Nursing for Uncle Sam

Nursing for Uncle Sam

Careers in government nursing are as varied as nursing careers in the private sector. However, when many nurses hear “government nursing,” they may assume that means working for a veterans hospital. But the Department of Veteran Affairs (VA) is only one of many government agencies where skilled nurses who want to work for the government can build their careers.

In fact, there are a variety of government agencies and positions where nurses can put their skills to work, including the Centers for Disease Control (CDC), the Indian Health Service (IHS), the U.S. Army, the National Institutes of Health (NIH), and the Center for Medicare and Medicaid Services.

Think a government career might be a good fit for you? Keep reading for stories from nurses who work for the government and tips on how you can too.

Military nursing takes sacrifice

“The army’s been very good to my family,” says Lt. Col. Christopher Weidlich, U.S. Army, who is currently finishing his Ph.D. in nursing at the University of Miami on a U.S. Army Long-Term Health and Education Training Scholarship (scheduled to graduate in 2013). He has served in the military for 17 years. “I really enjoy taking care of people, and doing whatever I can to help them out.”

When Lt. Col. Weidlich graduated from high school in 1990, his original goal was to become a doctor. “I wanted to go to medical school, but I didn’t have the grades to support it,” he says. “When I graduated from high school, I found out the Army was offering nursing scholarships.”

He went on to graduate from the University of Miami in 1994 on an Army ROTC scholarship and decided to stay in the military after graduation. He worked as an army psychiatric nurse and a psychiatric mental health nurse in various locations, including Nebraska, Georgia, Kentucky, and North Carolina, in addition to Iraq and South Korea.

After several deployments, Lt. Col. Weidlich feels that while military life comes with unique challenges, he has enjoyed his career. “Being a military family has its ups and downs like any profession, but it’s hard on my kids,” says the father of four.

Despite the personal sacrifices, Lt. Col. Weidlich says his career so far has been a very rewarding experience for him and his family, and advises other nurses considering military nursing careers: “If you go into the military, take advantage of your education,” he stresses. “There are a lot of schools that you could go to within the Army. I would recommend you take any educational opportunities that are there.”

Careers with government agencies

Nurses seeking a more stable lifestyle will find an abundance of opportunities within government agencies. Many have built their careers in the government, like Dinora Dominguez, Chief of Patient Recruitment and a public liaison in the Office of Communications at the NIH Clinical Center, Department of Health and Human Services. Dominguez has worked for the NIH since she graduated from college in 1986.

Dominguez always held an interest in doing research and was attracted to the NIH due to the research involved in her position. Today, she coordinates clinical trials and educates the public on the importance of participating in clinical trials—something she’s passionate about.

Bruce Steakley, R.N., B.S.N., a nurse manager in pediatric and adult inpatient behavioral health at the Ambulatory Care Behavioral Health Clinic (NIH), has a career that spans 30 years. He first came to the NIH six years ago.

“After working in community-based mental health inpatient settings and one outpatient setting for all those years, I got discouraged with psychiatry and the state of mental health care delivery in the country,” Steakley says. “So I left and tried other avenues of nursing, but was bored. And so I always returned to mental health and discovered my current position by word of mouth. A friend of my wife told me about this job and I decided to apply for it and now, here I am.”

Clifton J. Kenon Jr., M.S.N., R.N.C.-O.B., C.-E.F.M., I.B.C.L.C., R.L.C., A.W.H.O.N.N., fetal monitoring instructor and maternal-child health nurse consultant at Indian Health Service, found his way to the IHS by posting his résumé on the website. “I was recruited to go work for the Indian Health Service as a maternal child health consultant in South Dakota in April of 2011,” he recalls. “And in this role, I’m actually able to have an influence and to lead maternal health programs for the Indian Health Service for our four-state region: North Dakota, South Dakota, Iowa, and Nebraska.”

Steakley also applied through the website, which he says is the best place for nurses interested in a government job to go. “I occasionally have people who somehow reach me on the phone and want to apply for a job,” he says. “I step way back from that and just refer them directly to There’s a structure for applying, and I follow the structure.”

Steakley notes that nurses seeking to gain entry with a government agency should bring patience to their job search.

“The hiring process is longer and slower, but somewhat more professional,” he says. “I was here on three different occasions, interviewing with three different sets of people. My sense was that they were looking for highly qualified people. I’ve since had opportunities to participate in a number of interviews with nurse manager candidates and clinical manager candidates. Over the years, I’ve hired a lot of people myself, and I think that although I see room for improving the process, I would nevertheless maintain it’s better here than in other settings.”

If you desire to make a leap from the private sector to the government sector, Kenon’s advice is to actively seek out opportunities, put yourself out there, and post your résumé on the U.S. Office of Personnel Management ( and websites.

“Continue searching for openings that would meet your qualifications or are willing to train, and call regional recruiters. Most government agencies have recruiters that are actively recruiting new talent to the agency,” he says, adding that recruiters love to hear from those interested in public sector careers. “[They] have unique and challenging opportunities for nurses that want to serve their country.”

Government work culture

Is working for the government much different than the private sector? Some nurses who have experience in both sectors note some differences.

Kenon was a labor and delivery nurse at Duke University Medical Center and the University of Virginia. “The difference between working in the private sector and public sector is being a public servant, as I like to see myself in working for the government. I am helping to fulfill the mission of the United States Department of Health and Human Services. And I’m helping to serve the American people with health care on a national level, as opposed to in the private sector where I was more concerned with serving a local aggregate of people or a specific community.”

Steakley, who worked for various community-based facilities before joining the NIH, says that he feels more supported as a government employee, adding that he has a lot of reinforcement from the three units he manages in terms of clinical management, clinical educators, and clinical nurse specialists. “That allows me to have a slightly more elevated role,” he says, which removes him from the “nitty-gritty” of direct patient care, and enables him to be more involved in management and “setting the philosophy, growth, and performance improvement plans for the unit.”

For Kenon, working for the IHS has changed his whole perspective on nursing. “As an African American nurse, being a public servant and working within the United States Government, it has given me a clearer picture and a greater professional identity for the role that nursing has in leading health care on a national and global level,” Kenon says. “Now, I see what an invaluable role nurses play all across the government with legislative change, translating change into practices, and actually being leaders for the health care delivery system.”

Abundant opportunities

If you think a career in the government is a good fit for you, Dominguez encourages other minority nurses to pursue it because there is a wide array of positions available—not just on the clinical side. She says there are many opportunities for nurses to “think outside the box.” As you start researching for a job, Dominguez says to think of the specific skills that you can bring to the role, and just go for it.

Kenon says a government nursing career is all about dedication. For nurses considering these jobs, his advice is to make sure they have solidified a mission in nursing and the core values of the profession.

“Whether you’re in the private sector or public sector, core values such as caring, innovation, passion, and diversity are going to need to be deeply imbedded in each individual nurse’s philosophy to have a successful career in government,” he says.

Most of all, Kenon believes nurses considering such a career should know that they will be dedicating their career and lives to serving the American people. “That is a calling not to be taken lightly,” he adds.

Once you get your foot in the door, opportunities are abundant for growth, Steakley says. “They’re all around. I think that the nursing leadership and the medical leadership in the clinical center are very supportive of intellectual growth of nurses,” he says. “So I think just getting one’s foot in the door is the hardest part.”

Kenon sees himself building a long-term career as a government nurse. “In five to 10 years, I certainly see myself continuing to serve the American people and hopefully continuing to work within maternal child health,” he says. “I love working for the Indian Health Service and I love serving the Native American and the Alaska Native people. And certainly, within 10 years, I still hope to be leading the maternal child health program within the Indian Health Service.”

Culturally Competent Disaster Nursing

Natural disasters are colorblind in terms of whom and how they strike. “When a disaster hits, it doesn’t hit by race, color or creed. It hits people who are humans and bleed,” says Marilyn Pattillo, PhD, GNP, CNS, deputy team commander of the Federal Emergency Management Agency (FEMA)’s National Nurse Response Team. Yet, how disaster victims react to displacement, illness and stress is very much culture-based.

“Cultural competence is an integral part of any disaster behavioral health intervention,” says Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness at the University of South Florida College of Public Health in Tampa. “In order to be effective, [health workers responding to disasters] must be aware of cultural differences among survivors and patients.”

This issue has taken on additional urgency in the aftermath of the heavily criticized government response to the devastation wrought by Hurricane Katrina. The delayed and muddled relief efforts were perceived by many African Americans as the product of institutional racism.

Nurses responding to natural disasters have precious little control over how government resources are apportioned, but they do have control over how they treat patients. The consensus among many nurses who responded to Katrina is that cultural competence was the norm in the immediate wake of the hurricane. This was because the first wave of responders consisted of local nurses with first-hand knowledge of the affected communities’ cultural needs.

“The immediate disaster response was handled by the local people,” explains Trilby Barnes, RNC, president and CEO of Medi-Lend Nursing Services in New Orleans and a member of the board of directors of the National Black Nurses Association (NBNA). Although the availability of care at some of the city’s hospitals was severely disrupted by the hurricane and subsequent flooding, Barnes says she was “one of the nurses who was still there to provide normalcy for the patients. [We were there] providing our cultural know-how [and] I do feel like it had a positive effect on the patients.”

“I didn’t see a [great] amount of discord [between health care workers and patients],” adds Father James Deshotels, SJ, APRN, a nurse and Jesuit priest who treated evacuees at the Superdome.

What Went Wrong

However, significant shortcomings in cultural competence arose in the following weeks and months, as new waves of disaster responders from across the nation–who lacked the local health professionals’ cultural familiarity with the affected communities of color–began to arrive.

Jennifer Field Brown, PhD, APRN, is the only white professor in the Nursing Department at historically black Norfolk State University in Virginia. When asked by the federal Substance Abuse and Mental Health Services Administration to work in a Louisiana shelter some six weeks after Katrina hit, Brown admits she was excited and jumped at the opportunity. But the racial and cultural tensions she observed during the two-week assignment have left her thinking for months.

“Many of the nurses were angry with the [largely African American] population that was still at the shelter,” she says. “There were many times when evacuees [said], ‘they don’t care about us.’”

Brown believes this perception was fueled by the cultural gap between the predominately poor and African American evacuees and the mostly middle class and white shelter staff. “[Some of] the response workers were appalled that some of the evacuees would not cash their checks because they had no family member with a checking account, [or] that they’d cash their checks and buy a TV. [The prevailing attitude among many of the shelter staff seemed to be] if you didn’t lose anything you are not entitled to anything.”

Deshotels, whose parents grew up in New Orleans, points out that strained race relations are not a new phenomenon in the Crescent City. “Because we have such a long history of racism and oppression [here], there is an always an air of tension and mistrust,” he says.

New Orleans used to have–and perhaps still has–a majority black population. Katrina scattered tens of thousands of the city’s African Americans throughout much of the country, so it is impossible to know for sure. But much of the city’s longstanding black middle class and working class have been displaced and have not returned. Cheryl L. Nicks, RN, CNNP, CGT, CLNC, CPLC, president of the New Orleans chapter of the NBNA, has been in touch with only three out of 65 members since the hurricane struck. She says, “Our chapter has basically been demolished.”

Caught Unprepared

Another shortfall in culturally competent health care that has worsened in New Orleans post-Katrina is the result of a dramatic and largely unforeseen population shift. In the place of many African American evacuees have come many thousands of Hispanic workers hired to help clean up and rebuild the city. Their arrival, a direct consequence of the hurricane, has amplified the difficulties the city’s public health system already faced in treating Hispanic patients.

The Roman Catholic Archdiocese of New Orleans created the Latino Health Access Network (LHAN) three years ago in response to the lack of sufficient health services for the Hispanic community. Shaula Lovera, director of LHAN, cites the absence of any evacuation information in Spanish as what she considers a typical example of the neglect faced by the Hispanic population before Katrina.

Now, the huge influx of Hispanic workers has dramatically increased the need for Spanish-speaking nurses and doctors. What used to be a small community of 14,000 in 2004 has grown to become a significant minority population whose access to health care is challenged by cultural, linguistic and economic barriers.

“These workers don’t make great salaries,” Lovera explains. “They have no access to Medicaid or Medicare. They don’t get health insurance from their employers.”
But often the biggest obstacle, she says, is simply navigating the hospital admissions process, with its personnel who don’t speak Spanish and its English-language forms that must be signed.

Before the hurricane, LHAN ran a Saturday clinic staffed by Spanish-speaking volunteer physicians and nurses. In 2002, before the clinic was established, only 2% of patients using LHAN’s services were Hispanic. But the number shot up to 17% after the clinic opened in 2003. This proves that Spanish-language medical attention was urgently needed, says Lovera.

The clinic, which was run by the Daughters of Charity, was badly damaged during the hurricane. Given the difficulties faced by Latino workers in getting treatment at local hospitals, LHAN has opted to bring bilingual nurses and doctors directly to the worksites. They give workers tetanus shots to guard against infections from accidents on the job and treat a series of common medical complaints. The lack of work boots, masks and gloves means that broken bones, sinusitis and cuts are a constant problem.

While this approach has been helpful, LHAN is stretched thin and has had to rely on volunteer doctors and nurses from outside the region. In lieu of always being able to find Spanish-speaking clinicians, they provide qualified medical translators.

Closing Knowledge Gaps

Based on these lessons learned the hard way, Lovera feels strongly that the federal government must focus on enhancing the cultural competence of disaster response teams. And she’s not alone. How agencies such as FEMA will respond to these recommendations from health professionals, if at all, remains to be seen. But in the meantime, a growing number of nursing educators are beginning to look at ways to fill this crucial knowledge gap.

Laura Terriquez-Kasey, RN, MS, CEN, is a member of a New York-based Disaster Medical Assistance Team (DMAT) that was sent to Louisiana following Katrina. The Department of Homeland Security’s National Disaster Medical System relies, in part, on a number of DMATs stationed throughout the country. The DMATs consist of highly skilled medical professionals that can be quickly deployed following a natural or man-made disaster.

Terriquez-Kasey’s previous disaster experience includes 9/11 and Tropical Storm Allison. “When I went into Allison and the flooding in Texas in 2001, we were a large group of nurses and it was very helpful to have the capacity to speak Spanish,” she says. Too often, Terriquez-Kasey believes, in the rush to “get everyone treated right away” the “cultural piece” of disaster nursing is simply overlooked.

It is an oversight that she tries to correct as a clinical lecturer at SUNY-Binghamton’s Decker School of Nursing. “There is a tremendous knowledge deficit in our health care where we don’t necessarily take the time to understand where the [patient] is coming from,” Terriquez-Kasey contends. “You can’t help someone if you can’t assess them, and if the patient doesn’t open up to you then you are really not doing your job.”

Pattillo, in her role with the National Nurse Response Team and as an assistant professor at the University of Texas at Austin School of Nursing, worries that too few nursing students receive proper training in this area. “Is cultural competency in disaster nursing being addressed? No. [Nursing schools] are not even addressing disaster nursing [in general] adequately.”

Still, Maria Warda, PhD, RN, dean of nursing at Georgia Southwestern State University in Americus, Ga., and vice president of the National Association of Hispanic Nurses (NAHN), believes there has been at least some progress in recent years. “[Considering that we were starting from zero], it is certainly a move in the right direction,” she argues.

Warda, who is an expert in Latino cultural competence, says she tries to instill in her students “an appreciation for and even a celebration of diversity. Then [I try to teach] basic communication skills that may not be perfectly culturally congruent but at least will convey human kindness, concern and empathy without offending. All that you can expect is that [nurses will develop] cultural competence for those patients whom they typically care for.” She insists that “it is not that complicated” to acquire cultural competence.

Norfolk State University’s Brown believes cultural competence must become part of disaster planning for every community, because in any disaster response there will always be outsiders arriving to help. Outsiders, that is, who may or may not speak the language of the community’s ethnic populations and who may or may not be familiar with local cultures and mores. Outsiders who need to be provided with information about what to expect regarding “the values and beliefs of the people [they] are going to work with,” Brown says.

She is critical of the prevailing approach to teaching cultural competence. “We talk about it in such broad, abstract terms of what we need to know about a person’s cultures, values and beliefs,” she explains. “We teach stereotypes even though we are trying to teach acceptance of differences. The only way we know is to teach those basic generalizations.” Brown points to work being done by the Florida Center for Public Health Preparedness (see sidebar) as “a great possible model. They are really getting things together.”

Beyond Cultural Competence

Local minority nurses from the Gulf Coast have other lessons from Katrina to share, including general advice about the more practical aspects of responding to natural disasters. Yevonne Means, LPN2, a medical-surgical nurse at Biloxi Regional Medical Center in Mississippi, recommends that nurses “bring your own food, your own water, your own blanket, whatever you need to camp out. [And] be prepared to stay for a while.”

Trilby Barnes stresses the importance of being mentally prepared for the long haul and having deep reserves of empathy for people whose lives have been devastated by a catastrophe.

“I would never want to remove the idea that there is a definite importance to cultural competence,” she says. “But I also believe there was something within me as a nurse, as a woman, as a mother, that allowed me to care for those patients. I couldn’t speak Spanish, but I still felt like I [conveyed the message] that ‘I am going to figure out what it is you need or die trying.’ I feel any nurse who [has] that compassion [can develop] the cultural competence.”

Take a Free Online Course in Culturally Competent Disaster Response

In 2004, the Florida Center for Public Health Preparedness at the University of South Florida (USF) in Tampa began offering a short online course called “Assuring Cultural Competence in Disaster Response.” The 1.5-hour course was developed by Jennifer Baggerly, PhD, LMHC, RPT-S, a professor at USF who responded to Hurricane Katrina as well as the 2004 tsunami in south Asia.

According to the center’s Web site, the course is designed to prepare public health professionals to offer culturally competent disaster interventions to survivors, witnesses and responders to bioterrorism and other major public health threats and community disasters. The course helps build competencies in such areas as:

• Identifying the role of cultural factors in determining and delivering disaster intervention services.

• Identifying cultural barriers to offering disaster intervention services.

• Approaches, principles and strategies for developing cultural competency in assisting disaster survivors from diverse populations.

• Using appropriate methods for interacting sensitively, effectively and professionally with persons from diverse cultural, socioeconomic, racial and ethnic backgrounds, and persons of all ages and lifestyle preferences, when assisting disaster survivors, their family members, witnesses and disaster responders.

Baggerly says the purpose of the course is threefold. “The first reason is to prevent harm to the individual you are attempting to help. There are numerous examples of well-intentioned public health workers actually hurting [patients]. If you are not careful you can end up promoting harm. The second reason is for [health professionals] to be more effective and achieve faster results in recovery. Third, it protects the public health worker from harm. Sometimes [you can make] an unintentional faux pas that may anger some [patients].”

Anyone who signs up can take the online course for free, although you have to pay in order to receive continuing education credits. According to Baggerly, the course was envisioned as a convenient and immediate training option. “Especially in disaster response where [it is] very fast-paced, [health workers] are trying to respond quickly, so there is some anxiety that builds up.”

Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness, stresses the course’s importance by citing research that indicates “those who are at greatest risk for adverse outcomes following any disaster are. . .non-English-speaking [and] economically disadvantaged [persons].” The course, she says, helps bridge the cultural gap to those very groups.

For more information about the “Assuring Cultural Competence in Disaster Response” online course, visit


A Magnet Moment: The Pursuit of Excellence in VA Nursing

A Magnet Moment: The Pursuit of Excellence in VA Nursing

Over the last 20 years, hospitals in the United States have become increasingly focused on the Magnet Recognition Program® (MRP), a national initiative honoring hospitals that have achieved the highest possible standards of excellence in nursing and patient care. The process of designating outstanding health care facilities as Magnet hospitals first began in the early 1980s during yet another international nursing shortage. Even though many hospitals were struggling to fill their nurse staffing needs, it was apparent that a few facilities were somehow unaffected by the shortage. An investigation of these hospitals, sponsored by the American Nurses Association (ANA) identified 14 key standards and qualities that truly set these facilities apart from the crowd.

As a result, ANA—through its credentialing body, the American Nurses Credentialing Center (ANCC)—developed what is now known as the Magnet Recognition Program. This program recognizes hospitals, medical centers and health systems which, like a powerful magnet, have the ability to attract and retain more registered nurses and other health care workers. Most importantly, the Magnet recognition is more than just an award: It is a systematic approach to the ongoing pursuit of excellence in patient care.

More recently, medical centers within the Department of Veterans Affairs (VA) have decided to join their private sector peers in the pursuit of this coveted recognition. Of the 155 VA medical centers (VAMCs) in the U.S., only three have earned the Magnet designation. The first was James A. Haley Veterans’ Hospital in Tampa, Fla., followed by the Michael E. DeBakey VAMC in Houston, Texas, and most recently, Portland (Ore.) VAMC in 2007. The medical center where I am employed, Overton Brooks VAMC in northwest Louisiana, has also decided to join the ranks of these prestigious facilities by pursuing Magnet status.

One of the criteria for Magnet recognition is that at least 20% of all direct care staff nurses hold a current nursing certification in their area of specialty. Simultaneously, there is also a national initiative within the VA’s Office of Nursing Services (ONS), encouraging certification by at least 25% of a VA facility’s direct care nursing staff.

Certification is the formal recognition of a nurse’s specialized knowledge, skills and experience that promote optimal health outcomes. It is documented by successful completion of a national standardized certification exam and adherence to practice standards identified by a professional nursing organization in a defined clinical area. It represents a benchmark and indicator of increased clinical knowledge and experience, analogous to board certification in other disciplines. Nursing certification is not a routine competency expected of all nurses practicing within a certain specialty (e.g., CPR training).

Benefits of Certification

For VA hospitals, the benefits of certification are exponential to the organization, the individual nurse and, most importantly, to the veterans we care for. Certified nurses are more competent, accountable and confident in their practice. Moreover, studies have shown that certified nurses practice in a manner that is most likely to improve patient outcomes.1 Other research has revealed that three out of four patients are much more likely to select a hospital employing a high percentage of certified nurses.2

Furthermore, nurses who hold a certification report higher levels of empowerment, which is a characteristic associated with job satisfaction and intent to stay in their current position.3 High percentages of certified nurses are found in facilities that have a reputation for recruiting and retaining the best nursing talent—for example, 26.4% of nurses in Magnet hospitals are certified.4

For the individual VA nurse, becoming certified in your competency area can:

•   validate your knowledge and expertise;

•   build confidence in your professional ability;

•   demonstrate that you meet high national standards;

•   demonstrate your dedication to nursing as a profession;

•   provide opportunities for career advancement;

•   validate you as a credible resource for your colleagues and patients; and

•   promote personal growth and satisfaction as a professional nurse.

Nursing certification is reflective of the Veterans Health Administration (VHA)’s current transformational performance measure to distinguish VA facilities as learning organizations, charged with creating an integrated and synergistic educational environment for all staff. In addition to the MRP, certification is used as an indicator of nursing excellence in other national health care recognition programs, including the American Association of Critical-Care Nurses (AACN) Beacon Award for Critical Care Excellence and the National Institute of Standards and Technology (NIST)’s Malcolm Baldridge National Quality Award.

Don’t Overlook LPNs

In general, hospitals’ efforts to increase their number of certified nurses have usually concentrated on professional nurses (RNs). But this overlooks the important role licensed practical nurses (LPNs) play in the VA health care system. Therefore, our medical center, in recognition of our LPNs’ system-wide contribution to patient care, is also including this group in our initiative to increase certification among all direct care nurses.

Overton Brooks VAMC currently employs approximately 75 LPNs serving in various areas, such as our primary care and specialty clinics, medical-surgical and mental health units, community-based outpatient clinics and community health nursing. In most instances, the LPN is working as a team member led by the RN. However, on many occasions the LPN is directly assigned to a specific provider, such as a physician or advanced practice nurse. This expanded role remains within the LPN’s designated scope of practice, in support of the veteran’s plan of care.

Several nursing associations and certifying boards, such as the Society of Urologic Nurses and Associates (SUNA) and the National Board for Certification of Hospice and Palliative Nurses (NBCHPN), offer various types of certifications for LPNs/LVNs. However, the VA Office of Nursing Services only recognizes two specific certifications offered by the National Association of Practical Nurse Education and Service (NAPNES) and the National Federation of Licensed Practical Nurses (NFLPN). The VA-approved certification offered by NAPNES is in long-term care (LTC) and the NFLPN certification is in gerontology. (See Table 1.)

The average age of a veteran at Overton Brooks VAMC is 60, and this near-geriatric population is increasing within the VA health care system in general. Therefore, it will be extremely beneficial for VA hospitals to have a pool of talented gerontology nurses on staff. For this reason, and in the absence of an LTC unit within our facility, we concentrated our efforts on the certification in gerontology offered by NFLPN.

This certification evaluates competency in four specific domains:

1. Phases of the Nursing Process: Gathering information regarding the patient; identifying the patient’s health needs and selecting appropriate goals of care; designing a strategy to achieve the goals established for the patient; initiating and completing actions necessary to accomplish goals; and determining the extent to which the goals have been achieved.

2. Areas of Patient Needs: Provision of coordinated and goal-oriented care; evaluation of patients’ basic physiological care; psychosocial, coping and adaptation needs of the patient; and developmental changes that occur in older persons.

3. Critical Thinking Skills: Identifying, gathering, discriminating and prioritizing data collection; discovering and then discerning the nature of relationships between concepts; determining how and why concepts are related; developing a process for establishing goals; and using problem-solving to achieve patient-specific outcomes.

4. Gerontology-Specific Topics: Nursing of elderly patients with physical and psychological disorders; special issues in gerontological care; foundations of gerontology; and promoting health and wellness in the geriatric patient.

Case Study: How We Did It

As the Magnet program director (MPD) for Overton Brooks VAMC, I was responsible for spearheading the LPN certification efforts. First, we sent out a call for participation to all LPNs within our medical center. The purpose of this initial call was to determine the number of LPNs who might be interested in certification, and in attending a dedicated review session to prepare for taking the gerontology certification exam. The LPNs were informed that all materials would be supplied by the medical center, the review session would be held on a Saturday and the test would be given at our facility, once again on a Saturday.

Answering this call for participation were 15 LPNs with varying levels of experience, employed in a variety of inpatient and outpatient settings. The LPNs were then asked to sign a letter of commitment acknowledging their individual willingness to attend the Saturday review session and the Saturday test. These were not scheduled workdays, and participating LPNs who worked on Saturdays were to use vacation time or request these days as scheduled days off. Unfortunately, this decreased the size of our participant group from 15 to 12. Even so, we moved forward with our initial plans to increase the number of certified LPNs.

Our next step was to obtain funding for the certification project. Initially, the project was discussed with nursing leadership, who viewed the certification in gerontology as a continuing education opportunity. Subsequently, the proposal was presented to the medical center’s executive leadership group, who determined that this very worthwhile professional development activity was appropriate for funding through continuing education funds. This enabled us to order the materials we needed.

Education Resources, Inc. (ERI) sponsors the certification testing and credentialing offered by the NFLPN. ERI has a long history of assisting practical nurses with various types of educational opportunities. The paper/pencil examination may be administered at the place of employment for LPNs or at an approved testing facility. Hence, the test was administered at our hospital and I served as the proctor.

ERI provided a review DVD, test booklet, pencils and proctor verification forms for each participant. They also provide each LPN participant with a diagnostic report, listing on the national LPN registry and individual certificates (for those who pass the exam).

When the DVD review materials arrived, my next job was to evaluate them to determine their adequacy in preparing our LPNs for this examination. I was qualified to do this because I have experience in working with practical nursing schools and NCLEX-PN® and -RN® preparations, and I hold an advanced degree in public health education and a doctoral degree in health policy. I also have more than 15 years experience in curriculum design, development and evaluation.

My initial review of the materials determined that further enhancement would be beneficial to this LPN group. Therefore, I developed our own additional review materials, including over 300 PowerPoint slides covering topics such as normal aging changes (physical and emotional), major disease processes affecting the elderly, and test-taking strategies. Additionally, the DVD was transcribed verbatim to a hard-copy format to facilitate adult learning.

As with any review course, it’s important to know your audience. Standardized review courses are generally tailored to a large audience. That’s why it’s so crucial to determine if the majority of your group members are functioning at the same knowledge level prior to conducting a group review.

In early May 2008, we conducted the review session with our 12 LPN participants. It lasted six hours, with three 15-minute breaks. Participants were encouraged to bring beverages and light snacks to the session; however, lunch was not provided.
The LPN group returned later that month to write a 105-item certification exam. They had two hours to complete the exam, though most were finished within one hour.

When ERI sent us the examination results, they arrived at my office in individual sealed envelopes to ensure confidentiality. In turn, the LPNs were notified that the results were available. Individually, each one came to my office, received their envelope and anxiously reviewed their results. Nearly all of the participants—11 out of 12—successfully passed the certification exam and are now proudly identified as certified LPNs in gerontology, holding the LPN, GC [Gerontology Certified] designation.

Cost-Effective and User-Friendly

The cost to our medical center was minimal. As itemized in Table 2, the estimated total cost was around $1,900. I volunteered a total of 12 hours of my time for the review session and the test proctoring.

In conclusion, this certification strategy has proven to be a worthwhile professional development opportunity involving a successful collaboration between direct care nurses, medical center leadership and our facility’s Education and Training Service, which provided financial resources. The benefits to our facility and our LPNs are evident. The group certification enabled us to:

•   increase the professional role of the LPN;

•   improve career advancement opportunities for these nurses;

•   help LPNs meet their personal and self-improvement goals; and

•   provide an avenue for LPNs to highlight their special skills and talents in gerontology.

We have rewarded each newly certified LPN with a within-grade step increase. The next phase of the project will be to replicate this user-friendly approach to group certification with other licensed nursing staff (RNs and advanced practice nurses), as well as unlicensed staff (nursing assistants and health care technicians). Our VAMC is well on its way to obtaining 20-25% certification among its direct care nurses—the first step in our journey toward achieving Magnet recognition.  n


1.  Cary, A.H. (2001). “Certified Registered Nurses: Results of the Study of the Certified Workforce.” American Journal of Nursing, Vol. 101, No. 1, pp. 44-52.

2.  American Association of Critical-Care Nurses and AACN Certification Corporation (2003). “Safeguarding the Patient and the Profession: The Value of Critical-Care Nurse Certification.” American Journal of Critical Care, Vol. 12, No. 2, pp. 154-164.

3.  Piazza, I.M., Donahue, M., Dykes, P.C., Griffin, M.Q., and Fitzpatrick, J.J. (2006). “Difference in Perceptions of Empowerment Among Nationally Certified and Noncertified Nurses.” Journal of Nursing Administration, Vol. 36, No. 5, pp. 277-283.

4.  Shirey, M.R. (2005). “Celebrating Certification in Nursing: Forces of Magnetism in Action.” Nursing Administration Quarterly, Vol. 29, No. 3, pp. 245-253.

Working at the Department of Veterans Affairs

The Department of] Veterans Affair’s most important asset is a highly motivated and diverse workforce of more than 200,000 people committed to our mission of service to veterans. Our employees are the foundation of the department and the key to our success. We offer a wide array of career opportunities to prospective applicants in many clinical, technical and administrative career fields at locations throughout the country. Our Web site can tell you more about these job opportunities. We hope that you will consider a career with Veterans Affairs and become a part of our proud tradition of providing the highest quality of service to those men and women who have served our great Nation. -Anthony J. Principi Secretary of Veterans Affairs

Just the Facts

The Department of Veterans Affairs (VA) was established on March 15, 1989, succeeding the Veterans Administration, which was established in 1930. In 1989, President Reagan signed legislation to elevate Veterans Affairs to the 14th Department in the President’s Cabinet.

The department has 224,724 employees 202,709 of which are employed by the Veterans Health Administration. It is the second largest of the 15 cabinets and is responsible for providing federal benefits to veterans and their dependents. This is a staggering responsibility when you consider the numbers: about a quarter of the nation’s population-approximately 70 million people-are eligible for VA benefits and services, and there are 26 million living veterans at this time.

The VA estimates it will spend $59.6 billion in 2003 to provide services and $25.9 billion of that will be spent in the area of health care. The VA’s health care system includes 163 hospitals, 850 ambulatory care and community-based outpatient clinics, 137 nursing homes, 43 domiciliaries and 73 comprehensive home-care programs. More than 4.5 million people received care in VA health care facilities in 2002. This was an unprecedented increase of 9.5% over the number of patients treated in 2001.

The VA will also invest nearly an additional $1.4 billion in research this year. These funds are made possible by the VA’s Medical Account, National Institutes of Health, pharmaceutical companies and other foundations.

The VA is at the forefront of medical advancements and research. It has become a world leader in research on aging, women’s health, AIDS and post-traumatic stress disorder. VA researchers have had key roles in developing the cardiac pacemaker, the CT scan and have made improvements in artificial limbs. The researchers have received many prestigious awards including the Nobel Prize for their work.

The biggest reward for researchers in the VA, however, is the ability to see the immediate benefits of their research. Many of the researchers are also practicing physicians, and this dual role allows them to put their research to immediate use.

Considering the work the VA does every year, it is no surprise that they require a large network of “highly motivated” individuals. Employment opportunities abound at the VHA and VA, and they value their employees, a fact that is reflected in employee’s generous benefit packages.

The Benefits

Starting salaries at the VA are dependent on education, training, years of experience, the duties of the position and, in some cases, guidelines from professional boards. The VA’s General Schedule Salary Table is available at

Health Insurance
As you can imagine, employees of the VA choose from a wide selection of health care plans based on their individual needs. Fee-for-service plans, health maintenance organizations and point of service plans are just a few of the options. The VA pays approximately 75% of the health benefit premium. Many plans offer dental coverage as well, and coverage may continue into retirement. Pre-tax options can also result in more take-home pay.

Training and Continuing Education
The VA manages the largest education and health professions training program in the U.S. They are affiliated with 107 medical schools, 55 dental schools and more than 1,200 other schools across the country.

VA employees can also benefit from VA Learning Online a program offering a number of general education and college-level courses on the Internet. The VA offers tuition reimbursement to individuals who are studying in fields deemed to have shortages.

The Employee Incentive Scholarship Program is available to employees continuing their education in areas where recruitment and retention is difficult.

Quality of Life Benefits

A childcare subsidy is available to full- and part-time VA employees. This subsidy is paid on a sliding scale based on income. Alternate work schedules are also available in some circumstances, and commuting assistance is offered to VA employees based on mass transit commuting costs.

Other Benefits

Additional benefits, similar to those found in the private sector, include retirement programs, life insurance and paid days off. Some of these benefits are more generous than those found in the private sector, however, and are detailed on the VA’s Web site at under employment opportunities.

Extra benefits not commonly found in the private sector include liability protection and job portability. Descriptions of these benefits are also available on the VA’s Web site.

Many Routes to the VA

If you would like to pursue a career with the VA, there are many avenues to get you there. On the Internet, go to to find links to the VHA Placement Service, VA Jobs at USAJOBS and VHA Executive Recruitment. You can also go to to do a job search by state, facility or occupation.

If you have additional questions, call the Health Care Development and Retention Office (HCSDRO) at 504-589-5267.

A Win-Win Partnership, VA Style

A Win-Win Partnership, VA Style

Recruiting eager students into the future nursing pipeline has become easier in recent years, thanks to the profession’s efforts to publicize the nursing shortage and promote the benefits of nursing as an attractive career. But filling the pipeline does little good if it narrows at some point down the line so that the end product is reduced to nothing more than a trickle.

According to the American Association of Colleges of Nursing, in 2007 more than 36,000 qualified applicants were turned away from entrylevel baccalaureate degree programs in nursing schools due to an insufficient supply of faculty, clinical sites, classroom space and clinical mentors. And with a whole generation of current nursing faculty rapidly approaching retirement age, many of the nation’s top nursing employers are beginning to explore innovative new ways to make sure they’ll have enough professionally trained nurses to meet their future staffing needs and provide the best possible patient care.

That’s one of the goals behind the U.S. Department of Veterans Affairs Nursing Academy (VANA), a five-year, $59 million project launched in 2007 to provide a pipeline of highly educated nurses to serve the health care needs of the nation’s veterans. VANA consists of partnerships between selected schools of nursing and VA medical facilities throughout the country. In these unique collaborations, nursing school faculty provide education and other services at the VA facility, qualified VA nurses serve as faculty members at the nursing school, and the VA hospital provides enhanced clinical experiences for students. Currently, there are 15 such partnerships in the VA Nursing Academy, a name that represents a collection of collaborative efforts rather than an actual physical entity.

“The purpose [of VANA] is to increase the number of students that can be admitted to [nursing schools], increase the number of new graduate nurses at the VA hospitals and retain them once they’re there,” says Blanche Landis, PhD(c), RN, the VANA program coordinator at San Diego State University School of Nursing, which is partnering with the VA San Diego Healthcare System.

“There are many benefits from the VA side in terms of improving the quality of care as well as elevating the practice of nurses within our organization,” adds Maude Rittman, PhD, RN, director of nursing at the North Florida/South Georgia Veterans Health System in Gainesville, Florida. Her facility’s VANA partner is the University of Florida College of Nursing, also based in Gainesville. The Department of Veterans Affairs, with 61,000 registered nurses, licensed practical nurses, vocational nurses and nursing assistants, has one of the largest nursing staffs in the world and is one of the country’s largest employers of minority nurses. VA nurses work at the department’s 153 medical centers and almost 900 clinics nationwide. The VA currently provides clinical education for some 100,000 health professional trainees each year, including students from more than 600 schools of nursing. Almost 22,000 of the VA’s registered nurses will be eligible for retirement by 2010.

Meeting Goals

The VA Nursing Academy’s Enhancing Academic Partnerships Program has four main goals:

  1. Expanding faculty and professional development at nursing schools and VA facilities;
  2. Increasing nursing student enrollment;
  3. Providing opportunities for educational and practice innovations; and
  4. Increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education.

To meet the faculty expansion goal, VANA provides funding for three full-time equivalent (FTE) VA-based faculty and two FTE school-based faculty in the first year of the program. Then it increases to six and four faculty respectively, until the last year, when the number drops to three and two respectively. This allows nursing schools to add and maintain enrollment of 20 more students for each five faculty members added, according to a national evaluation funded by the VA and conducted by the UCLA School of Public Health in 2008.

The second goal, increasing enrollment in nursing schools, has already been achieved at the University of Florida College of Nursing, which was one of the first schools to participate in VANA. In fact, enrollment has exceeded expectations, says Maxine Hinze, PhD, RN, the college’s VANA program director. Twenty-eight additional baccalaureate students were admitted in the first year of the program, and 24 additional students were admitted the second year. Enrollment has also increased in the accelerated BSN and RN-to-BSN programs, Hinze reports.

VANA’s third goal is in alignment with the VA’s overall mission of investing resources into becoming a learning organization, says Rittman. “This implies that people who join our organization continue to learn and grow within the organization,” she explains. “To me, this program is a step in that direction, in that we are implementing evidence-based practice [at our facility]. In our [VANA] model, [nursing school] faculty are actually embedded in the nursing unit and become part of the unit.”

Recruitment Results

This heightened emphasis on education and innovation is designed to not only improve patient care but also help boost recruitment and retention of VA nurses—the VANA program’s fourth goal. The VA believes that integrating nursing school faculty into its hospitals will provide more stimulating clinical and learning environments, increase VA clinical education opportunities and inspire more new nursing graduates to seek employment at VA facilities where they’ve had a positive clinical experience.

“The idea is that they will fall in love with [VA nursing] and want to continue on,” Landis says. “Students will become more familiar with the [VA] system, more familiar with veterans and will want to be more involved in the care of vets.”

The University of Florida College of Nursing and the North Florida/South Georgia Veterans Health System have a one-year nursing residency program as part of their collaboration, says Hinze. This also helps increase recruitment and retention. In its first year in the VANA program, the VA facility recorded a 92.3% retention rate, in that 36 of 39 new graduate nurses hired at the hospital were still employed there after one year. In contrast, median turnover rates for graduate nurses in general during their first year of employment currently range from 35% to 61%, depending on location.

“The first year of employment can make or break a nurse,” Hinze notes. The VA facility was also able to hire a larger-than-usual number of nurses with baccalaureate degrees after the first year of the partnership, Rittman says—18 to 20 as opposed to the normal six to 10. It also hired more new graduates than usual (39). And while the hospital hired only 24 new graduate nurses after the second year of the program, this was due in part to reduced turnover, meaning there were fewer jobs available.

“We had 70 applicants and could only hire 24 because our vacancy rate was lower,” Rittman explains. Although the VA Nursing Academy is not targeted specifically toward recruitment and retention of minority nurses and students, many of the VANA partnerships are located in areas with large minority populations.

“We have more Hispanic veterans [receiving care at our facility],” Rittman says, “and so we do like to hire Hispanic nurses and African American nurses [who can provide culturally competent care].” Nurses who work for VA hospitals must be U.S. citizens, she adds, and that requirement has at times prevented her facility from hiring promising international nursing graduates who have immigrated to the U.S. but have not yet had a chance to earn citizenship.

Because the Department of Veterans Affairs has a very high level of racial and ethnic diversity compared to the private sector—both in terms of workforce and patient population—it has long been an employer of choice for nurses of color. “It’s also a good environment for male nurses, because many of them have been in the military and have been medics,” says Rittman. “So the VA is a very comfortable place for them to be.”

Making It Work

To help ensure that the Enhancing Academic Partnerships Program is working effectively and accomplishing its goals, the VANA project calls for periodic program evaluations at both the local partnership and national levels. The evaluations include structure, process and outcomes assessments of clinical practice, education and program activities.

The 2008 national evaluation reported several challenges to making the program work, including assimilation of nursing school faculty into the broader organizational structure of VA facilities and assimilation of VA nurses into the academic culture of nursing schools. Other challenges included time-keeping for faculty, performance evaluations and reports that teaching required a more significant investment of time than VA nurses had anticipated.

But on the positive side, the evaluation identified beneficial spill-over effects, such as the strengthening of ties between VA facilities and their partnering nursing schools, opportunities for collaborative research, opportunities to expand simulationbased learning, sharing of advanced educational experiences, and increased enrollment of current VA nurses into graduate-level nursing programs.

Still another finding was that VANA’s innovative structure helps address one of the biggest problems contributing to the nursing faculty shortage—the fact that academic salaries are often much lower than what nurses can earn in clinical practice. Because the VA nurses who serve as nursing school faculty maintain their existing VA salaries, this provides an incentive for VA nurses with master’s degrees or other advanced training to become involved in teaching.

While VANA is clearly a win-win proposition for nursing schools, VA hospitals and nursing students, the program’s long-term goal is to improve care for veterans.

“The vets will ultimately benefit if [the nurses] who are providing the care have the best instruction, the best education and the support they need to develop [professionally],” says Landis. “All patients deserve the best care, but I think [veterans are a unique population with their own special needs]. This program exposes students to the [health care] needs of vets and certainly increases their understanding of those needs.”

For more information about the VA Nursing Academy, visit

Allied for Education

As of academic year 2009-2010, the VA Nursing Academy (VANA) comprises 15 partnerships between nursing schools and VA medical facilities:


VA Site
Nursing School Partner
Charles George VA Medical Center
(Asheville, N.C.)
Western Carolina University
School of Nursing
Birmingham VA Medical Center
(Birmingham, Ala.)
University of Alabama at Birmingham
School of Nursing
VA Pacific Islands Health Care System
(Honolulu, Hawaii)
University of Hawaii at Manoa
School of Nursing & Dental Hygiene
VA New York Harbor Healthcare System
(New York, N.Y.)
Pace University Lienhard School of Nursing
VA Pittsburgh Healthcare System
(Pittsburgh, Pa.)
Waynesburg University
Ralph H. Johnson VA Medical Center
(Charleston, S.C.)
Medical University of South Carolina
Edward Hines, Jr. VA Hospital
(Hines, Ill.)
Loyola University of Chicago
College of Nursing Michigan Consortia
(Ann Arbor, Battle Creek, Detroit, Saginaw)
University of Detroit Mercy and Saginaw Valley State University
Oklahoma City VA Medical Center
(Oklahoma City, Okla.)
University of Oklahoma Health Sciences Center
College of Nursing
Providence VA Medical Center
(Providence, R.I.)
Rhode Island College School of Nursing
James A. Haley Veterans Hospital
(Tampa, Fla.)
University of South Florida College of Nursing
North Florida/South Georgia Veterans Health System
(Gainesville, Fla.)
University of Florida College of Nursing VA Salt Lake City Health Care System
(Salt Lake City, Utah)
University of Utah College of Nursing
VA San Diego Healthcare System
(San Diego, Calif.)
San Diego State University School of Nursing
VA Connecticut Healthcare System
(West Haven, Conn.)
Fairfield University School of Nursing

Picture Perfect

Patients admitted to hospitals come with a variety of different education levels and reading abilities. It is the responsibility of all health care providers, including nurses, physicians and pharmacists, to ensure that patients understand all of the written instructions they receive regarding their treatment, such as patient education handouts and the instructions that accompany their medications. Many hospitals do assess the education levels of patients, but the instructions provided are written primarily on the sixth- to eighth-grade reading level. What about those patients whose literacy level is less than the sixth grade, or who are not able to read at all?

In 1992 the National Adult Literacy Survey (NALS), conducted by the National Center for Education Statistics, affirmed that at least one quarter of all Americans–some 40-44 million people–are functionally illiterate, and that another 40 million Americans’ literacy skills are marginal.1 More recently, Rose Mary Pries, program manager for patient health education at the Department of Veterans Affairs, estimated that more than 90 million people in the United States have difficulty reading.2

According to the NALS, Americans of color–including Hispanics, African Americans and Asians–have disproportionately low literacy levels compared to the Caucasian majority population. Now consider the tremendous growth of immigrant populations in the United States. These immigrants, who may speak little or no English, are a major part of our health care system.

In 2005 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced a new standard that addresses the health care industry’s responsibility to provide treatment instructions that match the patient’s literacy level.3 In my work at the Dallas Veterans Affairs Medical Center, I have focused on complying with this new JCAHO requirement. As a cardiology nurse practitioner working in the medical center’s congestive heart failure clinic, I often received referrals from primary care providers for patients who were labeled as noncompliant with their medications. Upon assessment of these patients, I found one commonality–low literacy.

It wasn’t that the patients did not want to take their medications as ordered. The problem was that they could not understand the instructions printed on their prescription labels. I found patients taking less than or more than the prescribed dose of medications, based on what they thought they “remembered” from the verbal instructions they were given. As a result, these patients’ blood pressures were elevated and their heart failure was not controlled. Some patients had BNP (B-type natriuretic peptide) levels as high as 5,000 (the normal range is 5-100). Others had 1-4+ edema and poor weight control. Some of these patients had more than one bottle of the same medication and were taking pills from both bottles simply because they could not read.

To develop a solution for this problem, I first performed a thorough literature search on patient education and low literacy skills. I learned that low-literacy patients are abundant in our health care systems. Fetter4 disclosed that when patients are unable to read and comprehend basic health care instructions, serious negative consequences can result. Patients can take the wrong medication or the wrong dose of medication, resulting in increased morbidity and mortality. It was documented throughout the literature that health care professionals have the responsibility to evaluate the patient’s level of literacy and his/her ability to understand and follow instructions, and then use that information to develop or utilize the most effective resources for enhancing patient comprehension of instructions.

Next, I looked at the Area Health Education Center (AHEC) checklist, a tool for evaluating the appropriateness of reading materials for low-literacy patients. It includes four items that stress the significant criteria that must be used for successful development of low-literacy materials:

1. Organization–measures whether the material has an attractive cover, whether the most important need-to-know information is stressed first and whether no more than three to four points are presented at a time.

2. Writing style–conversational, with little or no medical jargon.

3. Appearance–ample space between sentences, pages uncluttered, a high degree of contrast, font size at least 12 points, illustrations that are simple and that amplify the text.

4. Appeal–culturally, gender- and age-appropriate materials that match the needs of the targeted audience; materials that are interactive by suggesting actions, asking questions and soliciting responses.5

One Picture Is Worth a Thousand Words

Now I was ready to start designing and implementing a protocol for teaching low-literacy patients to take their medications correctly. According to a recent study by Houts et al, pictures that closely link written or spoken text can, when compared to text alone, markedly increase attention to and recall of health education information.6 These authors further state that all patients can benefit from this technique, but patients with low literacy skills are especially likely to benefit. Armed with this knowledge, I decided to create a system focusing on the use of universal symbols that would visually communicate the written words printed on the medication bottle.


I found computer clip-art symbols that could be understood by people from a variety of racial and ethnic backgrounds and that were large enough to be easily located by the patient (see illustration below). For daily medications, I chose a rooster with the sun coming up to indicate the morning dose. For the bedtime dose I chose a bed. For PRN medications, I chose a sad face to indicate that the medication should be taken as needed. I also added a clock symbol alongside the sad face and circled the number of hours between doses. I copied these symbols onto silver-dollar-sized self-adhesive stickers and stuck them on the patient’s medication bottles.

Then came the process of explaining the system to patients. Before sitting down with a patient, I made sure all of the patient’s medications were sorted and labeled with the appropriate label. Verbal instructions began with an emphasis on making sure the patient understood the symbols that were placed on the medication bottles. Next, I reviewed all of the bottles with the patient and a family member (when present). I then filled the patient’s pillboxes–one for morning medications and one for evening medications. The PRN medications were not placed in the pillboxes. I spent time with the patient until I was certain he/she understood the PRN medication as well as the amount of time between doses.

I always asked the patient to repeat the instructions back to me so I would know for certain that comprehension had taken place. The majority of medications can be ordered with once or twice daily dosing and I tried to stay within those guidelines to make it easy for the patient. I placed the same symbol on the bottom of the pillbox as on the medication bottle. I usually use two different color pillboxes and this was very helpful for getting the patient to understand the difference between morning and evening doses.

When the patient had a clear understanding of how to the system worked, I advanced the patient to filling his/her own pillboxes. First, I taught the patient to place all of the morning medications in one group and the same for the bedtime medications. If a medication was to be taken twice a day, I had the patient place the bottle with the morning group first; once the morning pills were dispensed, I had them place the bottle in the bedtime group.

Next, I taught the patient to open only one bottle at a time. If he/she poured too many pills, I had them return the pills only to the bottle that was open. Once the correct number of pills had been placed in the pillbox, I told the patient to close the medication bottle and move it to a new area away from the pill bottles still to be opened. I followed this process with both groups of medications.

Finally, I had the patient repeat this process weekly until there was absolute certainty that he/she understood the process.

Real Results

I identified low-literacy patients by having them bring all of their medications to the first clinic visit. I would ask the patient to read the directions on the medication bottle. When the patient could not read the labels of several medications, I knew there was a literacy problem. I approached the patient by saying, “I have a way to teach you how to take your medications accurately so you can improve your disease and feel better.”

The first patient I taught to use this system was a congested heart failure patient. His BNP was 4,300 and his blood pressure was 218/116. This patient had been hospitalized 14 times in one year to try to control his heart failure. It was well documented that the patient was noncompliant with his medications but the reason for the noncompliance had never been documented.

Since being taught to understand and manage his self-medication regimen, this patient has not had a hospital admission for the past three years. His blood pressure is under control as well, with readings of 98/60 to 106/70 consistently. The cost savings to our facility alone are reason to maintain this teaching style with low-literacy patients.

More than half of all Americans may be unable to read and understand written instructions about how to take their medications. When patients are unable to comprehend basic instructions, poor health outcomes are the result. Low-literacy patients fail to follow instructions because they lack understanding, not because they are intentionally noncompliant. Nurses, physicians and pharmacists must take the lead in ensuring that the patient understands the instructions that accompany his/her medications. Every patient should be assessed for literacy skills and then provided with instructions in an appropriate format that is specifically matched to his/her reading level.

Creativity and innovative teaching strategies are a must with low-literacy patients. Nurses, with their unique emphasis on holistic, patient-centered care, are in the ideal position to design and deliver practical interventions that will help these patients be successful as they engage in self-medication.


1. Kirsch, I., Jungleblut, A., Jenkins, L., and Kolstad, A. (1993). Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. U.S. Department of Education, National Center for Education Statistics.

2. Pries, Rose Mary (2006). “Educating Veterans with Lower Literacy Skills” (PowerPoint presentation).
3. Joint Commission for Accreditation of Healthcare Organizations (2005). Educating Hospital Patients and Their Families.

4. Fetter, M.S., (1999). “Recognizing and Improving Health Literacy.” Journal of the Academy of Medical Surgical Nurses, Vol. 8, No. 4, pp. 226-227.

5. Wilson, F.L. (2000). “Are Patient Information Materials Too Difficult to Read?” Home Healthcare Nurse, Vol. 18, No. 2, pp.107-115.

6. Houts, P., Doak, C.D., Doak, L.G. and Loscalzo, M. (2006). “The Role of Pictures in Improving Health Communication: A Review of Research on Attention, Comprehension, Recall, and Adherence.” Patient Education and Counseling, Vol. 61, No. 2, pp. 173-190.