, I wanted them to have things I did not have prior to becoming a nurse: resources and a mentor. I wanted to apply these principles on a broader and larger scale so I went into the field of nurse education.
I would say the first year or so I was not very good at it. Or at least I did not feel as though I was a good teacher. I did not have a mentor or anyone to show me the ropes so I just taught them the way I was thought, which did not work.
What challenges have you faced in your career and how have you overcome them?
In my career my biggest challenges have come from lack of resources and lack of mentors. I grew up in a low-income single parent home with no vehicle. We did not have the funding or access to resources to get informed about career programs while in high school or even most scholarships. I wasn’t aggressive enough in thinking of my future and did not have enough drive when I was younger to seek those resources.
Once I decided to become a nurse, I didn’t really know how to become one, what nurses actually did, and what type of nurse I wanted to be (even when I graduated I still did not know that part). I had a lot of ideas, but I did not know how to bring them into fruition.
I overcame the lack of resources and lack of mentoring by joining organizations (good old-fashion Google search) based on my interests. When I was obtaining my BSN I got accepted into Sigma Theta Tau (the nursing honor society). Going to those conferences really opened a lot of doors for me. I am so grateful for the aid of the nurses and educators that I have met throughout my nursing career. They were able to point me into a lot of great directions. I am still growing and have a great deal more that I want to accomplish.
What challenges do you see minority nursing students face and what is your advice for them?
I see lack of resources as a big one and lack of mentors. Minority students (and I include males in this) have a high risk of falling through the cracks in nursing school. There seems to be a reluctance to seek aid when dealing with difficulties. It is hard to get over, because typically it is culturally ingrained.
My advice is to seek help right away when you are having trouble. If your school does not assign faculty mentors, seek out an instructor that you feel you can connect with. Shadow a nurse if you are not experienced with the duties of a nurse, so you have an idea of if it is right for you. Don’t be afraid to ask for help; if you do not understand, seek help (think of the patient’s safety).
Most nursing schools have scholarships, open labs, writing labs, and tutors available for their students; make use of these resources and give yourself support. View any setback as a learning opportunity and grow from the experience. Never stop learning even after you are licensed and working on the floor. Google search some nursing organizations (you can even join some as a student for a cheaper price) and they can lead you down some interesting paths. Also, once you obtain your knowledge, pass it on. You never know who you will be helping with your expertise and experience.
Where do you see yourself in 5-10 years?
I see myself with at least 10 articles published and maybe a book, of course having obtained my PhD. I want to still be educating nursing students and maybe have obtained my NP. I want to continue to learn and grow each day to become the best educator that I can be. I want to do more in community and be a greater help to those in need.
Marygrace Colucci (center) along with her supervisor/nurse manager Louise Esposito (right) and Marianna Vazquez, CNO (left)
Imagine moving to the United States from the Philippines and building a nursing and military career. That’s what Marygrace Colucci, RN, BSN, MSN, did when she migrated to the U.S. in 1995. Today, Colucci is living her lifelong dream as a staff RN in the ophthalmology operating room at Northwell Health at Syosset Hospital in New Hyde Park, New York.
In May, Colucci was honored with the Zuckerberg Nursing Excellence Award during National Nurses Week. The award recognizes exceptional nurses at Northwell Health.
“Ever since I was a little girl, I wanted to be a nurse,” Colucci says. “I have seven siblings, so my parents could only send me to a two-year midwifery program due to the financial constraint to support a four-year BSN program. I graduated at 18, passed the midwifery board but couldn’t get my license until I was 21 years old. I started working as a midwife in the hospital with just a permit, and I remember having so much fun delivering babies, and assisting in C-section procedures.”
Colucci says that when she first arrived in the U.S., it was a huge culture shock. “I missed my family and friends. I was homesick, but eventually got over it,” she says. “I was afraid to talk to people because of the language barrier; not because I didn’t know how to speak the language, but more because I was shy of my English and my accent.”
Colucci was inspired by her cousin who served in the U.S. Army as a nurse. “He was sort of my role model, and that is why I joined the Army Reserve in 1998,” Colucci says. “Joining the Army helped me overcome most of the challenges I had to face back then such as the language barrier, being shy, and lacking self-confidence. The Army taught me how to face all kinds of adversity. I’d have to say the Army really turned me into the kind of person I am today.”
Another supportive influence for Colucci has been her husband. “When I graduated with my associate’s degree in nursing, he told me I should go back to school, which I intended to do anyway. I went on to finish my BSN, and he told me again that I should go for my master’s, which I intended on doing. But him pushing me to go further was really a good motivator. And now that I’m done with my NP, he said go for your doctorate, which I’m still considering.”
Colucci says for now she is focusing on her military career. She hopes to be promoted to major in the future. “I also want to focus on helping soldiers from my unit, which I am currently commanding,” she says. “I try to motivate my soldiers and tell them that they can do so much with their skills, and that there are so many opportunities available if they’ll just work hard for everything that they want to achieve.”
“I also tell my fellow Filipino coworkers to advance their education by going back to school,” she says. “I told them that if I can do it, so can they. I’m not really smart; I just happen to be disciplined and really put a lot of time and effort into everything I set my mind on achieving.”
Colucci sees herself working in emergency medicine in the future. “I had a great time when I was doing my clinical at the urgent care centers. I told myself I will embark in that field if given the chance. I think emergency medicine is a very good and rewarding field to practice. I would like to be promoted to major in the next two years; and eventually to lieutenant colonel in the Army Nurse Corps.”