Caring Across the Language Barrier

The start of my junior year medical-surgical rotation began the same way it usually does for many other nursing students–with a feeling of nervousness due to the uncertainty of how my first day on the clinical unit would evolve. Upon receiving my patient assignment, I realized my day would be unlike that of my classmates, because my patient could only speak Spanish. My clinical instructor had made the assignment based on my Hispanic background and my fluency in Spanish. 

I received the nursing report, which was limited to the physical assessment because of the nursing staff’s inability to communicate with this gentleman. No admission information, health history or personal information about the patient had been obtained, because he had been dropped off at the Emergency Department with no one to help interpret for him. The admitting diagnosis was kidney failure with a secondary diagnosis of cirrhosis. Laboratory values and diagnostic tests were conclusive with the diagnoses.

When I entered my patient’s room, I immediately noticed the fear and pain in his eyes. He was grimacing and teary-eyed, which broke my heart. I was sure the language barrier must have created feelings of loneliness and fear. When he heard my Spanish greeting, his whole appearance changed. He smiled and asked me if I spoke the language, and I answered “yes.” He said, “Hay, gracias,” which means thank you, with a sigh of relief.

The patient was able to talk to me about his abdominal pain and his arrival at the ED. He explained that his boss, who did not speak Spanish, had brought him to the hospital and immediately left. When I asked if there were any friends or family members who could assist him with his communication needs during his hospitalization, he replied “no.” He told me that he lived with a group of other migrant workers and that they were unable to leave work.

I realized at this point that he was completely alone, with no one to help him with his medical, legal and emotional needs. In the back of my mind I knew that meeting the needs of this patient was going to be a significant challenge for me, a student nurse. But I was keenly aware of the impact my nursing interventions could make. I put my nerves aside, gained my confidence and told myself that I was there to help this patient receive the medical care he deserved.

Communication and Comfort

I proceeded with my nursing assessment, gathering and writing down as much information as possible. I provided the patient with information about the daily routine of the hospital, such as what to do when he had pain, how to use the call button and when meals were served.

I asked if he knew why he was in the hospital. He didn’t exactly know what was wrong with him. He acknowledged that he was in pain and said he needed pain relief so he could go back to work. He complained of generalized right quadrant pain and stated that this was not the first time he had experienced this type of pain. My physical assessment revealed a distended abdomen that was tender to palpation.

After I gathered my assessment and provided comfort to my patient, I returned to the nursing station to talk with his primary nurse. We discussed his medical and personal situation. It was necessary for this man to understand his medical condition and his need for urgent treatment. It was also necessary for the hospital to obtain legal documents such as a living will, power of attorney and a phone number for notifying his next of kin.

I returned to the patient’s room and explained to him that he was very ill and would not be going back to work anytime soon. I educated him about his disease. I asked him if he drank alcohol and he replied that he did drink every day but not in large quantities. I explained that his kidneys were failing, his liver was seriously diseased and that it was necessary for him to avoid drinking alcohol.

I could see the fear in his eyes, and his skin color changed. His closed his eyes and began to cry. I tried to comfort him. He continued to cry, asking how this could have happened to him and what was he going to do, because he couldn’t lose his job. He spoke about his family who lived in Mexico and how he wished he could see them. He said he came to America for a better job and sent the money he earned to his family, but was never able to contact them. He sent letters to his wife and daughters but never knew if they received them. He confided that it had been 10 years since he had seen or spoken to his family. He started crying with such intensity that it broke my heart, and I cried with him. I remember holding his hand, feeling helpless as he sobbed that he wanted to see his family.

At the end of the day, I finished by reviewing the information he needed to know about his hospitalization and medications. I told him how important it was for him to stop drinking alcohol and to take all medications prescribed to him.

When I entered his room one last time to say good-bye, he told me how grateful he was that I had been his student nurse. He said, “I felt relieved and less scared knowing that you were able to understand me and explain everything to me.” At that moment I truly realized my potential as a student nurse to make a difference in a person’s life. I remember telling him before I left to “stay positive and take care of yourself as much as possible.”

As I left the clinical unit I felt a sense of satisfaction and honor to have been able to take care of this patient. I came to the realization that I was able to provide this man with some comfort and put a smile on his face during a dark time in his life. By intervening on behalf of this non-English-speaking patient, I had made a difference for him, for the staff nurses and for myself. As a result of this experience, I feel more committed to fulfilling the needs of my patients, and particularly those patients who face barriers to care.

 

Nursing Volunteer Efforts

A nurse is defined not simply by the medical knowledge he or she acquires. Personality traits—ambition, selflessness, courage—also characterize those in the field. Being a medical professional requires a level of giving that those in other occupations may not experience firsthand. There’s a sole focus on the health of others, and a drive to set aside all personal matters for the well-being of complete strangers. For some nurses, the selflessness has taken them to another world, one where they step outside the confines of a hospital setting and into an area devastated by a natural disaster.

Over the past decade, there has been no shortage of disasters: Hurricane Katrina, the earthquake in Haiti, and the tsunami in Japan, to name a few. But through all of these events, one thing has remained certain: nurses and medical professionals act as steadfast caretakers to help victims physically and mentally recover from such disasters. Nurses act as the liaison between the devastation and the happy, healthy life the victims had before—and strive to have again.

These are the stories of the nurses that helped make that happen.

Eugenia Millender
Haiti Earthquake, 2010

Eugenia Millender, Ph.D.(c), M.S., R.N., P.M.H.N.P., C.C.R.N., experienced multiple hurricanes as a Florida resident and Panama native, and knew firsthand what it was like to have such a major natural disaster strike. But even after the earthquake in Haiti, she couldn’t begin to imagine how the quake could drastically change so many lives so quickly.

“As a human being, I couldn’t imagine how a person could one day have their whole family, friends, and neighbors, and the next day, lose them all,” she says. “Day after day, the stories I heard got worse to the point that I just couldn’t watch anymore. I wanted to do more than pray.”

Working full time as a critical care nurse, Millender was no stranger to sad situations. But she had experienced “nothing so massive,” until she traveled to Haiti. And from the moment she got off the plane, it was pure chaos, she says.

“There were thousands of people walking with nowhere to go. Children were walking alone because now they were orphans,” and on the way to the hospital, there were countless bodies on the side of the road, Millender says.

“Once I reached the hospital, there was no orientation, no introductions, no explanation of what to do, how to do it, or when to do it, because there were hundreds of people in the parking lot of the hospital waiting for care,” Millender says. She adds that in the following days, there were many aftershocks, including one that was as high as a 7.0 on the Richter scale.

Millender remembers one patient she had, a 21-year-old woman with an arm that was almost dead and covered with flies and maggots. They didn’t have the equipment for amputation, and even if they did surgery, she would likely die from infection. Millender made many phone calls to help the woman—even contacting hospitals in the United States—but ended up sending her to the Israeli Army on the island since they had more advanced medical equipment. Millender later received good news from the woman’s brother: they amputated her arm and were taking excellent care of her.

After her work in Haiti, Millender moved away from acute care, and into community care and prevention, saying that she wanted to be an agent of change, not of treatment.

“I want to prevent, educate, and empower,” she says. “I want to change policies to improve the health care of the underserved. This is a step I probably would not have taken before the earthquake.”

Millender noted the resilience, perseverance, and hospitality of the Haitian people, saying they cared as much for her as she did them.

“Even when they did not have food or a place to eat, they made sure that I was cared for,” she says. “Caring is a universal language. I did not have to speak French or Creole to show how much I cared.”

Norma Graciela Cuellar
Hurricane Katrina, 2005

For Norma Graciela Cuellar, D.S.N., R.N., F.A.A.N., her biggest moment of assurance for becoming a nurse was in her mother’s last days.

“She said, ‘I know what you do. You are a nurse. I know how much these nurses have done for me and I know what you do now. I am so proud of you,'” Cuellar says. “To this day, no one has ever reassured me that I made the right choice to go into nursing as those words from my mother did.”

Having spent so much of her life along the Gulf Coast, and with family still there when she joined the faculty of the University of Pennsylvania’s School of Nursing, her heart sank when she heard about the approach of Hurricane Katrina. Cuellar’s family was living in New Orleans and Hattiesburg, Mississippi, and her sister owned a condo in Long Beach, Mississippi.

“That Monday, I went to work when I knew the hurricane was hitting. I could not concentrate. People at work acted as if nothing was happening,” she says. “How could I be somewhere safe, being aware that people could actually be dying, fearful of survival?”

Feeling helpless, Cuellar volunteered with the Pennsylvania chapter of the American Red Cross. “I was sent to the Cajun Dome in Lafayette, Louisiana, for my assignment,” she says, adding that there were 1,100 people there—mostly from New Orleans—that had to leave their homes.

Cuellar was assigned to be the charge nurse for the medical unit. The volunteers worked 12-hour shifts, but any time nurses left, there was always a chance they wouldn’t come back. “Sometimes, I wanted to beg them to stay because we didn’t know if we would get replacements for them,” she says.

There was one story that stood out in her mind about a man who thought his life was coming to an end. “He was looking out his kitchen window and saw a wave of water coming towards him. This was when the levee broke,” she says. “He couldn’t get out fast enough, and the water was up to his waist.” In tears, the man described how he was trying to get to safety while dead bodies were floating in the water around him.

Cuellar and her staff were so busy, it was often difficult to take the time to hear the victims’ stories, but she says, “the most important thing is to listen. These people wanted to talk and they needed to talk. They needed reassurance.”

Although working with these victims was the hardest thing she had ever done, she recommends that everyone volunteer with disaster victims at least once in their lifetime.

“You will get a different perspective of what is in your community and what the needs of the people were before the disaster hit,” she says. “It is a challenge to yourself and it will make you more aware of who you are and how you will practice in the future.”

Joyce Hyatt
Haiti Earthquake, 2010

When Joyce Hyatt, R.N., M.S., M.S.N., C.N.M., D.N.P., heard about the earthquake in Haiti, she fell asleep with horrific images in her head from the disaster. She woke up the next morning and told her husband that she had to go to Haiti to help the victims.

Born in Jamaica, Hyatt works as an assistant professor at the University of Medicine and Dentistry of New Jersey (UMDNJ). The desire to become a nurse came at an early age for her.

I was inspired to become a nurse after watching my grandmother, a lay midwife in Jamaica, diligently perform her duties: delivering babies in the community,” Hyatt says. “I knew she was doing something good. She was helping people, she was loved and respected, and I wanted to be like her.”

She had initially planned on becoming an operating room nurse, but when she inadvertently assisted with the birth of a baby in a hospital elevator, she knew that was her calling.

“The overwhelming joy I experienced when the baby cried led me to realize this was my true calling,” she says. The following week, she applied to the University of the West Indies School of Midwifery, where she received her degree in nursing and a certificate in midwifery.

Hyatt had the support of colleagues and her church when she decided to go to Haiti. She had also joined an organization called Midwives for Haiti, a group that was training traditional birth attendants to become skilled midwives and to offer compassionate care to women.

When she went to Haiti, Hyatt worked in a hospital in a village outside Port-au-Prince. Many of the patients, particularly women and children, went to the hospital to deliver their babies or to seek general medical care

She worked mostly with other volunteer midwives, resident nurses, doctors, and medical students from the area who had lost their medical school in the disaster. “Everyone was compassionate, kind, and caring, not only to the patients, but toward each other,” she says.

Many visions of the disaster in Haiti remain with her. Even a few weeks after the earthquake, the effects were still evident: collapsed buildings, tents that housed victims, and organizations providing donated food. “[There were] people with missing limbs, some with burns or other injuries from the earthquake,” she says, adding that there was “an air of sadness” in the affected areas.

Some of the challenges she encountered with patients were ambulating women in labor, promoting position change, and trying to provide comfort in the absence of pain medication. Hyatt also helped in an orphanage during her time in Haiti. And for the first time in over 30 years of being a nurse, she used her CPR/neonatal resuscitation skills.

Despite the challenges, Hyatt noted how volunteering time and resources can truly make a difference to victims of a natural disaster.

“Helping these patients was one of the most rewarding experiences of my life. The patients were very grateful for the help they received, and most were just grateful to be alive,” she says. “I have become more aware of and more appreciative of what I have.”

Cynthia J. Hickman
Hurricane Katrina, 2005

After hearing about the suffering caused by Hurricane Katrina, Cynthia J. Hickman, M.S.N./Ed., B.S.N., R.N., B.C.-C.V.N., C.M., broke into tears.

The news reported that buses were coming to Houston, Texas, with displaced families. After hearing requests for water, clothes, and other sustenance, Hickman wanted to do anything she could to help the victims. But local media outlets said to wait until “a true assessment could be made” of the situation.

“I thought to myself, what kind of assessment was needed with so much human suffering?” she says. “I was scared, afraid, and sad. The worst emotion of all was an overwhelming feeling of helplessness. It was at that point I cried.”

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For Hickman, a case manager at St. Luke’s Episcopal Hospital in Houston, this was her first time helping victims of a natural disaster. She had always wanted to train, but just never had the time. “When Hurricane Katrina hit, I learned a lot of things fast. I knew I was not going to face people just within my specialty,” she says.

The list of suffering was long: diabetics without insulin, infant dehydration, depression, and more. “The [hospital’s] expectation of available staff and the roles we were to play would change based on instructions from the command station,” Hickman says. “My role as a non-direct care member of the staff was more of ensuring that patient and family needs were met and to assist with medical equipment or community services if patients were hospitalized.”

The stories of the victims brought back distressing memories for Hickman. The faces of the people and children wondering: What just happened? What do I do? Have I lost everything?

“I spoke to a lady who could not find her son, who was with a family member while…the levee collapsed,” she says. “Still today, I don’t know if she ever did.”

Hickman says food hoarding was a frequent occurrence among the victims brought to the George R. Brown Convention Center. “Many had no idea what the following days would hold. Survival by any means possible was the behaviors of many,” she says.

Most of the evacuees she worked with were African American (New Orleans’ population is roughly 67% black). But Hickman notes that the hurricane didn’t show any regard for ethnicity. “Disasters are unplanned and unwanted, but occur,” she adds.

Hickman quickly realized there were lessons to learn before, during, and after a natural disaster. Though she often thinks about what she could have done differently, she believes that anyone in a community can help during a time of disaster.

“The natural disaster reminded me why I became a nurse: to mentor, teach, care, and support those needing a hand,” she says. “My reason for volunteering was very simple. There was a need, and I wanted to meet the need to the best of my ability.”

Marie O. Etienne
Haiti Earthquake, 2010

For Marie O. Etienne, D.N.P., A.R.N.P., P.L.N.C., the earthquake in Haiti was personal.

A native of Port-au-Prince, Etienne was in her office grading papers when a fellow professor came in and asked if she had heard about the quake.

“I was in a state of shock, feeling a sense of urgency to call my family to find out if everyone was safe,” she says. Her family members in Port-au-Prince lost their homes. Another family member had a broken leg. And her cousin, who was attending medical school at the time, died as a result of the earthquake.

Currently a professor at Miami Dade College School of Nursing, Etienne traveled to Haiti a few days after the earthquake struck. There, she served as a nurse practitioner with Project Medishare, where she cared for amputees, children, and families who “felt powerless,” she says.

“I felt so guilty that I was able to walk, breathe, and feel okay while so many people were crying in pain and suffering with either one or two limbs amputated,” Etienne says. “I did everything I could to help the patients and families…giving them hope, hugs, and a little smile to keep them going.”

One patient that stands out in her mind was a 26-year-old woman who was brought in with a GI bleed and elevated blood sugar, barely conscious. She held on to Etienne saying, “Please don’t let me die.” Although they did everything they could, the woman didn’t make it.

“I could not control my tears and emotions, yet we had to remain focused to handle and care for other victims,” she says.

One major lesson that stood out during her time in Haiti was Maslow’s Hierarchy of Needs to prioritize patients’ survival: airway, breathing, circulation (A, B, C). Etienne adds that providing culturally sensitive and compassionate care was essential.

“I had to remain strong, calm, and ready to serve at any given moment,” she says. “During the recovery phase, I learned to appreciate the smallest things in life, because the victims were optimistic even when they had no reason to be hopeful.”

Etienne speaks proudly of Miami Dade, saying that students took part in several vigils and helped raise funds for the victims. She also speaks highly of her colleagues who volunteered in Haiti, having worked with the Haitian American Professionals Coalition (HAPC) and members of the Black Nurses Association (BNA) Miami Chapter both before and after the earthquake. She also worked with the Haitian American Nurses Association (HANA), noting that 30 HANA volunteers, under the leadership of former President Guerna Blot, R.N., M.S.N., M.B.A./H.C.M., O.C.N., arrived to assist with the shortage of Creole translators and provide culturally competent care.

“The medical and nursing team were outstanding in terms of handling the pressure of saving lives,” Etienne says. “When giving care, give it all you’ve got by being caring, compassionate, skillful, and a dedicated nurse.”

In July 2010, Etienne received an Unsung Hero Award in recognition of her efforts in Haiti’s earthquake recovery by the Haitian American Leadership Coalition. She continues to coordinate medical missions to Haiti with the HANA team.

Caring for Our Aging Population

Talk about a momentous birthday—the oldest baby boomers started celebrating their 65th birthdays in 2011, ushering in what appears to be a huge change in health care demands in the United States. As the population ages in unprecedented numbers and is living longer than at any other time in history, the field of gerontological nursing is facing big changes with staffing needs and day-to-day practices.

Experts in gerontological nursing are reporting a greater demand for nurses now and in the future. As the number of patients increases, a sufficient number of nurses will be needed to care for them and to relieve the workload. The solution is complex and depends on the collaborative actions of government agencies, health care providers, colleges and universities, and nurses themselves.

According to a 2005 report by the National Institute on Aging and the U.S. Census Bureau, projections indicate that by 2030 the older population will total 72 million residents, doubling the number from the year 2000. By that time, one in five citizens will be 65 or older. And, according to the report, seniors are living longer lives, but 80% of them have at least one chronic health condition (such as heart disease, diabetes, or respiratory problems) and half of them have at least two. So even as the population enjoys living longer, the health care needs of older adults are more complicated.

“There is a strong assessment that the current workforce today is not prepared to care for the population,” says Amy Cotton, M.S.N., G.N.P.-B.C., F.N.P.-B.C., F.N.G.N.A., and president of the National Gerontological Nursing Association. “Another issue of great concern for colleges is when graduates are not prepared to care for the population they have to care for, it creates a lot of job stress and can lead to a lot of turnover.”

Typically, health needs become more complex as people live longer lives. There is a pressing need for competencies surrounding normal aging, cultural norms, and the very fine line of effective communication with the patient. And as the age gap between the younger workforce and the increasingly older patient gets wider, awareness of those variations is essential to provide good care.

“Those generational differences can create a schism,” says Valerie Kaplan, Ph.D., A.R.N.P., F.N.P.-B.C., F.A.A.N.P. and a senior policy fellow with the American Nurses Association. For instance, older generations grew up following a doctor’s orders with no questions asked. Younger generations—who often search for second opinions and cutting-edge treatments—might find that a puzzling way to approach personal health.

In addition to the age differences, census predictions indicate that the population will be composed of more ethnically diverse elders by 2030, with 72% being non-Hispanic white, 11% Hispanic, 10% African American, and 5% Asian. “There is a diversity explosion in growth for various ethnic groups in this country,” Cotton says.

As those populations age, there arises a pressing need for more diversity among nurses. Cultural awareness of family expectations, patient lifestyle, and cultural norms often gives the nursing staff an indication of how to proceed with care plans. The more a nurse knows about a patient, the more likely the care plan will be successful from the beginning.

Natalie Nieves, a case manager for VNA Health Care of Hartford in Connecticut, sees firsthand the need for nurses of all backgrounds. “Minorities can be majorities in the inner cities,” she says. “Being bilingual is a plus in my field. [Patients] trust you a lot more, and they confide in you a lot more.”

When a Spanish-speaking patient can speak with a nurse also fluent in that language, they glean more from the conversation, since the details do not get lost in translation. “There is no barrier,” Nieves says. “It is clear, concise, and direct. It is amazing the difference it makes.” As valuable as an interpreter is, having a relationship where both parties speak the same language just makes it easier. “When a nurse goes out with an interpreter,” says Nieves, “the patient feels like they are talking to two people at once.”

The elderly patient benefits are both emotional and physical when they are receiving health care from a bilingual nurse. “There has to be an understanding of how cultural norms impact decisions,” says Tara Cortes, Ph.D., R.N., F.A.A.N., Executive Director of The Hartford Institute for Geriatric Nursing and professor at New York University’s College of Nursing. For instance, Nieves, who is of Hispanic descent and fluent in Spanish, has noticed this in her own practice when she visits patients who might not relate how a diet full of foods traditional to his or her upbringing might impact something like blood sugar levels.

“We need to encourage minorities to nursing,” says Nieves. “We need them out there.”

For most nurses working with an older population, good communication is of primary importance. “If you can’t, at a basic level, communicate with an older adult, you will miss the boat when caring for that adult,” Cotton says. “That communication is a critical piece and a basic piece that is easily missed. We have such a hurry-up system.”

Sabina Ellentuck, who is launching a second career as a nurse, says she tries to take a breath and focus on the patients before she approaches them. In a way, quieting her own thoughts helps her slow down, greet her patient, find out how they are doing, and speak with them for a while before moving on to the health care procedures. “You have to be able to connect with them or they will not listen or do what you ask,” she says.

That bit of personal interaction also gives a valuable perspective. “It is feeling good and communicating and having fun with them,” says Ellentuck. “On top of which there is this big need.”

Most nurses, whether or not they work primarily with a geriatric population, will care for elderly patients at some point in their careers; knowing the normal signs of aging is an essential skill. “You have to think of what aging does to vision and hearing,” says Cotton. There can be changes in balance, memory, or mobility. Personal interactions and communication also allow nurses to glean an understanding of what is a normal result of aging and what might be a red flag for something more serious.

But nurses feel the time crunch. “There is pressure to do things quick, but it is extremely important to connect with the patient and be a good detective and pick up signs when something is wrong,” Ellentuck says. “It is hard to do that when you are rushed. The balance really is the challenge of integrating good health care while doing all these things.”

While the need for nurses continues to grow, pay disparity is often a roadblock, says Cotton. When nurses can earn more money in an acute care setting than in a long-term facility setting, they are generally drawn to the higher pay scale. Cotton says payment reform has to occur to attract more nurses to the field. After all, many nursing students graduate shouldering large debts, and paying them off is of primary importance. “It is hard to support yourself with what a geriatric nurse makes today,” says Cortes.

Many experts say the foundation for successful gerontology nursing practices begins in school and continues as nurses enter the workforce.

“The first exposures to gerontological nursing practices are critical,” says Cotton at the National Gerontological Nursing Association. Students need exposure to healthy, vibrant elders, as well as those who are sick or frail. And age does not always indicate health. Students need to be able to refute the myth that aging goes hand-in-hand with illness. “Changing that perception requires interaction with healthy and well elders,” says Cotton.

Valerie Cotter, D.N.P., A.N.P./G.N.P.-B.C., F.A.A.N.P., and advanced senior lecturer and Director of the Adult Health Nurse Practitioner Program at the University of Pennsylvania School of Nursing, says schools are trying to make it interesting for students to come into the field of geriatric nursing. One of the best ways for that to happen is for students to see the passion that so many professionals have for working with an older population. Describing that job satisfaction to students is essential, Cotter says, especially if the students have not had an opportunity to experience in their own lives.

“I was fortunate to have a good relationship with my grandparents,” says Cotter. “As a nurse, I gravitated to older adults. I love the life story and the narratives. Older adults have many more experiences, and you look at health within the context of those life experiences.” Through education as well as their personal experiences, nurses are able to sharpen their skills to the complex needs of the elderly and recognize red flags quickly. “You have to know the baseline status to recognize change,” says Cotter.

In 2002, according to an article in Health Affairs, 58% of baccalaureate nursing programs had no full-time faculty with specializations in geriatrics.1 “We still don’t have enough geriatric content built into the undergraduate curriculum,” says Cortes. “We need nurse practitioners for geriatric care. We do not have enough physicians to care for this population. Nurses can do a tremendous job of keeping the older population safe and at home and functioning at their highest level.”

Even a nurse who works in ICU needs to know if the patient has had a flu shot to provide comprehensive care. A nurse might encounter a healthy and active 90 year old or 67 year old with high blood pressure, complications from diabetes, or other serious health issues. “The reality is we are still providing care for adults across the continuum,” says Kaplan. “As they age, their health care needs are not driven by where they end up in the health care facility, but by the health care problems. [Nurses] need to identify the care needs of patients not based on where they work.”

While an important foundation of geriatrics is educational, Kaplan says, nurses need a general understanding of what it is to care for someone who has lived through different times. “The brain changes are sometimes more challenging than the physical changes,” Kaplan says. They are also more difficult for some family members to come to terms with. The nurse’s job, says Kaplan, is to be present for the patient. “If they are in 1945, then you are in 1945,” she says. “It is important that nurses as caregivers recognize that and not challenge that.”

Nieves says there is so much going on with an elderly patient that nurses are forced to use all their nursing skills on the job. “You use every single thing you have got,” she says. “I really truly enjoy my job.”

The industry is constantly developing models for consistent, coordinated, and collaborative care for older adults, says Cortes, but it is the nursing staff that carries it out. Nurses care for the whole person, she says. Caring for an elderly population is much more complex than treating only health issues. With elderly patients, you must consider their lifestyle. Are they eating enough? If not, is that because they forget or because they do not have enough access to food or transportation to get food? Do they have a small appetite? Is their medication impacted in any way by their foods? Are they taking their medication exactly as prescribed? How involved is the family, and how will family beliefs and attitudes change the course of the care?

To encourage nurses to specialize in geriatrics, it’s important to get nurses into the field and show them how rewarding it can be. “I’d love to see the number of nurses certified in geriatric nursing and practicing as NPs, and caring for elder adults increase,” says Cortes. “Nurses will be much more involved in developing those practices. It is very positive.”

Ellentuck finds the changes galvanizing. “It is a very exciting time now in how we think of helping older adults—many assumptions no longer exist,” she says. “A prime focus now is on function and getting people moving, moving out of those wheelchairs (if possible), doing activities that connect to the person’s interest or background. . . . To me, this is very exciting, and I look forward to being involved and doing these new practices that are truly patient-centered care.”

Reference

  1. Christine Tassone Kovner, Mathy Mezey, and Charlene Harrington, “Who Cares for Older Adults? Workforce Implications of an Aging Society,” Health Affairs 21 (2002): doi: 10.1377/hlthaff.21.5.78.
Elsie Soto, RN: 40 Years of Home Care in Nueva York

Elsie Soto, RN: 40 Years of Home Care in Nueva York

After spending four decades climbing the stairs of New York City’s tenement apartments to deliver compassionate, expert home care to hundreds of Spanish-speaking patients in the South Bronx, Washington Heights, and other communities, Elsie Soto, R.N., a veteran public health nurse at Visiting Nurse Service of New York, may be forgiven for enjoying 2011 as the year she became something of a nurse “celebrity.”

In recognition of contributions made during her lifelong career in home care nursing, Elsie was named “Clinician of the Year” nationwide by the Visiting Nurse Associations of America, an award presented at VNAA’s annual meeting in Baltimore, Maryland, in April.  In May, Elsie was honored by the Home Care Association of New York State with a prestigious statewide “Caring Award,” for which all Empire State professionals, paraprofessionals, and family caregivers are eligible. This award goes to one “who has exhibited the compassion, skills, and service that set their contribution apart, or whose actions on a particular day, or over a period of time, exemplify outstanding compassion,” according to the award website. Rounding out a trifecta of recognition, Elsie was also recognized by Nursing Spectrum magazine with a 2011 “Excellence in Nursing Award” as a regional finalist in community service.

“I want to thank my familia at VNSNY—including many coworkers, past and present—and my patients for allowing me to enter their homes and do my magic,” Elsie said in her acceptance speech. In my life, I’ve always been surrounded and guided by three important and influential women: mi mami Elena for caring, Florence Nightingale for commitment, and VNSNY founder Lillian D. Wald for service.” Elsie also acknowledged her fivebrothers “who were [her] first patients,” her husband and children, and the early support received from a priest and nun (“long before the word ‘mentor’ became popular”) who encouraged her to pursue a career in nursing, even though it took Elsie away from Catholic high school in the Bronx.

Mi casa es tu casa

Bilingual in Spanish and of Puerto Rican heritage, Elsie has long played a leadership role in providing culturally sensitive care to VNSNY’s Latino patients in NYC—a population that in sheer numbers is second only to Los Angeles among Spanish-speaking communities nationwide. In addition to the exceptional care Elsie has provided most recently in the predominantly Dominican neighborhood of Washington Heights, she also serves among VNSNY’s key representatives in the New York chapter of the National Association of Hispanic Nurses. Several years ago, when NAHN honored VNSNY with an “Institutional Award” for the agency’s efforts to “raise awareness of health care disparities and increase diversity in nursing practice,” Elsie was asked to personally accept it.

Elsie is no stranger to accolades and recognition. In 1993 and again in 2008, Elsie was nominated by VNSNY colleagues and went on to win ESPRIT Awards, the organization’s highest honor. (ESPRIT Awards are named for VNSNY’s values: Excellence, Service to Customers, People, Fiscal Responsibility, and Teamwork.)Elsie and her patients were also the focus of a 2007 cover story in ADVANCE for Nursesmagazine entitled “Mi Casa Es Tu Casa: Culturally Sensitive Home Care for Hispanics at VNSNY.” She has also been featured in news articles about VNSNY’s agency’s longest-serving veteran nurses.  

Since joining VNSNY as a 20-year-old LPN, Elsie has striven to stay as “flexible as a willow,” relying on a sense of humor to help patients through the tough times. Colleagues cite her stellar commitment to patient care and praise her willingness to always go above and beyond.When nominating Elsie for an ESPRIT award, one coworker wrote, “Elsie is knowledgeable regarding all dimensions of her patients’ conditions, including both clinical and social aspects.”

Elsie shares a memorable patient story from her vast trove: “I was asked to pre-pour meds and informed that my patient’s front door would be open. It was evening when I arrived. To my dismay I found the patient waiting for me in the dark. I immediately turned the lights on. Finally, sitting down to pre-pour his meds, I realized that he was blind. I apologized for not being mindful. He started to laugh, and told me stories of others who had been guilty of the same ‘crime.'”

Elsie still remembers one of her very first home care patients, “Anna,” who lived alone in the South Bronx back in the 1970s. For more than nine months, Elsie provided daily care for Anna’s breast cancer wound. As a new nurse, Elsie remembered feeling silently skeptical when Anna said the wound would heal. Eventually, it did heal, and Elsie recalled feeling a mixture of joy and sadness when she said goodbye to Anna on her final visit.

In addition to using her prized bilingual ability in Spanish to care for VNSNY’s huge numbers of Hispanic/Latino patients, Elsie has also provided home care to patients in many other immigrant communities in New York City, one of the world’s most diverse megacities. From caring for culture-shocked Vietnamese refugees in the Bronx in the wake of the Vietnam War to Russian, Chinese, East Indian, Pakistani, and patients from other ethnic groups, Elsie has personally carried on the mission of VNSNY: “caring for all New Yorkers.” In an example of such service, in the aftermath of Hurricane Katrina in 2005, Elsie was one of fewer than 50 VNSNY nurses to be recognized for aiding Katrina evacuees at Disaster Assistance and Welcome Centers set up by the New York City Department of Health.

Today the nation’s largest nonprofit home health care organization, VNSNY was founded in 1893 by Lillian Wald, the “mother of public health nursing,” to serve the teeming immigrant population of New York City in the 19th century. Through the work of clinicians like Elsie and some 2,600 other nurses on staff, the agency has continued this role into the 21st century.

“The Bronx is burning!”

New York City is home to the nation’s second-largest Latino community, comprised of Spanish-speaking peoples from more than 20 nations. Collectively, they comprise more than a quarter of the city’s population, according to the U.S. Census Bureau. By contrast, Elsie is among a small minority—one of the estimated 2% of U.S. nurses who speak Spanish—and among approximately 4,500 Spanish-speaking nurses serving an estimated 2.5 million Latino residents of New York City. Elsie’s role as a coordinator of care and public health nurse has kept her on the front lines at VNSNY, which employs New York City’s largest pool of Spanish-speaking health care providers.

Born to parents who immigrated to New York City from Moca, a town in the mountains of Puerto Rico, Elsie is the only girl in a family with five younger brothers. They grew up in the South Bronx. During this period, the borough was plagued by crime, drugs, and frequent arson fires. “The Bronx is burning,” the saying went. Elsie credits her parents and Catholic schoolteachers with providing a bulwark against the devastation and modeling responsibility to one’s community.

Elsie became an LPN through a program at Jane Addams Vocational High School and then went on to become a registered nurse at Bronx Community College in 1974 (later pursuing B.S.N. studies at Mercy College). She became involved in home care early and worked in her own neighborhood for 14 years. The needs in this area were especially great in the 1970s and 1980s. Elsie recalls a litany of problems with “riots, job losses, crime, decay, drugs.”

“I personally witnessed the arrival of heroin in the Bronx and watched how it decimated people in droves,” she says. For two years in the mid-1980s, Elsie’s treatment area included the Webster Projects, scene of the highest homicide rate in New York City, with approximately one killing per week. Elsie personally cared for one of the four young men shot in 1984 by notorious “Subway Vigilante” Bernhard Goetz. She recalls needing security escorts on nearly every visit in those days. 

Being a Spanish-speaking Latina is an asset in her community, Elsie says, “because even though they know I’m not Dominican, or Cuban, or Mexican, I do speak the language. We have that basic cultural identity. Automatically things are clearer and more relaxed and they think ‘you may not be of my origin, but you speak my language.'” As in any culture, nonverbal communication in the Hispanic culture is as crucial as verbal communication.

These days, with a caseload of about 15 patients a week, Elsie serves patients in mostly Dominican neighborhoods of Washington Heights in upper Manhattan. Although Elsie essentially shares the same language as her predominantly Hispanic patients, she expresses appreciation for the subtle and not-so-subtle differences among various communities. Elsie notes that Hispanics are defined as “persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures.” The term Latino encompasses Brazilian, Asian, and African cultures as well.

“We may share the same town name (there is a Moca in the Dominican Republic too) and ways of connecting,” Elsie says, “but we’re diverse. That’s what makes us so unique. Because of my accent, Dominican, Cuban, and Mexican patients will know that I am from Puerto Rico, but we’re all connected. I try as much as I can to learn about their culture from them and to let them learn from me.”

La familia and culturally sensitive care

Elsie notes that to deliver culturally sensitive care, home care nurses must be mindful of the importance of la familia in Hispanic culture. “You have to include the family as part of the healing process,” she says. “Whoever it is—abuela (grandmother), aunt, godmother—you have to incorporate them because they have wisdom to offer, and so that you can be successful.” She adds that religious and cultural beliefs also play important roles in caring for the Hispanic patient. Many believe pain is an expected part of life and a consequence of immorality.

Elsie Soto with fellow ESPRIT winners in 2008Elsie Soto with fellow ESPRIT winners in 2008

“Some people will say ‘I’ll take the pain because this is part of my punishment,’ and coming from the Hispanic culture, I can identify with the idea of paying for something I did wrong years ago,” Elsie says. “You have to give respect to the notion of pain as a punishment from God. I tell patients that I understand, but I think you have been forgiven, and now I am here because God is telling me to facilitate your pain and let you go more peacefully.”

On a daily basis, Elsie deals with the fact that Hispanic Americans suffer one of the highest rates of diabetes in the United States, with a prevalence that is more than 50% greater than among average New Yorkers. “As a Hispanic, I implement this knowledge that we have in my work at VNSNY—and on a personal level, I share that my mother and father died very young and that diet plays a role in their heart disease and diabetes,” Elsie says. “But I’m also flexible and do not completely try to demoralize my patients because it’s not going to work,” she adds. “I try to modify the diet but not completely take away their food.” Elsie is drafting a Spanish-language publication on this topic for the Alzheimer’s Association of New York.

Eight years ago, Elsie was one among a small group of VNSNY staff who joined together to revive the dormant local chapter of NAHN, founded in 1975 and committed to improving the health of Hispanic patients and communities and increasing educational, professional, and economic opportunities for Hispanic nurses. Thanks to such efforts, the NAHN chapter is vital once again.

Elsie is involved in a pilot program called the Hispanic Leadership Project, to develop such skills among Hispanic nurses. Elsie notes that the project sprang from a yearlong nursing course called the Minority Leadership Program that she took some years ago at Rutgers University. Elsie also attends NAHN’s national conventions. In summer 2009, she presented a poster on diabetes and comorbidities among Hispanic patients at NAHN’s annual meeting in San Antonio, Texas. She and others presented on the pilot Hispanic Leadership Project.

“Home care has been my ‘second home’—an amazing journey for me,” Elsie says, when asked how her profession and role as a home care nurse has changed in the past 40 years. “The fundamental care of nursing has not changed. What has changed is the introduction of technology in the home and in our manner of communicating. My journey has been filled with much love for the work I perform and the people I work with…” 

Online Higher Education: The Key to Training, Recruiting, and Retaining More Hispanic Nurses

The numbers tell the story. 

Hispanics are the fastest-growing segment of the United States’ population—they currently comprise 16% and are expected to grow to 30% by the year 2050, according to the U.S. Census Bureau. However, Hispanic nurses make up only 3.6% of all registered nurses in this country, as reported by the 2008 National Sample Survey of Registered Nurses (NSSRN).

While other minority populations experience problematic underrepresentation in nursing, it is especially apparent in the Hispanic community, and the gap widens every day. In 2008, only 5.1% of all RNs spoke Spanish, according to the NSSRN. There are not enough Hispanic nurses to deal with the health care issues facing this growing population, and the language barriers and lack of cultural understanding created by the void lead to substandard health care for the entire community. In fact, a July 2006 article published by USA Today pointed out that the lack of English language proficiency in patients directly contributed to diminished health care for those individuals.

A 2008 workforce survey showed that Hispanics were 28 years old on average when obtaining their initial licensure compared to an average age of 25 for whites. The most common type of initial R.N. education among Hispanics was the associate degree in nursing (55.1%) followed by the bachelor’s (39.4%), and then a hospital diploma (5.5%). Why does the associate degree come out ahead? The reason may be financial. The A.S.N. provides earning power earlier than a four-year bachelor’s program in nursing. Hispanics were also more likely to pursue a bachelor’s degree after obtaining the initial R.N. (41%), but were less likely to pursue graduate degrees (11%) than white, non-Hispanic RNs (39% and 14.5%, respectively). Hispanic nurses comprise only 3.5% of all nurses in advanced practice fields.

The vast majority of Hispanic nurses (68.8%) work in hospitals and then in ambulatory care (6.9%). Hispanic nurses also hold only 10.9% of all nursing management jobs, possibly due to the low number of Hispanic nurses with graduate degrees. Finally, there are fewer Hispanic mentors in higher education and nursing leadership positions who can guide other Hispanics. Attracting and retaining nursing students from racial and ethnic minority groups can’t be accomplished without strong faculty role models. According to 2009 data from American Association of Colleges of Nursing member schools, only 11.6% of full-time nursing school faculties come from minority backgrounds, and only 5.1% are male.

As the U.S. population becomes more diverse, leaders in multicultural segments, including Hispanic communities, must encourage minorities—and minority nurses—to become leaders themselves, so when they continue to build upon their skills and advance their careers, they will help themselves and their communities. Health care for this underserved population should ultimately improve if it helps members of the Hispanic nursing community become leaders in health care, experts in the growing field of nursing informatics, and trained nurse educators.

Taking advantage of the online learning environment

Many factors promote successful career development and mobility among Hispanic nurses, and one of the most important is the opportunity for educational advancement. Online higher education programs in the field of nursing help students develop critical leadership skills that, in turn, lead to improvements in their overall community. The online format provides flexibility, providing students the opportunity to take courses while meeting their professional and personal obligations, contributing to multiple other benefits of studying nursing online.

Minority students at all educational levels can see graduates from these programs as role models and examples of how they, too, can achieve success. In cases where students may be struggling, it’s especially important when they can point to a nurse in a leadership position—someone who looks and sounds like they do—as an inspiration to keep going, whether it’s toward getting a Bachelor of Science in Nursing (B.S.N.), a Master of Science in Nursing (M.S.N.), getting a promotion, or taking on an important social change initiative to help a group in need.

Many of these minority students seek out mentors in school, possibly other minority nurses, and often go on to become mentors for the next generation of nurse leaders. For example, many of Walden University’s graduates work and teach in associate degree nursing programs, which have a large representation of Hispanic nursing students, and they help in retain these students through mentoring.

In some ways, online education “levels the playing field” for minority students, fostering increased participation and confidence that may lead to their greater success in the classroom and workplace. Many Hispanic students speak English as a second language and may write better than they speak. Since writing is integral to online learning, it adds a level of confidence that Hispanic students may not feel when sitting in a traditional, bricks-and-mortar classroom. There is no sitting in the back of the room or far from the action and dialogue up front. Consequently, minority students who may struggle in a traditional setting often thrive in online classes, which provide a unique venue for students to have a new voice, speak up, and become leaders in the classroom and beyond.

Increased participation in the online classroom has additional benefits for Hispanic and other minority nursing students. These students not only have the opportunity to hone their personal and professional skills and talents, but they can also develop relationships and network with other nurses across the country. A nurse working in the Cuban American community in South Florida may share best practices with a nurse working with the Mexican American population in Southern California. Or perhaps non-Hispanic nurses working with Hispanic patients may consult with their Latino classmates online for advice regarding how to provide the best care for these patients. Online higher education gives students a special way to connect so they can enhance their education and make a difference in the lives of many.

Making strides toward improving access

As a minority fellow of the American Nurses Association and a current board member of Ethnic Minority Programs for the organization, I work with my colleagues to develop proactive strategies to train, recruit, and retain more minority nurses, especially Hispanics. As Associate Dean of Walden University’s School of Nursing, I lead an experienced, dedicated, and talented team of faculty and staff focused on creating the next generation of leaders in the minority nursing community. Through programs like our Master of Science in Nursing and Bachelor of Science in Nursing Completion Programs, we can make great strides toward increasing the number of Hispanic nurses who serve as role models for the larger minority community.

For many M.S.N. and B.S.N. students, the training they receive in their online courses is put to work directly in their own communities. During their practicum or capstone course, M.S.N. students can choose projects that are inclusive of the needs of their workplace or neighborhoods. Often, these projects involve working with underserved populations to solve problems in community health care. B.S.N. students undertake similar projects in their community health practicum. They can all tap into their nationwide network of fellow students to come up with the best solutions for problems they encounter.

I especially recognize the importance of recruiting faculty members at the doctorate level from minority groups. Since there already is a shortage in the number of Hispanic nurses, you can only imagine how few in this population have earned their doctorates. Yet, they do exist, and when they teach, they make a difference.

One example is Patti Urso, Ph.D., A.P.R.N., C.N.E., Specialization Coordinator of Nursing Education, who currently teaches nursing education courses at Walden. Dr. Urso, a Cuban American originally from Miami, is a nurse practitioner who now lives in Hawaii and works with other underserved populations from Polynesian and Micronesian communities. In Hawaii, she engages with Hispanic patients through community churches and is involved in forming a new chapter for the National Hispanic Nurses Association. She hopes to inspire her students to reach out to underserved communities, and she mentors Hispanic students in the capstone course of the nursing education program.

One of the ways Dr. Urso works to connect with Hispanic nurses is through contact with alumni such as Lydia Lopez, one of the first graduates from Walden’s M.S.N. program in 2007. As a nurse and mentor, Ms. Lopez is committed to being a role model who recruits and retains minority nurses, keeping them interested in their course work and giving them the necessary tools and strategies to facilitate academic success. “True role models are those who possess the qualities that we would like to have and those who have affected us in a way that makes us want to be better people,” she says.

The nursing profession needs both men and women from all ethnicities to meet the needs of society. Minority nurses—especially Hispanics—with bachelor’s degrees and, eventually, master’s and doctoral degrees—who are prepared to educate and lead a new generation of minority nurses—will help improve this critical situation and provide essential health care for all.

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