Continuing Education and Training Gaining Greater Emphasis As Need for Case Managers Grows

Continuing Education and Training Gaining Greater Emphasis As Need for Case Managers Grows

A study conducted by the Commission for Case Manager Certification (CCMC) cites increasing demand for certified case managers. The CCMC’s 2014 Role and Function Study also found that employers are willing to pay higher salaries for professionals whose education, training, and certification demonstrates a higher level of knowledge, skills, and overall competency. Further, the study revealed that 40.2% of employers are now requiring their case managers to be certified. Contrast this figure to the 25.9% of employers requiring certification in 2004. The CCMC’s conclusion regarding a growing demand for well-trained and credentialed case managers is supported anecdotally by the actions of many health care organizations.

Clearly, case management presents a strong career path for nurses and even greater opportunities today. The opportunities can be even greater for minority nurses, including African Americans, Asians, Hispanics, Filipinos, and Native American and Alaskan nurses, for which there is already a concerted effort to recruit so that they can bring their cultural competencies to our nation’s increasingly diverse patient population. However, continuing education and training are musts for any nurse who truly wants to make a difference in his or her patients’ lives while also realizing his or her full professional potential and earning power. The education starts by understanding how the market is driving increasing demand for case managers and, the educational resources available to help them become key catalysts for the delivery of better health care in America.

Not Just a Personal Choice–Employers Demanding Higher Skills

While the Patient Protection and Affordable Care Act of 2010 (ACA) raised the bar on expected standards of care and paved the way for increased demand for case managers, market conditions were already driving the need up. The graying of America, coinciding with the increased incidence of chronically ill patients of various ages succumbing to diseases of the 20th and now 21st century (e.g., obesity, high blood pressure, and chronic pulmonary obstruction disease) all have placed greater demands on health care providers. This, in turn, prompted many to increase their hiring of case managers—also being called care coordinators, patient advocates, and a host of other titles. For example, back in 2012, the UCLA Health system in Los Angeles began hiring full-time care coordinators to work with doctors serving in its primary care clinics. By 2015, UCLA had 24 “Comprehensive Care Coordinators” serving in its ambulatory primary care clinics.

Other health care organizations across the country, including hospitals, accountable care organizations, managed care firms, and insurers were and are actively increasing their case management staff. Some examples are: Advocate Health Care, Bon Secours Health System, Banner Health, Mercy Health Select, Partners Healthcare and the University of Michigan Health System. Based on the CCMC’s figures, by 2015 there were 37,000 certified case managers serving in U.S. health care organizations versus 20,000 in 2010. An estimated 89% of the certified case managers are registered nurses. The balance is comprised of social workers (4.4%), vocational rehabilitation counselors (2.3%), and others.

Despite the growing demand for case managers, the profession is not without its challenges. Of the over 100,000 professionals involved in case management, their average age is estimated by various surveys to be 53 years old. The transfer of knowledge from these experienced professionals to their younger counterparts is essential as demand rises and many of the field’s most skilled are entering the retirement years. Through continuing education, training, and mentoring of newer case managers by experienced case managers, some of the deficits in skills and knowledge can be addressed.

The federal government is acutely aware of the importance of training for RN case managers. In fact, the government has established a fund of $20 million for training, specifically in the areas of data collection, reporting, and practice changes to help smaller health care practices improve. Many minority nurse case managers serve in smaller health care practices, in addition to large urban hospitals, so they may very well be beneficiaries of this federally-funded training. Employers too are hosting more educational and training programs for their case management staff and encouraging their personnel to participate in continuing education programs, not just for licensing compliance purposes, but for their own skill development and career advancement.

Based on current PayScale data, Certified Case Managers with the title of Nurse Case Manager are averaging annual salaries of between $60,514 to $89,132, depending on the employer and region of the country. Directors of Case Management are commanding average annual salaries within the range of $75,978 to $145,177, and those with the title of Registered Nurse, Utilization Management, are averaging annual $61,545 to $98,197.

Most RN case managers can aspire to become leaders in their departments, assuming they have earned their CCM designation and are committed to being continuous learners. Knowing the options in continuing education case management training programs and resources available and how to select wisely is tantamount to building best practices in case management and assuming leadership roles.

Continuing Education and Training Resources

StateCE, a part of Vista College, reported that nearly 76 million adults in the U.S. are enrolled in some form of continuing education. Many human capital development experts believe that training from outside continuing education providers offers a distinct advantage over in-house training programs. It is their contention that this education helps individuals gain a deeper level of knowledge—both theoretical and practical, as well as enhancing their problem-solving and collaboration skills. In addition to gaining higher-skilled employees, employers gain the added benefit of continuing education promoting staff retention. A study by Spherion Atlantic Enterprises reported that 61% of employees who receive continuing education remain with their current employers for at least five years.

Continuing education (CE) resources include independent organizations, colleges/universities, professional organizations, and internal training departments. Their offerings range from onsite CE-credit seminars and certification workshops, webinars, and various long distance e-learning programs. The best continuing education programs and resources for case management have certain traits in common. They are:

  • Developed and provided by credentialed professionals with both clinical and business experience;
  • Goal-oriented, whether the goals, for example, be: certification, gaining best practice skills, gaining knowledge about a specific medical condition and/or patient population, learning how to manage a case management department, or learning what it takes to start your own case management firm; and
  • Have specific learning objectives clearly conveyed regardless of whether the program or educational resource involves an instructor or self-learning.

Along with meeting these criteria, there are other specifics which seem to be important in the effectiveness of a continuing education program. For instance, data uncovered in 19 studies and discussed in a Nurse Education Today article titled “Review of continuing professional education in case management for nurses” found that the “most appropriate program length appears to be at least 16 hours.” Further, the findings were that a combination of interactive lectures and small group discussions were associated with the most positive learning outcomes. What we know is that each type of continuing education program or resource has a valuable role to play.

Different Benefits of Different Educational Formats

Following are some examples of different continuing educational offerings, their various formats, and the benefits they deliver:

Onsite Seminars. These seminars are presented by qualified instructors with both clinical and business experience and are ideal for engaging case managers, giving them a direct line to an experienced professional whose insights into processes and nuances are without a doubt vital to professional growth and advancement. These events also give case managers an opportunity to share their experiences with and learn from their peers. On that level, they help to boost morale, build professional camaraderie, and instill a sense of professional pride.

CCM Certification Workshop. This workshop has a specific purpose in helping a case manager prepare for their certification exam. These workshops, especially those backed by the CCMC, deliver education and up-to-date information about best practices in today’s case management, while also imparting need-to-know information regarding the eligibility requirements and application process for the gold-standard case management credential—the CCM®—and how to prepare for the exam.

Setting-Specific Educational Programs. Setting-specific programs, such as a Hospital Case Management Seminar, are customized for a specific hospital’s needs and designed to help a hospital case management staff achieve improvement across key quality metrics, as well as overall health care efficiency and cost-effectiveness. Because the program is hospital-specific, it also has the residual benefit of instilling in each participant a renewed passion for their role and commitment to their organization.

Agency-Specific Educational Programs. These programs are for case managers serving with the Veterans Administration system or Indian Health Services organizations; both of which encounter very unique challenges both from a patient and administrative perspective and thus require continuing education that recognizes and helps case managers function at their best within the constraints of these settings.

Patient Population, Medical Condition, or Challenge-Specific Educational Programs. These programs, such as those tackling pediatric case management, obesity, our nation’s multiculturalism, the aging population, or health literacy problems, delve deeply into a specific topic to give case managers a broader, more comprehensive understanding of a medical condition or challenge they are likely to be handling already.

Seminars on DVD. These offer the best of both worlds. Case managers can gain access to a great seminar, perhaps being conducted in a city too far from their location, by simply purchasing the seminar on DVD. This gives the case manager a virtual seminar experience right from the convenience of their own home or office. It also enables case management department supervisors to have a “refresher course” right at their fingertips for easy access to continuous learning, and to provide to new staff members. Many of the profession’s best seminars on DVD come with handouts, video clips, and some even offer a phone consultation with the program instructor.

Seminar e-Workbooks. These are also ideal for case managers who can’t attend a seminar but recognize the importance of their learning the information presented at the seminar. Often, these e-Workbooks are provided on convenient flash drives and include PowerPoint presentations, case studies, and other resource materials.

Textbooks and Related Home Study Programs. These are perhaps the perennial continuing education resource for case managers. Every case manager’s personal library and every health care organization’s training room should be equipped with the profession’s best textbooks. Today, some of the most prolific authors, whose textbooks are used by nursing schools worldwide, also offer companion home study programs to their books and associated continuing education tests approved for CE credits. For instance, The Case Manager’s Handbook Home Study Program offers a continuing education test, which has been approved for 80 CE Credits. It can be taken online to prepare for the CCM exam or to help case managers meet their CE credit requirements.

Learning Management Systems. These are another option for personal learning growth and career advancement. They are typically module-based to make for easy, convenient learning and are organized in a sequence that promotes the best building of knowledge and acquisition of skills.

Closing Remarks

Continuing education should not be viewed by case managers as a necessary evil for maintaining their professional license, but rather as a valuable tool worthy of their investment. Continuing education is essential for building knowledge and skills, helping case managers become better patient advocates and better employees able to support their employer’s quality of care, risk management, and fiscal objectives. Moreover, through continuing education accessed through a multitude of options, case managers can take control of their own careers and position themselves for optimum advancement opportunities, salary gains, and potential leadership roles. It is incumbent upon minority nurse case managers to recognize that the investment they make in their continuing education and continuous learning is a clear path to gain a greater voice in our nation’s health care system. Through continuing education and the greater opportunities, it affords, they are in a better position to raise awareness of the value of high-quality case management, and in turn, make a greater difference in the lives of all patients across all communities.

Get the Most Out of Your Nursing Association Membership

Get the Most Out of Your Nursing Association Membership

Have you thought about joining a professional nursing association or are you already a member of one? Nursing associations offer a variety of member benefits including opportunities to network and grow your career through continuing education and conferences. It can be a worthwhile investment – if you make the most of your membership. It will impress your boss a lot more if you can say that you are active in your association versus just listing it on your resume.

Here are a few ways to make the most of your nursing association membership:

Take Continuing Education Courses

As a nurse, you should also be a lifelong learner. Some nursing associations like the American Nurses Association ( offer continuing education courses at a discounted price for members.  Classes offered include Bullying in the Workplace: Reversing a Culture and Why Does Conflict Competence Matter?, among many others. 

These continuing education courses offer education in areas probably not covered while in nursing school and can give you guidance and confidence in working in healthcare settings.

Network, Network, Network

This is a given, but you should be networking with other RNs and joining an association is a great way to meet other nurses outside of your current place of employment. Share best-practices and gain a supportive network of other nurses passionate about the field.

If your association offers monthly meetings or other gatherings, be sure to attend. You will broaden your perspective and your network.


Does your association have local chapters, committees or events that need volunteers? Rolling your sleeves up is a great way to get to know other nurses, network and make a difference.

Connect with Other Minority Nurses

As a minority nurse, there are nursing associations targeted to specific ethnicities such as the National Black Nurses Association (, the National Association of Hispanic Nurses ( and the Asian American/Pacific Islander Nurses Association (

Joining a nursing association dedicated to minority nurses offers a gathering place for minority nurses to work together toward providing better patient care and outcomes for diverse patient populations.

For instance, the National Black Nurses Association’s mission is “to represent and provide a forum for Black nurses to advocate and implement strategies to ensure access to the highest quality of healthcare for persons of color.”

If you’re a brand new nurse or a veteran nurse, nursing associations have a lot to offer. Consider joining one and getting involved today. 

Denene Brox is a Kansas City-based freelance writer. 

Image credit: Stuart Miles /

Preparing for the Future

Preparing for the Future

“The burgeoning knowledge from the International Human Genome Project and other genetic research has made it possible to identify individuals at risk for disease, and to diagnose and treat disease in ways that until recently were not possible. These discoveries can improve health through early diagnosis, health promotion activities, more targeted treatments and increased understanding of prevention. All health care professionals need to understand the implications of genetic knowledge and develop skills competencies in genetics, including the social, ethical, legal, economic and policy implications.”

–Suzanne L. Feetham, RN, PhD, FAAN, senior fellow, Health Resources and Services Administration (HRSA)

If you think that as a minority nurse caring for patients in a hospital, teaching at an academic institution or working to eliminate racial and ethnic health disparities in a community-based setting, genetics has no bearing on your activities, think again. According to the National Human Genome Research Institute (NHGRI), all diseases have a genetic component, whether inherited or resulting from the body’s response to environmental stresses.

Today, learning about the role of genetics–the study of single gene disorders–and genomics–which recognizes that most health conditions involve multiple genes combined with environmental factors that contribute to the “expression” or triggering of those genes–in preventing and treating diseases that disproportionately affect minority populations is quickly becoming an imperative for nurses of color. However, because the knowledge gained from the breakthrough International Human Genome Project (HGP) is still so new, very few nurses–regardless of race or ethnicity–have had much exposure to this emerging field that is already beginning to revolutionize health care as we know it.

A primary reason for this is the fact that genetics and genomics have historically not been incorporated into the nursing school curriculum. Nine years ago, when Joyce Newman Giger, RN, EdD, APRN, BC, FAAN, professor of graduate studies at the University of Alabama at Birmingham School of Nursing, joined the faculty and wanted to teach genetics, she was surprised by the response. “They wanted me to go away,” she recalls.

Even when genetics is taught to nursing students, it is usually limited to the study of birth defects, never addressing adult onset diseases. But as Giger, who is African American, so aptly puts it, “Genetics is about diseases that occur from the womb to the tomb.”

If genetics is introduced in biology courses, it is not reinforced in the nursing core courses or clinicals, adds Cynthia A. Prows, RN, MSN, program director for the Genetics Program for Nursing Faculty (GPNF) at the Children’s Hospital Medical Center in Cincinnati.

Getting Up to Speed

Prior to the mid-1980s launching of the HGP–an international collaborative effort to map and sequence all of the genes that comprise human beings (known as our “genome”)–there was a lull of discoveries in that area. Since then, however, scientists have been amassing genetic information at warp speed.

As an example, the time necessary to identify a gene has accelerated from years to months to weeks and is now occurring daily. As of 2001, the sequence of the genome’s three billion base pairs of genes was approximately 90% finished, with completion expected in spring 2003.

“Previously, the teaching of genetics [in nursing] has been associated with single gene disorders, such as cystic fibrosis, and chromosomal anomalies, like Down Syndrome,” says Nancy James, RN, MA, program coordinator of the Genetics Interdisciplinary Faculty Training (GIFT) Program at Duke University in Durham, N.C. “Nurses must learn to start looking through a genetic lens because we now know that all common, complex disorders, such as diabetes, arterial sclerosis, cancers and depression, have a genetic component. As clinicians, we must be able to incorporate this genetic knowledge into practice.”

Another barrier is that some nurses are apprehensive about taking more advanced courses in the biological sciences, believing that it is too difficult a subject matter to comprehend. “Many nursing schools don’t integrate molecular biology into the curriculum because [they feel] ‘it is too hard for nurses to understand,’ but that’s ridiculous,” Giger argues.

“We take biology, chemistry, anatomy and physiology.” Still another factor is that many minority nurses don’t continue their education past the two-year diploma or associate’s degree level. Very often, the biggest obstacle to obtaining an advanced degree is financial constraints.

“Minority nurses tend to hold associate degrees because they can’t afford a four-year college,” explains Ora L. Strickland, RN, PhD, FAAN, an African-American professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta. “But in order to be a scientist [and conduct genetic research], you have to have a PhD. With most minority nurses stuck at the associate degree level, we don’t have enough of them who can move to the PhD level rapidly.”

In the wake of the HGP, however, a growing number of nursing schools are attempting to remedy the genetics education gap, even if that means curtailing other subjects, such as chemistry, to make room. For example, the School of Nursing at the University of Washington in Seattle received funding from the Health Resources and Services Administration (HRSA) to begin teaching genetics four years ago.

“The impetus was the new advances in biotechnology and genetic research,” says Betty Gallucci, PhD, a professor at the school. “It was the feeling that genetics research will provide so many health benefits that nurses needed to be knowledgeable about it.”

Last summer, the university received an NHGRI-funded grant to expose underrepresented minority students to genomics education. The goal of the Genomics Outreach for Minorities program is to provide undergraduate nursing students with opportunities to gain experience in a research setting, such as a laboratory.

Teaching the Teachers

Many experts believe that the best way to teach nurses about genetics and genomics is to educate the educators. That’s why the goal of programs like GIFT and GPNF is to increase nursing faculty’s knowledge about genetics and its clinical application as well as to increase the amount of genetics content in nursing curricula.

“Genetics is advancing so rapidly that we really need to get people up to speed quickly,” Prows emphasizes. “And we’re not going to get genetics into the nursing curriculum unless we reach the nursing faculty and make them comfortable with teaching it.”

A key component of the GPNF, which is funded by the Ethical, Legal, and Social Implications (ELSI) Research Program of the NHGRI, is the annual onsite Genetics Summer Institutes (GSIs), now in its seventh year. “The nursing faculty that attend the GSIs learn genetics on a basic level,” says Prows. “We try to take away the mystery and provide a foundation for them so they can go back to their institutions and use the information either in their teaching or research.”

Last year, a grant from ELSI and HRSA’s Bureau of Health Professions, Division of Nursing, enabled the program to expand by adding an online Web-Based Genetics Institute (WBGI). Based on the GSIs’ content, the 18-week WBGI is team-taught by program instructors and guest lecturers.

The GPNF also holds a two-day genetics update workshop every two years for past GSI and WBGI participants. The third biennial workshop will be held this June. To encourage minority nurses to participate in both the GSI and the workshop, the GPNF waives the registration fee and provides travel scholarships through an ELSI Program grant. As a result, nearly 15% of the enrollment consists of nurses of color. Similarly, the Web program’s fee is waived for minority nurses.
Since attending the GSI in 1998, Sonia Cunningham, RN, MS, associate professor of nursing at the University of Texas at Brownville, has integrated genetics throughout her curriculum. She not only lectures on the subject, but also assigns research projects, writing assignments and other enrichment activities to provide additional genetics content. And she believes other nursing faculty will find it easy to do the same.

“It requires only commitment to the idea,” says Cunningham, who is African American. “Genetics needs to be integrated into the curriculum at every nursing school at every level.”

Based on a similar premise as the GPNF, the GIFT program at Duke University brings together graduate faculty teams from nurse practitioner, nurse-midwifery and graduate physician assistant programs from across the country to learn about advances in genetics and methods to facilitate incorporating genetics throughout graduate curricula.

The educational program consists of three parts. Phase I is an online genetics primer that addresses key concepts, such as genes, chromosomes, alleles, types of genetic mutations, genetic risk and inheritance patterns, and taking genetic family histories. Phase II is an intensive week of on-campus lectures, seminars, opportunities to practice family history-taking using standardized patients, cultural sensitivity workshops and strategies for faculty development and methods of curricular revision.

In the final phase, faculty team members have access to online resources–such as recorded lectures, teaching modules, faculty forums and “ask the expert” forums–to assist them in incorporating genetics into the curriculum at their own institutions.

The GIFT program will accept 10 faculty teams this year and 10 teams in 2004. The cost of team members’ participation is covered by a cooperative agreement from HRSA’s Division of Nursing and its Division of Medicine and Dentistry. In addition, participants receive a stipend to help them implement curricular change at their institutions. Although the program is targeted to faculty who teach at the graduate level, James points out that many of the participating institutions offer undergraduate nursing degrees. Therefore, team members can implement the educational tools in whatever program they feel is appropriate.

For nursing faculty who can’t attend a genetics institute or workshop, there is the Foundation for Blood Research’s Practice-Based Genetics Curriculum for Nurse Educators. This field-tested curriculum package consists of four teacher-assisted modules: ethical, legal, and social issues in genetic testing; high-risk pregnancy and prenatal diagnostic procedures; periconceptional prevention and prenatal screening; and late diagnosis and presymptomatic testing of genetic conditions. The package includes didactic materials, data collection materials, resource and supplemental educational materials, and evaluation methods.

Dale Lea, RN, MPH, APNG, FAAN, assistant director at Southern Maine Genetics Service, served as the principal investigator for the three-year grant from the National Institutes of Health and the NHGRI to develop the genetics curriculum modules. “It’s difficult for faculty to integrate a new concept into an already crowded curriculum,” she says. “So we wanted to develop an approach that would make that less of a barrier.”

Some nursing faculty members who have purchased the modules have used pieces of them to integrate an aspect of genetics into their curriculum, Lea reports. Others have created a genetic symposium, supplementing it by bringing in professors to talk about cultural issues, patients to talk about their experiences, or scientists to talk about research. Still others have used the modules for continuing education. Cunningham, for example, has used them to teach continuing education courses in genetics to graduate nurses in the community.

One other resource worth mentioning, even though it is not exclusively for faculty and emphasizes research rather than teaching and curriculum development, is the Summer Genetics Institute (SGI) sponsored by the National Institute of Nursing Research (NINR), Division of Intramural Research. Targeted to graduate students and advanced practice nurses as well as nursing faculty, this full-time summer training program features classroom and laboratory components designed to provide a foundation in genetics for use in clinical practice and research. The program is highly competitive, accepting only 14 to 18 participants each year.


Expert Advice

If you’re a nursing student at the undergraduate level who wants to learn more about the role of genetics in health care, the experts interviewed for this article suggest taking electives in the basic biological sciences, or better yet, attending a nursing school that includes genetics in its curriculum. Prows recommends asking your clinical instructor to assign you to patients who have illnesses with a hereditary component, such as sickle-cell disease, Huntington’s disease or breast cancer. Volunteer work with local chapters of groups dedicated to fighting these ailments, such as the Sickle-Cell Disease Association of America, can give students a first-hand look at those conditions, Gallucci suggests.

Graduate students pursuing a master’s or PhD should seek out individuals involved in genetic/genomic research who could serve as mentors. One way to make these contacts is to become a member of professional associations like the International Society of Nurses in Genetics (ISONG) or the National Coalition for Health Professional Education in Genetics, an interdisciplinary group that promotes education and access to information about advances in human genetics. “Attending ISONG meetings is a great way to make contacts, network and find out who’s doing genetic research in graduate programs,” says Gallucci.

Research-minded nurses with advanced degrees will also want to explore the opportunities offered through HRSA, NINR and the ELSI Research Program. The latter program is a rich resource for nurses, according to Lea, and you don’t have to have a PhD to participate in an ELSI project.

But perhaps the most exciting opportunities for nurse researchers of color are those available from the NHGRI as part of its Initiatives and Resources Related to Minority and Special Populations. In May 2001, the National Advisory Council for Human Genome Research approved an action plan “for the inclusion of underrepresented minority groups in research training, research collaborations, and education and outreach activities supported by all components of the [NHGRI].”

To achieve this goal, the Institute offers such resources as:

• Research training and career development programs for underrepresented minorities at all educational levels, from high school students to faculty.

• Opportunities to participate in collaborative research projects focusing on diseases that disproportionately affect minority populations.

• Community outreach and public education resources that nurses can use to help minority communities understand the implications of genome-related research.

• Funding opportunities–including research, career development, training and education grants–for researchers, faculty and students who are members of minority populations or affiliated with minority institutions.

“The area of genetics is a wide-open field,” concludes Strickland. “Although we know a lot, there’s still so much more to be known. If minority nurses aren’t involved in genetics research and applying genetic knowledge at the bedside, we will be left behind.”

HRSA Calls for More Genetics Education for Nurses

Fewer than 10 master’s-level and doctoral programs currently exist to prepare nurses in genetics, according to a recent report released by an expert panel convened by the Health Resources and Services Administration. The report, entitled “Expert Panel on Genetics and Nursing: Implications for Education and Practice,” identified five principles for improving genetics education among nurses:

• To promote access to quality health care for all, genetic education should focus on preparing providers to care for underserved, vulnerable and special needs populations.

• Academic nursing leaders and health professional faculty should be committed to a long-term plan to meet the genetic care needs of the public by 2010 and beyond.

• Education programs should be interdisciplinary and focus on the translation of genetic knowledge into practice and research.

• Genetic content should include molecular biology (genomics and protenomics) and the social, ethical, economic, and legal implications of genetic knowledge.

• The nursing workforce should be culturally competent; should reflect cultural, racial and ethnic diversity; and should be distributed geographically to serve in all areas of the country.

Completing the Circle

The great circle of life: It’s the lesson that Simba, the young lion cub in Walt Disney Pictures’ The Lion King, learns as his story unfolds. When Simba loses his father, his view of life changes and eventually he comes to accept “akuna matata”–no worries—as his philosophy. The animated classic illustrates how life has a beginning (birth) and an end (death), but what we encounter in between greatly influences our perceptions.

Of course, life and death are far too complex to be neatly packaged like a children’s movie. But the cultural attitudes, traditions and beliefs we encounter in our lives do affect how we approach these major events. From welcoming a new baby into the family to witnessing the passing of a loved one, it’s at these highly emotional times when we turn to others–such as family, community and health care providers–for support and guidance. It is also at these times–particularly at the end of a life–when nurses can make their greatest impact and perhaps reaffirm their decision to become a nurse.

According to the 2000 U.S. Census, one out of every four Americans is non-white. The traditional American melting pot of assimilation that characterized much of the 20th Century has today evolved into a colorful garden of racial, ethnic, cultural and religious diversity. Because virtually every culture has its own distinct beliefs, customs and practices concerning death and dying, the nation’s health care profession is recognizing that it can no longer take a one-size-fits-all approach to caring for the terminally ill.

By choosing a career in the emerging field of end-of-life (EOL) care, nurses of color can make an exceptional contribution to providing minority patients and their families with culturally competent and sensitive care at a time in their lives when they have never needed it more.

Accepting the End

Most nurses have resigned themselves to the reality that, throughout the course of their careers, some of their patients will lose their battle against illness and disease. Whether it’s a prolonged fight against cancer or the unexpected tragedy of a brain aneurysm, death is an inevitable part of health care. Traditional training, however, teaches health care providers that they must use every available resource to try to thwart a fatal outcome. This is a cornerstone of nursing education and is aided by the constant influx of new, life-saving technology.

It’s not surprising, therefore, that throughout much of the last century, health care providers received very limited education on how to help patients cope with the end of their lives. Helping the dying prepare for that transition was most often left to religious counselors or the patient’s family. But that is changing now, as more health care professionals find their roles evolving to include caring for patients’ needs at all stages of their illnesses.

“It’s not necessarily the length of a life that’s important, but the quality of life,” says Polly Mazanec, RN, MSN, AOCN, a clinical nurse specialist at the Hospice of the Western Reserve in Cleveland. “As nurses, we have been trained in the high-tech ways of keeping people alive, but now we’re also learning how to help people die comfortably and with minimal pain.”

One of health care’s more well-publicized efforts to focus directly on end-of-life issues was the emergence of hospices nearly 30 years ago. Generally speaking, a hospice is a “serene,” compassionate environment in which terminally ill patients can spend their last days in dignity and freedom from pain. Hospice staff are trained to ease suffering, manage diseases’ symptoms and provide emotional support to critically ill patients and their loved ones so that they can be comfortable and reach a sense of peace.

“With end-of-life care, we have to switch from a cure-oriented mode of practice to one of comfort and support,” explains Mazanec

The popularity of this approach to end-of-life care is evident in the growing number of hospice facilities nationwide. According to the National Hospice and Palliative Care Organization (NPCO) in Alexandria, Va., an association representing hospice and palliative care programs and professionals, its member facilities admitted 700,000 patients in 1999–up from 540,000 in 1998.

Interestingly, the majority of hospice patients are white–83% in 1995, says NPCO. The organization estimates that in 1995 only 8% and 3% of hospice patients were African American and Hispanic, respectively.

Why the disparity between the majority and minority populations? Many health care experts point to culture as one of the major contributing factors.

Respecting Cultural Differences

Patients’ cultural norms and beliefs play an important role in their health care decisions–from seeking out a provider to complying with treatment instructions to their ability to communicate with caregivers. This is especially true with end-of-life care, because the patient often brings with him or her a lifetime of perceptions.


“A patient’s vulnerability is intensified at the end of his or her life, so health care providers must be careful to respect cultural differences,” comments Diana Harris, MA, a research associate in the Department of Ethics and Health Policy Initiatives at the Albert Einstein Healthcare Network in Philadelphia. The department has been examining end-of-life care issues in culturally diverse communities with staff, patients and local community and religious leaders.


In minority communities, traditional cultural beliefs and customs surrounding death and dying can hold extreme importance for patients and their families. Depending on the culture, death may call for loud, open wailing, chanting or quiet contemplation.

“Culture is very important and I don’t think it’s being given the consideration it deserves when it comes to end-of-life care,” says Gwen London, executive director of The [Washington] D.C. Partnership to Improve End-of-Life Care. “I don’t think the current health care system is set up to deal with cultural differences.”

Culture, however, isn’t simply defined by race, ethnicity, gender or religion, experts contend. Rather, it’s a combination of all these factors plus many more, including socioeconomic status, education and, especially for immigrant groups, level of acculturation to the American way of life.

“Nurses have become cultural brokers in health care,” notes Carolyn Bloch, RN, MSN, CNS, a certified transcultural nurse specialist and transcultural/diversity consultant with the Los Angeles County Department of Health Services, Office of Diversity Programs, along with her twin sister, Carol Bloch, RN, MSN, CNS. “Nurses can introduce immigrant patients to American health care procedures, but the patients come with their own cultural views, and nurses must find a balance,” Carolyn explains. “This is especially important with issues of death and dying.”

Spiritual Sensitivity

Finding comfort in religious traditions is another way patients and their families cope with death and dying. For example, Catholics believe it is important to receive Holy Communion and Last Rites by a priest during their final hours. In Judaism, it is a sign of respect for relatives and friends to watch as a loved one passes away. And Buddhists, with their belief in reincarnation, may use chanting to calm the patient’s state of mind at the time of death because they believe this will impact the person’s character at rebirth.

Nurses must be aware of these beliefs and practices so they can attend to dying patients’ spiritual needs in the proper way, notes Alice Cornelison, RN, PhD, an assistant professor and assistant to the associate dean for clinical affairs at Howard University in Washington, D.C., a Historically Black University. For example, she says, Muslims believe the dying person should be turned toward Mecca before and after death.

Religion, however, is not the only cultural element affecting how people feel about death. Sometimes, it’s an ancient custom or belief that has carried on through generations. The Bloch sisters point to a case of a Chinese-American physician who was diagnosed with cancer. According to his family’s cultural beliefs, the sick member must not know or be told of his condition for fear of saddening the spirit and bringing death even sooner.

“Because he was a doctor, this man had been the family member who made all the decisions regarding health care,” explains Carol Bloch. “But when he became sick, he had to relinquish the role of decision-maker. His culture demanded that he not know he was dying.”

This, of course, is the opposite of the American philosophy that the patient has a right to know about his diagnosis and prognosis in order to make decisions about treatment options. In this man’s case, Bloch says, health care providers communicated with designated family members and not the patient. The Blochs also cite the example of a Persian immigrant patient whose beliefs required that a dying person not be told of his condition. This was so important to the family that a relative stood guard outside the hospital room door to make sure the patient was not told what was happening.

Hispanic culture holds similar beliefs about preventing the spirit from hastening death, which is why many families in Hispanic communities opt to have a loved one pass away at home, rather than in the hospital. Here, too, the patient’s extended family is often responsible for making treatment decisions. For example, it’s not uncommon for a wife to defer her health care choices to her husband or to family members to be made as a group.

In contrast, other cultures may welcome a more interventive approach, seeking out life-prolonging technology and the hospital environment. Depending on past experiences, some patients may want full control over their treatment decisions, including employing every plausible option.

However, says Harris, some minority patients have concerns about whether they will receive the same quality of care and the same range of treatment options that are offered to white individuals. “Some of this apprehension,” she adds, “doesn’t just arise with the issue of end-of-life care, but may have been rooted very early in their lives.”

This is particularly true with African Americans. In some black communities, there is an overall distrust of the health care system, which may be a reason behind the small percentage of African Americans who opt for hospice care.

While some of these generalizations may seem like stereotypes, and may not apply in all cases, Carolyn Bloch believes that culturally knowledgeable nurses are better equipped to find the most appropriate way to assist all parties involved with end-of-life care–the patient, family members and even other health care staff.

“If they know that Hispanics tend to refer to the family unit, nurses can relieve a lot of anxiety for the patient simply by asking, ‘Would you like to have your family here with you?’” she notes. “Also, incorporating those cultural aspects into a treatment program can help decrease the nurse’s anxiety, because you’re not struggling with trying to change the patient into doing things ‘the American way.’”

When in Doubt, Ask

Even if EOL-care nurses share the same ethnic or cultural background as a particular patient, or have extensive knowledge of that culture, experts caution that they should resist the temptation to make blanket assumptions about a terminally ill patient’s preferences and needs.
“Although a patient may belong to a certain [cultural] group, he may not follow all the practices,” comments Mazanec. “That is why it’s so important to ask questions to find out what he, as an individual, wants at the end of his life.”

Furthermore, nurses have so many duties to fill their shifts that they may not have extra time to storehouse multiple facts about multiple cultures. “It isn’t possible, or even reasonable, to expect every health care provider to be fluent in multiple cultural traditions,” Harris agrees. “But I do think it’s essential for caregivers to have respect for cultural differences and to listen.”

Adds Mazanec, “I don’t think we always need to have cultural matching between patients and nurses to achieve quality end-of-life care. Nurses just have to be able to ask the right questions and treat all patients’ beliefs with respect.”

End-of-life experts agree that asking questions is the most efficient method of discovering how culture could impact a dying patient’s care. Non-threatening questions such as  “What did you do for a living?” can yield very telling responses. Questions regarding family members or friends can help nurses determine whom the patient wishes to have near him at this stage. Even a direct approach, such as asking “Is there anything you want me to know about your beliefs or customs while I’m taking care of you?” can immediately explain to nurses how they can incorporate a cultural perspective into their treatment. These questions need not take up huge amounts of time. They can be asked while bathing patients or administering medications or simply while carrying out other nursing responsibilities.

“It’s important to have these conversations with patients and their families in order to understand what they need,” Mazanec emphasizes.
Harris adds this advice: “While facilitating these discussion, however, nurses should not bring their own frustrations or biases to the table.”

Getting Educated

Nursing educators are working hard to facilitate end-of-life discussions within the profession so that nurses can become better equipped to help patients at this crucial stage of their diseases. As an example of the lack of knowledge currently available to health care providers, Mazanec cites a recent study of nursing and medical textbooks that revealed that only 2% of the books contained references to EOL care.



To change this situation, in February 2000 the American Association of Colleges of Nursing (AACN) established the End-of-Life Nursing Education Consortium (ELNEC) Project with a grant from The Robert Wood Johnson Foundation. Among the national program’s objectives is to help schools of nursing incorporate end-of-life care information into their curricula.


In collaboration with four nationally recognized nurse experts on end-of-life care, ELNEC has developed a comprehensive EOL-care course curriculum, including supplemental faculty materials such as outlines, Power Point overheads and additional readings. The course is organized into nine content modules, including one devoted exclusively to cultural considerations in EOL care (see sidebar). To date, the ELNEC course has been presented to representatives from nearly all of the 50 states, who, in turn, have taken the information back to colleges and universities in their areas.

“[Schools] are realizing that this is not simply an elective choice but an essential piece of the nursing education program,” says Mazanec.

ELNEC also has recently begun to contact hospitals’ staff development departments and continuing education authorities to provide working nurses with an orientation to end-of-life care, because many of these nurses may not have had exposure to EOL issues while they were in nursing school. “Too much end-of-life content is being learned in on-the-job training after graduation,” comments Cornelison.

Other organizations, too, are examining how they can assist nurses and other health care providers with developing end-of-life care skills. In the nation’s capital, the District of Columbia Hospital Association joined with local health care educators, community leaders and others to form The D.C. Partnership to Improve End-of-Life Care. One of the partnership’s multiple task forces, spearheaded by the nursing school deans at Georgetown University and Howard University, is addressing ways to expand the EOL education options currently available to health care professionals. One result of these efforts is the creation of an EOL-care course–a collaboration between the participating schools–which is being offered in the D.C. area for the first time this fall.

Through a combination of specialized education and cultural sensitivity, nurse can make a difference in creating a peaceful end-of-life experience for patients and their families. By creating a positive and understanding environment where patients of all cultures can complete the circle of life in their own ways, nurses can take part in a profound human experience and reaffirm the dedication to taking care of others that brought them to nursing in the first place.

A Model for Culturally Competent End-of-Life Care Education

In this nine-module EOL-care curriculum developed by the American Association of Colleges of Nursing (AACN)’s End-of-Life Nursing Education Consortium (ELNEC) Project, cultural considerations are not an afterthought but an essential component of the program:


  1. Nursing Care at the End of Life: Overview of death and dying in America; principles and goals of hospice and palliative care; dimensions of and barriers to quality care at EOL; concepts of suffering and healing; role of the nurse in EOL care.
  2. Pain Management: Definitions of pain; current status of and barriers to pain relief; components of pain assessment; specific pharmacological and non-pharmacological therapies, including concerns for special populations.
  3. Symptom Management: Detailed overview of symptoms commonly experienced at the EOL; for each symptom, the cause, impact on quality of life, assessment, and pharmalogical/non-pharmalogical management.
  4.  Ethical/Legal Issues: Recognizing and responding to ethnical dilemmas in EOL care, including issues of comfort, consent, prolonging life, and withholding treatment; euthanasia and allocation of resources; legal issues, including advance care planning, advance directives, and decision making at EOL.
  5. Cultural Considerations in EOL Care: Multiple aspects of culture and belief systems; components of cultural assessment with emphasis on patient/family beliefs about roles, death and dying, afterlife, and bereavement.
  6. Communication: Essentials of communication at EOL; attentive listening; barriers to communication; breaking bad news; and interdisciplinary collaboration.
  7. Grief, Loss, Bereavement: Stages and types of grief; grief assessment and intervention; the nurse’s experience with loss/grief and need for support.
  8. Achieving Quality Care at the End of Life: Challenge for nursing in EOL care; availability and cost of EOL care; the nurses’ role in improving care systems; opportunities for growth at EOL; concepts of peaceful or “good death,” “dying well” and dignity.
  9. Preparation and Care for the Time of Death: Nursing care at the time of death, including physical, psychological and spiritual care of the patient, support of family members, the death vigil, recognizing death, and care after death.

Source: American Association of Colleges of Nursing, ELNEC Project, April 2001

Ready for Anything

In the wake of the September 11 terrorist attacks and the anthrax scare of fall 2001, American nurses can no longer observe a troubled world and reassure themselves that terrorism won’t happen here. But they can be prepared to respond if terrorists strike again

The nation is counting on nurses to play a vital role in responding to any future terrorism disasters that may occur. Specifically, nurses will be needed to work on the front lines to treat victims, educate other medical professionals, teach communities about emergency preparedness and help people cope in the aftermath of attacks.

Nurses are a natural choice for this role because they consistently rank among the nation’s most trusted professionals–a key benefit as they work to prepare communities for eventualities that most Americans find terrifying. And because “dirty bombs,” chemical weapons and anthrax spores don’t discriminate on the basis of skin color or ethnicity, minority nurses who can provide culturally and linguistically competent public health preparedness to diverse communities will be urgently needed.

“Hospitals must assign leaders to help them prepare for terrorist disasters,” says Greg Evans, PhD, MPH, director of the Center for the Study of Bioterrorism and Emerging Infections at the St. Louis University School of Public Health. “Nurses, rather than doctors, are the ones to fill those important leadership roles.” To do so, he adds, nurses will need training in disaster preparedness, bioterrorism and leadership skills.

To meet that need, the federal government, nursing associations, schools of nursing and health care systems are all working to train, educate and organize nurses to respond to terrorism, as well as other potential public health emergencies, such as the recent Severe Acute Respiratory Syndrome (SARS) epidemic. Government officials and nursing leaders are encouraging nurses who want to help after catastrophes to join organized efforts so they can get the proper training and be part of systematic responses.

In June 2002, President Bush signed into law the Public Health Security and Bioterrorism Response Act, which authorized significant funding improvements in public health infrastructure and emergency health preparedness. Currently, several major national initiatives are under way, giving nurses a variety of different channels through which they can serve.

The National Nurses Response Team

The American Nurses Association (ANA) and the U.S. Department of Health and Human Services’ Office of Emergency Response are establishing the National Nurses Response Team, a force of registered nurses trained to respond to a major bioterrorism event, such as the release of smallpox or anthrax. The nurses would be responsible for providing mass vaccinations or chemoprophylaxis to hundreds of thousands of Americans, or even millions.

The association and federal officials want to recruit 10 regional teams of 200 nurses, says ANA senior policy analyst Cheryl Peterson, RN, MSN. In case of a terrorism disaster, the federal government would deploy nurses on the team for no more than two weeks at a time and would pay them for their service

Racial and cultural diversity in the response team will be critical, as it is in all areas of nursing, Peterson stresses. The team must be able to communicate medical information and educate the public quickly after a crisis. Nurses of color can play a key role in helping other members of the team understand diverse cultures, establishing trust in minority communities, responding to individual and community needs with cultural sensitivity and communicating with limited-English-speaking populations.

According to Peterson, public health experts were already studying how to better inform nurses about bioterrorism even before 9/11. After a religious cult released sarin, a nerve gas, in a Tokyo subway in 1995, an American College of Emergency Physicians task force studied whether health care providers were ready to respond to such a disaster here. The answer was no, Peterson says. That revelation, along with the attacks on the World Trade Center and Pentagon and the subsequent anthrax incidents, served as an alarming wakeup call.

Nurses who join the National Nurses Response Team will be trained through national online courses and regional continuing education programs. Peterson says officials hope to have the team in place by the end of this year.

Serve Nationally, Locally or Both

Although the National Nurses Response Team is a particularly exciting initiative because it focuses exclusively on nurses, it is not the only option available to nursing professionals who want to make a difference in helping their country prepare for and respond to the threat of terrorism. Here are several other programs in which nurses can make valuable contributions:

  • Disaster Medical Assistance Teams. A Disaster Medical Assistance Team (DMAT) is a group of medical personnel who work on the front lines providing medical care after a disaster. This can include natural and environmental disasters as well as terrorist attacks. The teams, which are part of the federal government’s National Disaster Medical System, are deployed to disaster sites with enough equipment and supplies for 72 hours. They help triage victims and prepare patients for evacuation. They can also help relieve local health care staffs that become overloaded during a crisis. The team members are paid by the federal government while serving, and their medical or nursing licenses are recognized in every state during their service.
  • Medical Reserve Corps. These groups are part of the USA Freedom Corps, an initiative developed after President Bush’s 2002 State of the Union address called for establishing a new program to give Americans the opportunity to volunteer and serve their communities. After September 11, many people across the country felt a renewed surge of civic duty but weren’t sure how or where they could help. Although the federal government helps fund the Medical Reserve Corps through grants, the groups are actually developed and run by individual communities so they can design the corps to respond to local needs. According to Craig Stevens, a spokesman for the U.S. Surgeon General’s office, any organization or group can start a Medical Reserve Corps, and volunteers don’t necessarily have to be health care professionals to take part. So far hospitals, churches, Rotary Clubs, fire departments and ­even a community newspaper ­have launched these volunteer efforts in 42 communities nationwide. Not only can local Medical Reserve Corps groups be organized to respond to disasters, they can also serve ongoing public health needs, says Stevens. For example, they may provide health education or develop vaccine programs. Nurses obviously can play a huge role in establishing Medical Reserve Corps units, he adds. And because these programs are so strongly community-focused, they can be a particularly effective way for minority nurses to establish culturally competent emergency preparedness efforts in communities of color.
  • American Red Cross. Registered nurses can join their local Red Cross chapters to get training and local experience in terrorism preparedness. They can also receive additional training to respond to disasters outside their communities. The length of assignment depends on the type and location of the disaster. Nurses who serve away from their local areas should be able to commit to at least two weeks deployment. Nurses can serve in a variety of ways through the Red Cross. They can provide community disaster education, recruit and train other nurses, work at Red Cross service centers and provide health assessments and first aid for Red Cross workersresponding to disasters.
  • Commissioned Corps Readiness Force. Nurses who work in the U.S. Public Health Service’s Commissioned Corps can volunteer for the Readiness Force, which deploys teams to respond to major public health emergencies. Since 9/11 and the anthrax attacks, the Commissioned Corps Readiness Force has placed increased emphasis on terrorism preparedness training for its volunteers.

Learning from the Experts

Before September 11, courses on terrorism and bioterrorism response were not exactly a staple of most nursing school curricula. Today, of course, it’s a different story, with a growing number of academic institutions incorporating this urgent new subject into their nursing programs.

One of the most unique efforts is under way at St. Louis University School of Nursing, which launched a first-of-its-kind online disaster preparedness certificate program in February. The idea for the program came out of a faculty meeting when professors asked one another, “If we have another 9/11, what are we supposed to do?” recalls assistant professor of nursing Dotti James, RN, PhD.

When nursing school alumna Elsie Roth, RN, MA, BSN, heard about the plan, she suggested that faculty members travel across the world to learn from the experts: Israelis. “Who would know better how to respond to terrorism than them?” she says. Adds James, “In Israel, they’re living with this constantly and take a very pragmatic approach: Get ready for it.”

Roth, a public health nurse who has traveled to Israel many times, volunteered to lead the expedition. As a lifetime member of Hadassah, a women’s organization supporting the Hadassah hospitals in Israel, she worked with her Israeli contacts to set up an in-depth learning program for the St. Louis University faculty at the Henrietta Szold Hadassah Hebrew University School of Nursing and Hadassah Hospitals in Jerusalem. Roth and four faculty members representing the School of Nursing and the School of Public Health spent an intense week learning from local military and public health officials, volunteers and emergency room doctors and nurses.

James says the experience was profound. They learned the technical and systematic methods the Israelis use to respond efficiently to terrorist incidents, such as suicide bombings, and they witnessed the impacts of terrorism on the day-to-day lives of residents and hospital personnel. They watched as health care workers trained new mothers how to put gas masks on their infants.

“The big thing we learned is it can happen here,” James emphasizes. “People are going to turn to us as nurses, and that’s not the time to say, ‘I don’t know what to do.’”

The certificate program requires six core courses plus four courses selected from a menu of 12 electives. The electives include such topics as biological terrorism, social and psychological impacts of disasters, basic epidemiology, and the unique needs of vulnerable populations (such as children, the elderly, people who are incarcerated, people who live in high-rise buildings and immigrants who don’t speak English).

“The Whole Issue is Education”

In addition to the ANA, other nursing professional associations are also responding to the need to prepare nurses to deal with the threat of terrorism. For example, the National Black Nurses Association is offering a full-day Red Cross Disaster Training session at its upcoming 2003 Annual Conference in New Orleans.


The Academy of Medical-Surgical Nurses is adopting a position statement calling for education for nurses on bioterrorism agents, signs and symptoms of exposure to such agents, treatment plans, containment and self-protection. “The whole issue is education, education, education,” says academy president Doris Greggs-McQuilkin, RN, MA, BSN, the first African-American nurse to lead the national organization. The academy is also incorporating a new chapter on disaster planning and bioterrorism into its core curriculum.

Earlier this year, the American Academy of Ambulatory Care Nursing held a special workshop on “Preparing the Nursing Workforce for Bioterrorism” at its recently completed 2003 Annual Conference. “We felt all of our nurses needed to be aware of the risk,” says the academy’s president, Catherine Futch, RN, MN, CNAA, CHE, CHC.

The threat of a bioterrorist attack is so frightening that most people would rather not think about it. But the best way to reduce the public’s fear is to educate them about the challenges and how to respond, Futch asserts. In this context, nurses’ ability to understand other cultures, communicate with diverse populations and provide linguistically competent public health education will be more important than ever, she adds.

Health care systems are still another group that is beginning to address the issue of terrorism response. And they, too, are aware that preparedness information must be easily accessible to patients of all races and ethnicities. For example, after the anthrax scare, Kaiser Permanente, the nation’s largest HMO, made sure it had patient education materials about anthrax available in various different languages.

Gayle Tang, RN, MSN, Kaiser’s national director of multicultural services, believes that planning how to provide culturally and linguistically competent medical care in response to terrorism will be a key issue. The big question, says Tang, who is Chinese American, is: How do we reach all the diverse populations, especially those who don’t speak English? By arming themselves with a strong base of education, knowledge and skills in terrorism preparedness and response, minority nurses can be indispensable leaders in efforts to answer that question.